Ohio State University | One Health

Life-saving and life-sustaining: Maternal, newborn interventions at work

July 8 2014

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!

Big audience for neonatal resuscitation training in Addis Ababa

July 7 2014July 7, 2014

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.

Counting dogs, with Gondar’s children helping us

June 20 2014June 19, 2014

By Ally Sterman, 2015 DVM and
Alexandra Medley, 2017 DVM and 2018 MPH/VPH
The Ohio State University

Our dog survey project takes us through various areas and communities in Gondar. Many of these areas are homes or rural communities that are heavily populated with families who have many children. As we walk around the areas, we quickly attract children. It is not common in many of these areas for individuals with white skin to pass through. When I was in Ethiopia the previous summer, in very, very rural communities children used to run and hide from us. This summer they run straight for us.

Often times we know they are coming for the screams of “you, you, you” or ” foreingee, foreingee.” Once they arrive, they begin to ask us our names, how we are and where we are from. Many will try to speak some English with us and others will suddenly become shy and run and hide. If you pull out a camera to take a picture, they also all hide but when we bring out the iPad to record data they become super interested in what we are doing. The brave ones come up and want to shake hands with us. Such a simple gesture brings a wide smile to their faces.

They have been very helpful, helping us identify what sex the dogs are, where they are and even bring them up to the front of the yards to help us see them better. In the suburban areas we had as many as 30 children following us and in the rural side entire small villages of children.

Interestingly, the local veterinarians have told us that the main breeding season is in the Ethiopian Spring (September by U.S. calendars), although we have seen many pregnant dogs and puppies. Despite our initial thought that each dog would be hard to tell apart, we have seen a variety of shapes, sizes, breeds and coat patterns. So far we have been able to casually determine that dogs are mostly found in the peri-urban, or housing, areas. Although dogs tend to remain in a small area, or territory, there are many friendly dogs that roam in groups.

We have seen many different medical conditions in the dogs, such as lameness, ticks, fleas, fighting wounds, and malnutrition, but none of this was outside of what we expected. We have completed our two rural paths, that are high up in the mountains where there are less than 15 houses per path. We have seen many dogs there, but more incredibly, the stunning panoramas of Gondar from up high. This season heralds strong winds and rain, and sometimes we had to brace ourselves from falling over as we navigated hilly terrain. In a few more days, we will wrap up our dog survey.

Public health course ends with a conference lecture in Gondar

June 19 2014June 19, 2014

By Armando Hoet
Associate Professor and Director of Ohio State’s Veterinary Public Health Program

Gondar Ethiopia, day 6

I am still not sure what happen, but I blinked, and there I was in the front row of the largest conference center in Gondar at the Medical School, seated between the president and vice-president of Gondar University , as one of the main keynote speaker for the 24^th Annual Research Conference of Gondar University.

This year the conference was even more special, which explain the large number of journalists and cameras, as it was the 60^th anniversary of the university (Diamond Jubilee).

Before the conference started the President shared with me his career path, starting as a sanitarian doing pre- and post-slaughter inspections, later becoming a Public Health official, studying part-time to become a physician and in the last 8 years he has been the president of the University of Gondar; leading a 30,000-student institution of higher education. He is in his own words “one of the strongest advocates of One Health.”

I believe the presentation went well based on the amount of interesting questions and post-conference trading of business cards.

As I am leaving tomorrow, I would like to thank my guide in Gondar, Professor Tamiru, who showed me the best of the city in this and my previous visit in 2012. And who took me today to the best view in town: The Goha Hotel.

Everything ended well, except for the Spanish team (5-1 to the Netherlands in the world cup) …

Finally, one of the best ideas I am taking back this trip is the unisex open bathrooms. I am sure they will pick up really fast at OSU.

Why misuse valuable space in duplicating men and women bathrooms, when we can share one? I am sure that we can use the extra space for additional offices. Right?

From the city of the Emperors of Africa

Thesis defenses and counting dogs in Gondar, the student perspective

June 16 2014June 16, 2014

By Ally Sterman, 2015 DVM and
Alexandra Medley, 2017 DVM and 2018 MPH/VPH
The Ohio State University

After a 13-hour flight, we arrived in Addis Ababa, Ethiopia. A thought that kept crossing through both of our minds was whether or not our 140 pounds of veterinary medical supplies would make it to Ethiopia, through customs, and with us to Gondar. After locating the correct baggage claim lanes (this airport has 4), we waited patiently for our oversized and heavy baggage. Thankfully we made it with no difficulty through customs and to our airport.

Flights to Gondar leave early morning and we stayed overnight at the Jupiter hotel near the airport in Addis. The view from our room was of a large abandoned field. By day this field was a grazing zone for various sheep and goats, but by night it was a parking lot for local vehicles. After exploring around the area, we ended up calling it an early night.

