A birth tragedy in Ethiopia with a moment of grace

African father holding his little sons hands.

The young couple had been married for a year. Their families had met and had shemaglis (agreements between elders of the families) for a year before the ceremony in the mountains of Northern Ethiopia. The young mother to be was very poor and lived in remote area hours from any clinic so there was no pregnancy planning or prenatal care. She presented to the hospital in early labor. A few hours later Neurosurgery was called.

The little boy had a beautiful face, arms, and legs but had a large defect in the back of the head. A naked imperfectly formed brain was exposed without skull or skin to cover it. Despite this the child was opening his eyes, weakly crying, and moving his tiny fingers.

Nurse relatives had brought the child to the operating room emergently hoping there was something I could do. The mother was recovering from a C-section done for fetal distress and was I was told in emotional shock. The father stood 3 feet away from the baby on the stretcher with a look of unbearable terror on his face.

This unfortunately was not the first time I had seen an anencephalic newborn. Many of them are actually stillborn. There was no heroic surgery I could do. The child would not feed and was doomed to die within a short time. The easiest thing to do sometimes for a neurosurgeon is to briefly say there is nothing we can do and walk away. Taking on the full emotional load here is a broadside that is tough to absorb.

However, I felt compelled by the look on the father’s face to remain but what could I do? Through an interpreter I explained the birth defect and prognosis. That with the next baby the mother should take folic acid daily three months before getting pregnant. Throughout this time the father kept his distance from the child looking at it like it was cursed. Frequently here they belief in buda which is that such babies are caused by curses invoked by some wrong doing.

I was watching the little hand of the baby moving as if it was searching for something. Something came over me, I like to think it was the Holy Spirit, and I reached out to take the father’s hand and pulled him close to the child. He was afraid and moderately resisted. Then I put the child’s hand into the father’s and hand gently causing him to grasp it.

The baby grew quiet and calm. The father’s look of horror turned to a sort of determination and love. He held that baby’s hand and then picked up the baby for a couple of hours until God called the child. Even though his son’s life was short the father had shared something irreplaceable and special in this tragedy. I learned the human experience is something we must not take for granted and valuable if only for a moment. That we thank God for every moment of Grace He gives us.

The Path to Becoming a Neurosurgeon in Ethiopia

Neurosurgical fellow and resident repair an injured nerve in the arm of a man injured at work

The path to becoming a neurosurgeon in the developing country of Ethiopia  begins in primary education and progresses through a gauntlet of achievement challenges through early adulthood.  Ayder Comprehensive Specialized Hospital, the teaching hospital for Mekelle University,  is currently training 16 neurosurgeons for Ethiopia and surrounding countries.

As children they often grew up in a multi-generational house without electricity or running water. Time to travel to and from school everyday is measured not in minutes but in hours. Before and after school they have to help maintain the house and family income such as caring for livestock, farming, or doing labor.

When they go to primary school they initially speak the first language they learned from their family (Tigrinya, Oromifya, Sedamo, Afar, Grogi, etc.) but must then learn Amharic and English progressively in elementary and secondary school. If they are lucky enough to have a television set watching it can give an advantage to learning English. To get a chance at college they must show significant reading and writing skills in the three languages by the 10th grade.

At the end of their 12th year of secondary school they have to take a national competitive exam. Science and most studies in university are taught in English so competence is mandatory. The top scorers get a chance to attend medical school for a little over 2000 places currently.

For six years in medical school they are apart from their families for the first time. Living in crowded concrete dormitories with frequent water and electricity shortages, bedbugs, and a monotonous diet of little else but shir0 with enjera  are common experiences. The last year of medical school they function as an intern which is really on the job experience that is very demanding in terms of hours and responsibility.

To get into a residency program to become a specialist requires getting a sponsor, usually a university or regional health bureau, and then competing for the few hundred slots by interview, grade record, and more testing. For example in Neurosurgery last year there were 21 slots only for the whole country. If they get into specialty training, the pay is poor,  less than a hundred dollars a month and they have to find some kind of housing. Usually they end up renting a room in a house for sixty dollars a month. They will work 12+ hours a day and have to spend the night in the hospital about every third or fourth day working all night to care for patients. The training program lasts five years with one month of vacation per year.

