Impressions and Images of Ethiopia

I have been back in Canada for six weeks now and am still processing my thoughts and impressions of the country. I am very thankful for the opportunity to visit such a complex, interesting and beautiful country.

Food is always an important part of a cultural experience. In Illubabor zone, we ate country food exclusively. My favorite meal of the day was breakfast and the dish called 'fool', a mildly spiced bean stew served with chopped onions. Special fool included scrambled eggs and sometimes a dollop of fresh yogurt - yum! Breakfast was accompanied by small fresh loaves of bread, which we used as our utensils.



The rest of the day's menu focused on meat - mostly sheep or goat with the occasional cattle. While we were in Bedele, we lunched at a restaurant that specialized in "kitfo', a finely chopped or ground dish often served almost raw. I always insisted that mine be roasted. Kitfo was certainly tasty when eaten with berbere spice and a welcome change from 'tibbs', the often chewy strips of meat fried or cooked over small charcoal burners.



I was always happy to go for lunch on Wednesday and Friday - fasting days in the Orthodox religion. Fasting food included a selection of dishes such as yellow peas or lentils, a stew of potatoes and cabbage, shiro and sometimes coleslaw. Except for breakfast, meals are served on injera, the flat bread made of the grain 'teff' which is unique to Ethiopia. Food is eaten by tearing off strips of injera to use as utensils. Needless to say, hand hygiene is very important and restaurants always provided water for hand washing before and after dining. I usually had my handy bottle of hand sanitizer as a backup!

Did I mention that Ethiopia has the best coffee I have ever tasted? Every day started with macchiato, coffee with milk and if we had the opportunity, we would 'take' coffee in a local village, often locally grown, freshly roasted and hand ground. Delicious! The local tea was always very flavourful.

One of the most memorable days was a hike into the Sor Waterfall near Mettu. Even though it was the rainy season, we heard that it was possible, if a bit muddy. We arrived at the end of the road in the middle of a downpour but decided to persist. To call it muddy was an understatement - it was a wet, slippery and our shoes and pant legs were soon covered in red mud.





We were assisted with four guides - two teenagers from the local village and two local guides, a young boy and a young man who found us walking sticks and provided steadying hands when we found ourselves falling over. Our path took us through maize fields, along a goat track, and surrounded by wild wonderfully fragrant and verdant coffee forests.

Imagine my surprise when we emerged above the waterfall to see an amazing scene - a party of people celebrating the anniversary of their local workplace with a picnic.

The sheep who were the main meal of the day had walked in themselves but all the other provisions including beverages were carried in by the revelers. We were invited to join the party and soon served very freshly cooked sheep and honey wine. The sun shone and a great time was had by all.

Final thoughts
* the health workers are providing amazing services in challenging circumstances
* the people in the countryside work so hard to survive and feed their families
* many young people and people within the health sector have a vision for a healthier and productive Ethiopia

My thanks to everyone who supported me through this mission - Canadian Public Health Association, Canadian Field Epidemiology Program, CDC Atlanta staff and the colleagues at World Health Organization in Addis Ababa. Thanks also to Tammy, my friend and colleague who was always there when I needed professional advice, personal support or funtimes in Addis! And of course, the support and understanding from family and friends at home.

Illubabor Part II - Bedele

We accessed the northeastern part of Illubabor Zone from the small market town of Bedele, home of the Bedele Brewery Company and major employer in the area. The Brewery also runs a small guesthouse and we were delighted to be accommodated there during our visit to the area.



Bedele town has a remarkable population of goats who seem to enjoy chewing 'chat' as much as some of the residents.



One unique area is called the 'desert' which is reached by a long drive down onto into the valley. This area is without trees and drier than the nearly highlands but also supports the growing of rice as well as maize. The village of Kolosir is a settlement for families displaced due to famine from drought-stricken areas of Ethiopia. The village has the most interesting backdrop - a straight hill rises from the plain.