We arrived to the airport early and upon arrival in Gondar were greeted by our partners from University of Gondar and taken to our hotel. Soon after settling in we headed to the vet school. We had the opportunity to listen to senior veterinary students defending their theses, which is the final project necessary to graduate. There are some striking differences between Ethiopia and U.S. vet school training. In Ethiopia the students defend a final thesis project instead of a cumulative boards exam (USA NAVLE), they attend school for 6 years (USA, 4), and primarily focus on large animal medicine because that is the primary need in the country.

After listening to the defenses we had a meeting with the faculty who helped us organize our dog survey. For the next week we are walking 15 different paths we have plotted through the city to count the roaming dog population and do a brief visual physical exam on each dog. Data we want to collect are the number of dogs seen along the path, sex, age, reproductive status, and any other clues to their health status.

Something we have learned already is how mountainous Gondar is, so although the paths are short, they take a while and we get a great workout. To get to destinations we take buses or taxis which are far more crowded than the average taxi in the US.

Taxis and busy city streets

We have seen many types of dogs so far, from a small Papillon cross to a large Mastiff. Our favorite dog is the mixed breed brown dog who resides directly outside our hotel, affectionately named Kino.

Kino, the dog

Building knowledge in Ethiopia as Gondar builds buildings

June 11 2014

By Armando Hoet
Associate Professor and Director of Ohio State’s Veterinary Public Health Program

Gondar, Ethiopia, Day 3

We changed venue today to fit some late arriving participants, which is great to know that you are gaining people as you go instead of the other way around. Because we changed venue, we started a little bit later than planned, just merely an hour. And as I mentioned before, you become a good jazz player in improvising and adjusting the timing and rhythm to be able to still produce a good melody.

The group is also starting to get more involved in the material, especially in the afternoon when we started the first group activities. They became really enthusiastic, and strong discussions and conversations occurred throughout the afternoon.

Interestingly, I wanted to film such heated interactions in Amharic (the official language), but as soon as I pointed the camera, silence. Got it, no filming.

In any case, I believe they are enjoying the course, especially because at the end of the day I received several requests for pictures.

I am not sure about you, but I do not have a lot of pictures requests from my students when I finish a class!

And of course, no matter what, do not forget the coffee break. During one of them we had the opportunity to enjoy Ethiopian donuts and learn more about our families and jobs (pay attention to the order of topics discussed).

Finally, it is impossible not to be amazed by the amount of construction around. Hundreds and hundreds of buildings and houses all over the place.

The city is rising around you as I type this. The interesting part is that they are using beautiful basaltic rock.

The mountains surrounding the city are mainly composed of basalt volcanic rock, which are several millions of years old. Rocks that are incorporated in one way or another in their building and houses.

As one of my hosts indicated to me, “When you see such rocks in a building, you know you are in Gondar!” In short the rock is a symbol of the Gondar region.

From the Home of Lucy, the world’s oldest!

In Ethiopia, expect the unexpected – and coffee!

June 10 2014

By Armando Hoet
Associate Professor and Director of Ohio State’s Veterinary Public Health Program

If Personal Space is big for you, then Gondar is not your place to be. Here it is customary to salute you with at least an extended handshake and a soft touch of shoulder to shoulder (you incline forward and gently touch your peer’s shoulder and stay there for a few seconds sharing pleasantries).

If the person greeting you already knows you, then you will get a full hug, which again last several seconds. And finally, if they have great respect for you, then the hug will be accompanied by three touches of the cheek , first right, then left and then right again. It is a big honor to receive such greetings, and I had several of those today. In conclusion, I received more hugs today that my wife has given me in a year. This heartfelt salutation definitively makes you feel welcome!!

Today we started the training, and the phrase “play by ear” perfectly describes the morning. I planned to start at 8:30, which in Ethiopian Time according to my hosts is around 9ish… Perfect, 9:00 it is. Then, the conference room was double-booked, not a problem.

The key in this type of extension and outreach training programs is to expect the unexpected and take it easy.

Finally, they gave us the Conference Room at the Dean’s suite reserved only for special occasions (which my courses always fit that description!!).

The dean’s conference room.

Then after some housekeeping and preparation of the video, we were ready to go at 10:00 a.m.

A former dean and a chair are among the faculty attending the training program, which is a very different crowd from two years ago, as all of the people attending today are faculty.

Also very important to know is that no matter what happens to the schedule, never, never, never, never, ever skip the coffee break.

Never, ever skip the coffee! Note the traditional coffee ceremony elements.

Ethiopia is claimed to be the birth place of coffee, so the coffee tradition is millenarian, and the “ceremony of coffee” is very important and a great opportunity to socialize. The process is very social and very beautiful because of the protocol that is followed: grass spread around for the green color that mean peace and calm, to the placement of flowers, to the accommodation of all the utensils in the short table, to the hot coals (see in the background) where the coffee is carefully reheat before serve, etc.

Pouring the coffee during the traditional coffee ceremony.

However, even though it is very traditional, my infectious disease brain did not let me enjoy it to the fullest, if you do not understand what I mean you are not paying attention to this picture:

This is it for today.

From the birthplace of humanity…!!