The modern concept of physician training is that it is a triad of knowledge (basic science and clinical medicine), skill (examining patients, interpreting diagnostic tests, surgical skills, etc.), and professionalism. In the first year of training they have to learn how to care for trauma patients and critically ill patients. During this year they have to master the basic skills of general surgery before they can formally begin neurosurgery.

From the second year through the fifth year they have to learn the equivalent of a PhD in neuroscience, be able to save a critically ill patient, finely interpret magnetic resonance imaging and CT scans, master fine technical skills with eye hand coordination greater than the finest musicians, and demonstrate capable leadership skills to lead medical teams to save lives. They need to read about and comprehend about 500 to 800 pages of books and journals every three to four weeks.

Around the world, the British model of training surgeons has been adapted which is what we call competency based. Neurosurgical residents progress from watching how patients are cared for and undergoing surgery at first and then progressing to less and less supervision. Every day they are constantly challenged by not only the diseases they are treating but by a strong Socratic method of teaching requiring them to always explain and justify their every decision and action. Gradually they reach a point where they function with distant supervision which is the real measure of their capability. By the end of their training which has averaged evaluating a hundred or more patients in a week and participating in surgery on about 5 to 7 per week such that they have seen thousands of patients and participated in thousands of surgeries they will be competent neurosurgeons.

Polio ravaged New York in 1916

A nurse attends a child with polio suffering respiratory failure in an iron lung in 1954

Almost 100 years ago before the living memory of most Americans another virus called polio ravaged the country. Tens of thousands died or were left with permanent paralysis from polio. New York City suffered the worst epidemic in history in 1916. It was known that a virus caused the illness but nothing else.

At this time in history there were only two scientifically based medical schools in the United States, Harvard and John Hopkins, so that most physicians practiced medicine based upon apprenticeship and anecdotal evidence. The model we use today of understanding the mechanism of disease and testing treatment in tightly controlled studies which are evaluated by experts before reporting did not exist.

Superstition and rumor ruled the day. Many unproven treatments where not only ineffective but also caused great harm. Some of the unproven treatments including giving quinine an antimalarial drug which killed 27 out of 33 children, giving poisons, doing lumbar punctures serially, and blood transfusion of human blood and horse serum .Despite these measures the mortality rate reached 25% of the thousands affected.

The March of Dimes, a foundation to raise money for research, was developed in part due to the story of President FD Roosevelt. This funding allowed science to develop effective answers.

Dr. Salk and Dr. Sabin were both able to come up with effective vaccines in the 1950s which changed the world. There was a problem in 1955 when 200,000 children received an inactive form of vaccine leading to episode referred to as the Cutter Incident. This did create the beginning of mistrust of vaccines. The United States Federal government and international governments and agencies worked together to create standards and make vaccines available worldwide keeping the risks of complications low which conquered this threat as long as vaccination continues.

Hydroxychloroquine COVID 19: Misleading poor scientific diligence leads to questions

Failure of researchers to adequately perform their research, of reviewers to scrutinize the research before publication, and of government experts to examine the research in detail facilitates its exploitation for fame and political gain.

On March 20, 2020 Raoult et al in a preprint report in the Journal of Antimicrobial Agents (meaning it had not undergone the usual rigorous scientific review by multiple peer scientists) stated that in small number of patients that was not randomized or case controlled (26 initially but only 20 completed the study) treated with hydroxychloroquine and azithromycin over a 6 day period had a reduction in the virus in that the viral DNA was absent. This set off a fire storm of controversy which remains ongoing.