The other striking feature of the village was a large tent previously used by the World Food Program for food distribution. Our UN vehicle was the source of great curiousity and my driver, Joseph, spent his time explaining that we were only there to visit the health centre. This new health centre was targeted to be upgraded from a clinic in order to provide more health services including a labour and delivery unit.



I always included a visit to the incinerator or biomedical waste disposal pit as part of my audit. At Kolosir, the path to the disposal pit was through the maize field but we did eventually find it!



And always, there were the children. I was constantly a source of interest and when I spoke to them, it was usually followed by great hilarity because of my accent or mispronounced words of Oromifa or Amharic. In Kolosir as in most villages, there was very little in the way of toys or other sources of entertainment for the children.

A very common sight was of children looking after younger children, such as the young girl to the left, with her younger sibling on her back. The young man on the right outfitted in the Ethiopia gear, had been my guide to the health centre and disposal pit.



My visits to the health centre were usually accompanied by young children who were sometimes camera shy and other times, wanted to be front and centre in the photograph.





In the trip down the valley, we came face to face with another Isuzu truck which provide the main transport on the back roads. They were usually loaded down with people, animals or other products for market and are a very a common sight but I just had to grab a picture as we passed.



On our return trip, we had time to take some pictures of the beautiful scenery. Joseph and Hamza, the Illubabor Zone Communicable Disease Control team leader were posing for a picture when they were joined by several local lads who told us that there were lions in the nearby forests.




In a population of 80 Million, mostly pastoralists (farmers), a striking feature of Ethiopia is that you are never alone. Even when the road seemed empty of people, as soon as we stopped the car to take a picture, people materialized from the fields or forests!

And on to Illubabor - Part 1

I am amazed at Toyota Landcruisers and WHO drivers! Together, we made a formidable team as we visited the beautiful Illubabor Zone on the second part of my mission. Illubabor is high in the western highlands close to the border of South Sudan. I visited all accessible woredas and health centres over a period of four weeks but was unable to get to the most remote sites due to the weather and road conditions.




The rainy season was upon us and the travel in this area was very challenging. Even the Isuzu trucks which are the lifeblood of the villages found the road conditions difficult; their usual cargo included 20 to 30 strong countrymen who were available to pull them out of most difficulties and made transport possible.



Most mornings, we drove through rain and occasional fog to reach the woreda health centres but our return trips in the afternoon were often in sunshine. This is lovely green equatorial rainforest with waterfalls, monkeys and fields of maize. The maize crop was being harvested and I had the opportunity to sample local maize roasted over small charcoal fires at the side of the road. Tasty if a bit chewy and in an area where the usual diet was largely carnivore, a welcome addition to the diet.



Illubabor region is quite diverse and because of the road conditions and distances, we split our time between Mettu and Bedele. Mettu is the larger market town with trade in local foods and wood products, a hospital and large teacher's college. The town has been blessed with significant support from Menschen fur Menschen, a German/Austrian foundation that built the hospital and some local health facilities, installed water systems in nearby villages and runs a wonderful local children's home. We had the great pleasure of spending some time with the children and staff who are their 'families'. My visits with them are one of the highlight of my time in Ethiopia - a happy and hopeful place to call home.



To the west of Mettu, we drove past a tea plantation and we able to purchase organic fragrant tea from the side of the road. Now I know that while coffee is grown in the shade, tea is grown in full sun.


My days consisted of conducting active case search and assessing immunization programs at health centres. During most of my visits, we took time to 'sensitize' the health centre staff on surveillance for AFP, measles and neonatal tetanus. Many newly trained health extension workers who will work in the villages were being oriented so I was delighted to be able to include them in my short presentations. As always, I continue to be impressed with health workers dedication to public health.

Training in Jimma Hospital

At the end of a training session with almost all of the nurses from Jimma Specialized Hospital, Dr. Tesfaye, the WHO Surveillance Officer who co-facilitated the session took this fun picture. The students were very intent while I talked but had no questions for me. When Dr. Tesfaye spoke in Amharic, they had many questions and a lively discussion. It was a good collaboration, however, because they enjoyed the slides!