In Gondar, ‘dinner to go’ has a different meaning

June 9 2014June 10, 2014

By Armando Hoet
Associate Professor and Director of Ohio State’s Veterinary Public Health Program

Day 1

After a 36 hours total time of traveling, I am safe and sound in Gondar. This is a small town in the northwest corner of Ethiopia. It is in the mountains, 2,133 meters above sea level (almost 7,000 feet), a location that produces beautiful views of the city and surrounding areas as you travel through town.

The lovely hills around Gondar

How do you move around? Well, the majority of the people walk from point A to point B. Those that have some income, can pay 2 to 3 Birr (the Ethiopian currency) for public transportation (basically small minivans similar to those in the 1960’s modified for public transportation), which is around 10 cents.

The minivan taxis are in the background behind the Bajaj.

If you are ready to throw your money around, you can take a taxi for 80 Birr ($4).

Inside a Bajaj taxi.

I tried to use the public transportation to go downtown, but every van was full with people and animals (mainly goats tied and place carefully under the seats), which more likely were the dinner for tonight.

You can conveniently buy your goat next to the bus stop for dinner to go, so you can process them as soon as you get home. Fresher and more organic is impossible!

Dinner to go: Goats for sale next to a bus stop.

So, I got my taxi, and I went to the main square to have a short (touristic) walk after lunch. I will share those pictures down the road. Then, I got another taxi to go back to the hotel.

I will have 25 to 30 faculty tomorrow to teach about International Trade and Public Health, which is just a fancy name for Introduction to Risk Analysis, so I need to get ready. Let’s see how the week progresses.

From Gondar (Ethiopa), The Camelot of Africa.

Patient patients in Gondar’s Vision Clinic

June 6 2014June 10, 2014

By Jeff Walline, Associate Professor
Ohio State College of Optometry

In Ethiopia, optometry is a bachelor’s degree, but I am here to teach six motivated students obtaining Master’s degrees in optometry. One purpose of their education is to expose them to optometry procedures that are practiced in the United States that are typically not practiced by optometrists in other parts of the world. Therefore, I teach them things that they cannot practice due to economic, social, and/or technologic constraints. However, the students are very interested in learning. Hopefully, they will also be able to practice these procedures in Ethiopia and teach future optometrists to practice them as well.

Below is a picture of patients waiting to have their eyes examined in the Vision Clinic. They wait in the courtyard of a three story building that appears old and decrepit in some areas and never completely finished in other areas.

Patients waiting to have their eyes examined.

Ethiopian people are very patient, and waiting seems to be a natural part of their lives. They wait for eye examinations, they wait for cabs, they wait for something that never seems to appear. However, they never complain about waiting. It just seems to be a part of their lives.

What I teach optometry students in two semesters, I have squeezed into one week. I don’t know how much of it actually “sunk in,” but I know that the students will certainly have more information than when I arrived. They are anxious for a final, but I didn’t know that I was to give one. I will prepare a final when I return and send it to them, but first I will prepare them for the final on my last day here.

I want them to have a positive feeling about their experience, and I think a strong performance on the final would help to solidify that feeling.

I have one more day to lecture. On Monday, I thought this day would never arrive. Now that it has, I look forward to going home but not with as much fervor as before. The people of Ethiopia are very kind and I will miss them.

What I see when teaching optometry in Gondar

June 5 2014

By Jeff Walline, Associate Professor
Ohio State College of Optometry

I am in Ethiopia to teach two courses at University of Gondar: advanced contact lenses; and children’s vision.

The students have a strong basis in pediatric care, and they ask very intelligent questions. They are very patient with me when I ask them to repeat their questions.

My University of Gondar students

Traveling from the Gondar airport to my hotel, I went through an entire evolutionary cycle. Near the rural airport, several men tended their sheep and cattle grazing on the lush, green grass. No fences or borders exist, except those extended by men with canes and ever-watchful eyes. Soon, grass huts appeared, with little to adorn them or signify life nearby. I imagined that the same people tending the herds lived in these small, round huts, but I have no confirmation.

Shortly, the rural life began to intertwine with modern life, as the livestock grazed along the roads infrequently traversed by fueled automobiles. Although vehicles existed, it seemed as though most people of Gondar walk from place to place as they generally carried walking sticks to seemingly help them traverse the hills and sometimes rugged roadside.

As automobiles increased in frequency, so too did people. More people waited, as opposed to actively walked, alongside the road. They waited for one of the minivans or the three-wheeled motorized carts that would transport them to their location. Our bus continued to pass slower vehicles and be passed by faster ones on the hills, seemingly never concerned about the side of the road on which one drives.

A woman preparing grain on the roadside.

I was dropped off at my hotel, located across the street from the Vision Care Training Center and Fistula Clinic, where I lecture to six Master’s students about pediatrics and specialty contact lenses. The electricity only went out for 5 minutes during the morning lecture, so we were able to use technology to project PowerPoint slides on the wall. However, the projector was very touchy.

So, I have witnessed everything from farmers to exceedingly bright, enthusiastic students, and every bit of the evolution connecting the two, and all of this within the small boundaries of Gondar, Ethiopia.