The normal routine for a scientific publication is for it to be reviewed by at least three independent recognized experts who have no links or interests to the authors or any products used. Under the best of circumstances this can take weeks and often takes several months. The pre-publication of this study which started on March 6, 2020 definitely did not allow a adequate analysis. One of the authors sits on the editorial board of the Journal which creates a real conflict of interest. The report was published without the inclusion of any raw data which is unusual in pre-print publications. Now the International Society for Antimicrobial Chemotherapy yesterday sent out a statement that the editor of the Journal should have recused himself and that scientific scrutiny and best practices should not be sacrificed.

An extensive analysis has been done by Elizabeth Bik and others over the past several weeks which finds many problems. The society which oversees the Journal now says it has significant problems with its validity. Although the study was approved by French authorities to extend 14 days there is only a 7 day report. Four of the patients treated who did not improve were not included in the study. The report of virus presence was only done on Day 6 and not on Day 7 or Day 14 as was approved by the French supervising body. Normally the treated and untreated groups should have similarities in demographic factors, history, findings, etc. but this is not present in this study. There are another 6 six patients whose reason for not completing the study remains a mystery. Finally the measure of success evaluated was in the volume of DNA indicating viral load not clinical improvement so the relevance of the study to clinical utility and outcome is unknown. So far 8 of the world’s prominent scientists in this field have raised major questions on it’s validity.

But this is only the beginning of the dilemma. Certainly because there is worldwide crisis, scientists and government leaders are eager to find treatments. However, one has to wonder to what extent those in government scientific positions really evaluated this paper. Did they really understand it well enough to know how weak it really was? Was it enough to say it was “anecdotal” or was that giving it too much credit. Then you add on Dr. Oz, the highly discredited TV doctor who has had at least 8 false claims made discovered by respected authorities and an avid Trump supporter pushing the benefits of this unproven regimen like it is the fountain of youth.

Unfortunately the lack of adequate review by the scientific publication and lack of review of it’s weaknesses which gave it more credibility that it was worth serves to give Trump and his supporters some cover. Remember he says “I am not a doctor”. Now we have a situation where millions of dollars will be spent and lives potentially put a risk because scientists and journals seeking rapid publicity were aided by superficial review of government scientists which all served the political self interest of a President who could care less about truth.

Let us hope that the necessary scientific scrutiny of this and any other potential treatments will from now on receive the rightful and intense evaluations that is absolutely essential for the public welfare.

Neurosurgeon’s Day-Our Connection to the Harvey Cushing Legacy

 

Harvey Cushing-Founder and Innovator of Modern Neurosurgery

Very few times in the history of medicine has one man so dominated the development of a specialty that his birthday is celebrated as the day to recognize the field but that is case in Neurosurgery. The legacy of Harvey Cushing connects Ethiopian neurosurgery to his life’s work. When I entered Harvard Medical School in the Fall of 1977 I knew was interested in the field of neuroscience but I did not at first understand how I had entered into the hallowed historical grounds where Harvey Cushing made so many advances.

Harvard Medical School

Harvey was destined to be a fourth generation physician who began his studies at Harvard Medical School after undergrad at Yale just before the beginning of the 20th century. After graduation in 1895 he and Ernest Codman pioneered physiologically monitoring in anesthesia which dramatically reduced the previous death rates. Subsequently he trained in general surgery at Johns Hopkins under William Halsted, the great pioneer of modern general surgery. Residency training at Hopkins was scientifically driven by William Osler who also mentored Cushing leading him to write a biography of Osler in 1926 which won a Pulitzter prize.

From 1902 to 1937 first at Harvard, then Hopkins, and finally at Yale, Cushing performed over 2000 operations of the brain pioneering surgical techniques for the treatment of brain tumors. He revealed how the physiology of the brain functions in terms of blood pressure and brain perfusion and how the pituitary gland works. Brain surgery went from being a last chance high risk procedure to having the ability to safely save lives through out the world because of his influence and teaching.

