A New Frontier, Palliative Care in Ethiopia
By Matthew J. Borgo
From February 23 through March 1, 2014, I had an experience which I will not soon forget. I had the great fortune of being able to travel to Addis Ababa, Ethiopia, spend time with the Gynecology/Obstetrics/Oncology team at Zewditu Memorial Hospital, and attend the 50th Annual Meeting of the Ethiopian Medical Association (EMA) in Addis Ababa, Ethiopia. The theme of this anniversary meeting was Medical Tourism and Healthcare and over one thousand health professionals were in attendance.
Ethiopia is a country of many different ethnic groups. With a population estimated at almost 97 million, it is the 14th most populous country in the world. Life expectancy is currently 60.7 years with 0.03 physicians per 1000 people. Given the significant shortage of medical doctors in the country, it can take weeks to months to see a physician, especially when seeking specialty care. Ethiopia continues to strive to make further improvements in the healthcare system and they have been gaining ground. In 2012, Ethiopia opened 13 new medical schools, which more than doubled the number that were previously in the country. Existing schools are also taking more and more students to try to help meet the need within the country. Over 3,100 students enrolled in 2012 (approximately 10 times the number who enrolled 5 or 6 years ago). This has led to stretching of the already limited resources, including instructors. Another major challenge is that doctors from Ethiopia often travel to other countries after completion of their studies for higher-paying jobs overseas. Also, doctors tend to stay in the cities, making it common for people in rural areas to never see a doctor during their life.
A poor neighborhood in Addis Ababa a few blocks from Zewditu Memorial Hospital, Part 1.
After sleeping off over 30 hours of travel, I embarked upon my adventure in Ethiopia. My first 2 days in the country were spent with Dr. Hezkiel Petros, who works at Zewditu Memorial Hospital in Addis Ababa. He works at the hospital in the division of Obstetrics and Gynecology with a number of other doctors. He spends his days seeing patients in the clinic; doing check-ups with pregnant patients; being present for deliveries and C-sections; performing surgeries for patients with a multitude of problems, including cancer; and prescribing chemotherapy when needed.
A poor neighborhood in Addis Ababa a few blocks from Zewditu Memorial Hospital, Part 2.
He picked me up in his Toyota Corolla on the morning of February 24th, not sure what the day would bring. The hospital has been used by many thousands of patients since it opened. We were greeted by a sea of people waiting their turn to see a medical doctor with their accompanying family in tow. We went up to the GYN/OB unit and rounded on at least 35-40 patients. As we entered the small rooms filled with 4-10 patients and their families, anyone who was not a patient left immediately. Patient and family centered rounds seemed to be a foreign notion. Patients had wide ranging issues that brought them to the hospital: women recovering from C-section or delivery, patients with 20-30 kg tumors in their abdomen and pelvic region both pre and post op, individuals receiving chemotherapy, and septic patients.
Zewditu Memorial Hospital Entrance.
The image of a 24 year old woman was imprinted upon my mind. A previously vibrant woman coming in for issues related to her pregnancy. She had unfortunately developed a molar pregnancy and while receiving treatment for this issue, suddenly become hemiplegic on her left side and completely lost the ability to communicate. She was there for 5 days with no improvement.
Hospital hallway on OB-GYN ward, Addis Ababa, Ethiopia.
In talking with Dr. Petros, he wishes for other ways of helping these patients. Palliative care is only something you may hear mentioned, but never really see in his experience. With so many other public health issues and a doctor shortage in the country, priorities have been placed on other initiatives at this time. Dr. Petros has taken on the challenge of learning about palliative care. Along with some of the other staff and nurses at Zewditu, they are striving to improve the care of patients facing serious and life limiting illness.
On my second day at Zewditu, I had the honor of giving a lecture discussing what is palliative care and then discussing pain management. I was greeted in the room by high-ranking individuals from Zewditu Hospital, members of the OB/GYN staff and residents, as well as a few residents from other specialties. The room itself was completely full, with many others standing around the sides of the room. The concept of palliative care seemed to be well received, but I was left with questions on the best way to begin implementation in the setting of limited resources and immense need.
Coffee with some of the attending physicians, including Dr. Petros.
In terms of pain management, opioids are difficult to find and there is great concern regarding their use. The largest hospital in the capital, Black Lion Hospital, has a supply, but many providers do not feel comfortable using this type of medication. Many individuals post-surgery—or those dealing with severe cancer pain—are using medications such as diclofenac and acetaminophen, as other options are simply not available. The thought of a fentanyl patch or other more advanced ways to treat pain are completely alien. I suppose I felt just as alien being in this very different world compared to being within the walls of the Mayo Clinic.
With great need comes great responsibility. To be successful in such a place, education will need to play a large role. As the country begins to graduate doctors at a record setting pace, the make-up of the Ethiopian Health System will change rapidly. As these doctors spread around the country, many patients who would have never left their village may be referred to the capital for further medical care. The needs and symptoms of these patients will be substantial. Thus, I think palliative care is an integral part of the solution.
Matthew J. Borgo, MD is an Emergency Medicine Physician, currently enrolled in the Hospice and Palliative Care Fellowship at Mayo Clinic. He was born and raised in Lake Geneva, Wisconsin.
Acknowledgement: I was under the mentorship of Dr. Judith S. Kaur (Division of Medical Oncology, Mayo Clinic) for this trip. Additionally, I am in debt to Dr. Kaur and Dr. Hezkiel Petros for their generous time and effort in helping to make this life changing trip happen. Thanks to Andrew M. Harrison for helpful edits.
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Dear Dr. Matthew J. Borgo
Greetings. It is with interest that I read your article on Ethiopia. Thank you. I have been a long time advocate of palliative care and pain management in Ethiopia and yes the challenges are tremendous ... but the commitment to this issue is also increasing especially at the policy level. There is a struggling national palliative care association all volunteer-based screaming to he heard. We have to date only 4 national PC professionals (2 of them senior oncologists trained in accredited institutions abroad, South Africa and India. Ethiopia has also managed to domestically manufacture quality assured oral morphine solution Ethio-Morph. I suggest that you access a NL Special Issue on palliative Care & Pain Relief on Ethiopia. Thanks again for highlighting the issue, too many are in PAIN! If there is anyway you can support this effort please free to contact me at e mail nardimoon@yahoo.com.
God Bless