Jimma Town

Jimma town has river gardens with a muddy red river running through it as well as a bustling market area and palace. It also has a stadium which is used for big church services and concerts.



Jimma has two universities, one with a medical faculty and teaching hospital and a large agricultural college. The Agriculture college has a partnership with Truro College in Nova Scotia. I met two Canadian students from Nova Scotia who were working in the animal clinic and doing some associated research. They were having a great time and didn't want to leave.

This little girl just wanted her picture taken by the farengi which made a nice change from the more usual "you you you"!


Jimma is full of ambitious young people, several of whom were interested in speaking to me to practice their English and also to ask for my perspectives on career and other opportunities. I spent a few hours with two bright young natural resources students discussing agricultural practice, land issues and the potential for ecotourism in Ethiopia. I found one of their comments quite interesting; because the country is not industrialized, their aquifers have been protected from pollutants. If these two students are given opportunities to contribute, Ethiopia will benefit immensely.

And of course, I also had another not-so-good Jimma moment when two young men stole my locket off my neck. I was walking just on the outskirts of town on a Sunday afternoon and these two young men began to talk to me. I dropped my guard for a few minutes and after dropping behind me, one ran up and snatched my necklace off my neck. The police did a great job of investigating and brought two suspects into the station for me to identify but in both cases, I wasn't 100% positive and didn't want to send the wrong people to jail. Anyway, I am unharmed and will be much more cautious about walking on my own in the future.

Jimma moments

There were many special moments in the past 5 weeks in the field, in and around Jimma zone.

This picture is my favorite so far, a young girl who served us macciato (coffee with milk) in her little family cafe outside of the Setema Health Centre. It was lunch time and we were waiting for staff to return so spent some time with her. She told us she was in Grade 7 but looked older than 12 years to me. I showed her pictures of Nova Scotia from the few postcards I brought with me. Most people in Jimma haven't seen an ocean so she was amazed at the picture of Lunenburg. Three other young fellows joined us and seemed happy just to be part of the conversation.


The next one is of Mohammed, one of the zone surveillance officers and Kinfe, my WHO driver. We had a long drive up into the hills that day to visit two woredas (health units) and their health centres. This picture was taken at the edge of a deep, very green valley inhabited by tigers and monkeys with a stream running through it. The picture doesn't capture the scene very well but it made us want to grab my tent and hike down for a weekend in the forest.



And lastly, yes, I did do some work, not just drink coffee and soak up the scenery. I 'sensitized' over 40 of the Jimma town health centre staff about AFP, measles and NNT. I spoke in English, using my CDC flipcharts and a powerpoint without projector (no LCD that day) thanks for my CFEP computer. Kade, the town focal person, then translated into Amharic and added his own extra comments. During the session, we discovered one suspect AFP case had been seen earlier in the week so sensitization works!

Back from Jimma - Mid mission

After 5 weeks in the the western highlands, I am back in Addis Ababa for a week of reports and meetings. We will be heading back out to the field on the weekend for our final four weeks of surveillance for acute flaccid paralysis (polio eradication), measles and neonatal tetanus. We are also working with local health districts and their staff to improve their awareness of the diseases under surveillance, vaccination practices and vaccine safety issues.

As to the pictures, in the top one, the woreda head and focal persons were holding a meeting with the health extension worker and kabele leaders on the side of the road in order to locate a potential AFP case. As they talked, everyone who was in the vicinity joined in on the meeting. We didn't find the case that day but they were able to locate the child later that week. In the second picture, Mohammed, the zone Surveillance Officer is showing me the way to the health post...across several logs. A crowd of small boys gathered to watch me negotiate the logs and thankfully, I got across without incident. In the third picture, the local community had gathered for routine immunizations and it turned into quite a social occasion.

As mentioned in the earlier post, the WHO office has a wireless connection which provides access to the blog. I will post more later this week.