Dr. Cushing performing surgery

As a medical student at Harvard I  saw patients on the grounds where Cushing lectured and went to operating room where Dr. Cushing performed brain surgery. I was fascinated and inspired by the life of Dr. Cushing and this experience in my early years led to my doing a special training in neuroscience as a medical student and then to train in neurosurgery after graduation.Later as resident in Neurosurgery at the University of Miami, Dr. Larry Page, who was trained at Harvard and the  Boston Children’s Hospital by neurosurgeons who trained under Cushing , was our main brain tumor training surgeon.

Six years ago I started the Neurosurgery program at Ayder Comprehensive Specialized Hospital-Mekelle University in Ethiopia where today we perform over 1000 operations a year. We currently are training 16 neurosurgeons for different regions in Ethiopia as well as Somaliland and Somalia. Following Cushing’s model of a neurosurgeon who cares about the world and his patients and uses the scientific model of research to improve life, we have created a multidisciplinary research team which has made significant discoveries in the epidemic of neural tube defects in Ethiopia. Our research led to the government studying a novel prevention program of fortifying salt with folic acid.

 

Professor Tony Magana performing surgery at Ayder Comprehensive Specialized Hospital-Mekelle University, Ethiopia

Happy Birthday to Harvey Cushing  you changed the world and helped inspire a kid from a small town in Texas to follow your example.

 

COVID 19 To Bring a Medical Ethics Crisis to Ethiopia

The probable impending crisis of COVID 19 in the medical resource poor country of Ethiopia will likely bring controversies in medical ethics decision making. When we see New York city hospitals pilling hundreds of bodies in refrigerated trucks and having severe shortages of nurses, doctors, and ventilators in the setting of the one of the world’s richest countries what does that predict for Ethiopia. If and when the crisis hits fully we know there will be shortages. Ethiopia spends about $28 per capita yearly on healthcare while the United States spends more than $10,000 per capita yearly.

Yet although the Ministry of Health mandates that each health care facility maintain and review medical ethics standards very few do. Additionally the few documents, such as the Ethiopian Medical Association guidebook on Medical Ethics, and proclamations of the Federal government deal mostly with very general cases of proper behavior.

Real issues such as how patients will be triaged (who gets the ventilator and who does not), should a patient who is “hopeless” be removed with family consent to help someone with a better chance, brain death, etc. remain unclear.

Ethiopia has strong religious convictions in the Orthodox, Muslim, and Protestant communities. How medical ethics questions and distribution of resources are decided will have to take in account the religious and cultural traditions that are unique to Ethiopia. It is better to start these discussions now with community leaders, religious leaders, and academics then rush to make them in the heat of an epidemic.

Donations to benefit the Tigray Regional Health Bureau via the Global Society of Tigray Scholar may be given as below.

Coronavirus: A Unique Dilemma for Ethiopia

 

Ethiopia is facing a potential unprecedented crisis from coronavirus and how she responds is complicated by factors in her culture, traditions, geography, economics, and history.

In 1963, I was an elementary school child living in the Rio Grande Valley of South Texas when I first learned about hurricanes. My father, a neurologist-psychiatrist, told us that a bad storm was coming. We had to take precautions and ride it out. This was perhaps the first time in my life I had to deal with uncertainty. Although my father looked confident I could sense that we could not know exactly what the future could bring. Hurricane Beulah hit with high winds and much rain destroying much of our town. I thought the howling winds would never end.

Now more than 50 years later I am in Ethiopia facing another type of storm. We have seen the storm form in China, attack Europe, and now with a few cases in Ethiopia it is knocking at our door. Ethiopia where I have lived since 2012 has had her share of calamity. She is an ancient civilization extending perhaps more than 10,000 years before the birth of Christ. Over the past century she has seen multiple attempts at foreign invasion, famine, and civil war. Yet her traditions and strong sense of spirituality tied to organized religion have always seen her through adversity.

As an academic physician and member of the medical faculty of Mekelle University I am very concerned and once again feeling that same sense of uncertainty I did so long ago.  How will she face this new dilemma?

The Risk of Epidemic in Ethiopia
Moritz Kraemer, epidemiologist from Oxford University, has identified Ethiopia as one of the countries in Africa most at risk based upon an exhaustive analysis of asset the country possesses or not. Now that Ethiopia has several cases documented in Addis Ababa, what are the risk for spread? Adam Kucharski and his group from the London School of Tropical Health and Hygiene predict from a pre-printed study that when a country like Ethiopia has at least 3 confirmed cases there is 50% chance for the infection to become endemic and spread.

The Effect of Culture,Economics, and Geography
Africa accounts for 16% of the world population but only 1% of health care expenditures. With a 100 million population Ethiopia is the most rural country on the globe with 88% living in the countryside. Many families have incomes less than the equivalent of $20 per month. It may take hours to a day or so to seek medical treatment in a poorly equipped countryside clinic. There is little public health education with 75% of the women and 45% of the men being illiterate. There are few hospital beds (0.3/1000) population, few doctors, and limited diagnostic facilities.

Most Ethiopians do not travel outside the country but Addis Ababa, the capital, is one of the busiest airports and hub of Ethiopian Airlines which has daily flights from around the world including China and Europe. There is little doubt that this was the vector which introduced coronavirus to the country.

Ethiopians are a “touchy feely” culture like the Italians who are so troubled now. While there is little in the way of a government social safety net the people typically depend upon long standing bonds with extended family for emotional and financial support through hardship. Community interdependence is the rule. It is not unusual for people hospitalized to have many visitors and always also to have attendants (family or friend) stay the night helping to care for a patient. Trying to impose social isolation or even just social distancing will be difficult if not impossible.

The economic principle of scarcity, meaning that great value may be placed on resources which are scarce, is strong in Ethiopia. When going to the bank, airport, market, and clinic they frequently are a bit pushy because of a fear that what they are there for while run out before they get their chance. This is no doubt a left over from the Imperial and Derg times leading to distrust of authoritative promise.

When one sees the vastness of Ethiopia, about the size of Texas, and difficulty with transportation, an initial impression is that perhaps the virus will stay only in Addis Ababa. Unfortunately, that lesson was answered years ago when the HIV epidemic started with just a few truck drivers delivering goods throughout Ethiopia.

Typically when Ethiopians who are Orthodox are sick, they will often seek spiritual healing through church services, blessings, and consumption of Holy Water.  In fact, every month I have patients with curable brain tumors who presented late only after pursuing this spiritual method.

Many regions of the country have no reserve to deal with pandemics. For example the Tigray Regional Health Bureau only has a budget of 500,000 birr ($15,000 USD) to deal with a potential coronavirus epidemic. The cost of a single coronavirus is test is currently $ 500 USD. The government must try to seek payment from the patient as it cannot sustain doing testing without it. 

There are not more than 200 functioning ICU beds with ventilators in Ethiopia. The experience in China, Japan, South Korea, and Europe have shown that if 50% of the population becomes ill, out of that about 20% will require hospitalization, and maybe 10% will need ventilator support. Unfortunately there is no way they will be able to treat 5,000 patients on ventilators.

What Will Happen to Hospitals?
Coming out of the Imperial and Derg times when social institutions like hospitals were rare and for the upper castes they are now seen as pillars of society with an implied unobstructed access. The CDC and WHO call for restricted entry to hospitals as well as the segregation of coronavirus patients to alternate facilities could provoke misplaced fears in the population. There will have to be a clear and repeated message explaining the scientific reasoning and how such measure are really best for the population.

Just like when I was a small boy, I cannot know exactly what will happen. I will stay in Ethiopia, the country and her people I have grown to love, and pray she finds her way through this test.

Advances in Subarachnoid Hemorrhage Treatment in Ethiopia

At Mekelle University Department of Neurosurgery-Ayder Comprehensive Specialized Hospital we have been developing an expertise in the treatment of stroke due to rupture of a cerebral blood vessel culminating in a successful clipping of a ruptured aneurysm.

Subarachnoid hemorrhage in Africa and Ethiopia
Stroke in Africa and more specifically in Ethiopia remains an almost taboo subject. It is shrouded in superstitious beliefs of curses and hidden poisons among most of the population who receive little public health education in what schooling they attend. A significant form of stroke is that due to rupture of a cerebral artery which creates the phenomena of subarachnoid hemorrhage. It is estimated that worldwide 9 in 100,000 years of human life or 1 in 50 people will suffer a subarachnoid hemorrhage.

Although rupture of a brain artery causing subarachnoid hemorrhage may lead to sudden death there are many patients who if given advanced treatment can be saved and return to functional lives. To receive this treatment requires special trained medical centers with experts in emergency medicine, neurology, radiology, anesthesiology, and neurosurgery. Up to now these centers have been lacking in most of Africa.

How subarachnoid hemorrhage causes damage
When a brain artery ruptures it may cause severe pressure on the brain which can kill or permanently disable. This type of large clot is unusual in most patients. Instead what happens is that the blood causes surrounding blood vessels to defensively constrict limiting the blood supply to the brain. This pathological process is vasospasm. Additionally the blood leakage can lead to chemical abnormalities of sodium or the mal-absorption of a fluid called cerebrospinal fluid which normal is produced and absorbed in a balanced way. Once a blood vessel ruptures once it will likely rupture again as each day goes by, a ticking time bomb.

Treatment of subarachnoid hemorrhage and ruptured cerebral aneurysms
Successful treatment of ruptured cerebral artery aneurysms requires rapidly making the diagnosis and beginning aggressive resuscitation of vasospasm and electrolyte abnormalities. The blood pressure must be closely controlled and the patients respiratory system supported. Upon stabilization the patient should undergo timely surgery or intravascular treatment to reduce the incidence of a second deadly rebleed. Whether microsurgery or intravascular treatment is better remains controversial.

A representative case at Ayder Comprehensive Specialized Hospital 
The following case is an example. A 55 year old Ethiopian grandmother suddenly complains of the worst headache of her life and goes into a coma. She is brought to Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia on the Mekelle University medical campus. Emergency physicians and internal medicine specialists stabilize her condition and perform a CT Scan which shows subarachnoid hemorrhage and suspician of a ruptured anterior communicating artery aneurysm.

 

A CT angiogram shows an anterior cerebral artery aneurysm

The patient is comatose with electrolyte abnormalities and out of control high blood pressure. She is admitted to the medical intensive care unit where she receives supplemental oxygen, high doses of fluids to correct hyponatremia and try to overcome the vasospasm, as well as a special medication, nimodipine, which can help to counteract vasospasm.

After 2 weeks she regains consciousness and a repeat CT angiogram ( a special CT scan which shows the arteries of the brain in detail ) is done which now clearly shows a 5mm aneurysm. Now that she is stable surgery must be done soon before a fatal rebleed can occur.

A large ballon is seen coming from a normal blood vessel which gets larger and thinner with time eventually rupturing

She is taken to the operating room with a specially trained anesthesia team which finely controls her blood pressure during surgery. An opening is made in the front and side of the skull while under general anesthesia and carefully working under the brain the ruptured blood vessel is exposed and clipped to prevent rebleeding.

Skull xray shows a clip has been placed closing the rupture aneurysm
The large aneurysm has been clipped while preserving the normal flow of blood to the brain

 

 

The Growing Infant Meningitis Crisis in Ethiopia

 

MRI of infant with meningits
Infant with meningitis seen on MRI to have hydrocephalus and meningeal enhancement

Ethiopia is facing a growing crisis in infant meningitis compounded by a false reliance on the power of antibiotics to treat the problem without definitive diagnosis and follow up.

A growing problem
As you may know north eastern Africa including Ethiopia is part of the so-called “meningitis belt” with the highest rates of bacterial meningitis in the world. Just a couple a months ago I was attending a meeting with Ministry of Health with the new five pediatric neurosurgery centers of excellence in Ethiopia where a new growing epidemic of chronic meningitis seen throughout the country was discussed. Over the past year we are seeing more and more cases of infants on an almost daily basis presenting with progressive hydrocephalus who have diagnostic cerebrospinal fluid consistent with chronic meningitis. Our average census is 5 to 8 in hospital all the time whereas a few years ago it was only one or two. Many of these children have hospitalizations of 12 weeks or more. Many have died and many are left with significant cerebral disability which could have been prevented by earlier intervention and appropriate treatment lengths.

Systemic deficiencies
While this epidemic seems to be worsening, Dr. Abreha (Head of Pediatrics and Pediatric Neurologist at Mekelle University) and myself are concerned that deficiencies in facilities and procedures within the medical system may be contributing to it. Unfortunately throughout Ethiopia almost no lumbar punctures are now done to diagnose meningitis. A sample inquiry of pediatric residents and interns found that 75% of them had never done a lumbar puncture. Additionally many clinics and hospitals do not even have lumbar puncture trays. A false sense of security exists that powerful antibiotics given a short period time can will solve the problem

Secondly, the lack of ability to process or even receive an CSF specimen for analysis beyond 5 PM forces the treating physicians to start treatment without first obtaining a culture which is against world wide standard of culture first then start treatment. This seems very contrarian to the frequent theme of the pharmacy and laboratory professionals in Ethiopia that there is abuse of antibiotics.

A key analysis is determining the glucose, protein, and cell count in cerebrospinal fluid. Dr. Abreha recently gave a sample of tap water to the laboratory to be tested on the automated machine and it diagnosed multiple WBC consistent with meningitis. The equipment supplied to Ethiopian hospital is not capable of accurate diagnosis. Technicians can do manual counts but these are time consuming and labor intensive. This inaccuracy has greatly impaired our ability to determine if patients are infection free which they must be before they can undergo definitive treatment for hydrocephalus which is a ventriculoperitoneal shunt.

Thirdly, around the world there is much controversy about for how long antibiotic treatment should be given ranging from 10 days to 21 days. The problem is that partially treated meningitis patients who have not been cleared from the infection often do not have fever, meningeal signs, or other clinical findings except hydrocephalus. Many infants are briefly seen for nonspecific fever and receive short courses of antibiotics in Ethiopia without specific diagnosis being made and without adequate follow up. Many of these children we believe are harboring these low grade chronic infections leading to their late appearance at Ayder  Comprehensive Specialized Hospital. This creates a great dilemma as these children often require treatment of intravenous powerful expensive antibiotics from 21 days to in excess of six weeks or more until the infection is cleared by the demonstration of two negative cultures off antibiotics and normal cell counts. In addition in order for the shunt to work the protein has to be less than 150 mg/dl. Failure to diagnose an active residual infection before a shunt placement will only aggravate the infection leading to shunt removal and complications.

The treasure and future of Ethiopia is in her children. Meningitis appropriately treated early and followed can have a very low morbidity and disability outcome. The current situation if not acted upon will result in increasing medical costs, increasing disability, and increasing infant death which could be prevented with simple directed community and institutional action. 

Recommended Course of Action
1. Immediate upgrade of laboratory ability in hospitals to receive CSF specimens 24 hours a day for culture, gram stain, sensitivity.
2. Training of interns and residents in performing lumbar puncture and making sets available
3. Institute an Ethiopian wide policy of obtaining CSF before starting antibiotics. Children with seizures, lethargy, focal deficit, or signs of increased intracranial pressure would be emergently sent to a referral hospital for CT Scan or if possible if they have an  open fontanelle undergo an head ultrasound locally to rule out mass before lumbar puncture.
4. Make sure all children treated for meningitis undergo follow-up and that a repeat lumbar puncture is done after treatment. This may seem over kill but given the crisis happening it is the only way to prevent these chronic cases.
5. Funding of community service, public education, and research projects on this vital issue in cooperation with the regional health bureaus.
6. Training of health officers, nurses, and general practitioners in proper diagnosis, evaluation, treatment, and referral of children with meningitis and hydrocephalus.