Ethiopian intentional punitive defunding and diversion of Tigray medical supplies

Ayder Comprehensive Specialized Hospital campus of Mekelle University

Intentional starvation and complete blockade of medical supply are primary strategies of the Ethiopian government towards the Tigray state in violation of not only moral propriety but also international law. How this unfolded will be told in this writing.

In discussion with displaced and in place faculty of Mekelle University this week I have learned that Ayder Comprehensive Specialized Hospital has more than 60 infants and children dying of starvation in the hospital averaging 2 or more deaths per day. Today there is no medicine, no nutritional supplements, no baby food or bottle formula, no laboratory, no x-ray, and the staff is all working voluntarily without pay. Every day children and adults are dying of simple treatable acute and chronic conditions such as hypertension, diabetes, childbirth, pneumonia, and accident just to name a few.  This intentional complete abandonment of the Ethiopian government’s responsibility to care for innocent noncombatants is a violation of international treaties and the Genocide Convention of the United Nations to which Ethiopia is a signatory. 

I previously published that we now can accurately estimate that the crude death rate, that is the number of expected deaths per 1000 population per annum will raise from its pre-war level of 6 by %500 to 32 (its level in 1950 when there was almost no health care) meaning over 228,000 people will die in Tigray each year due to complete lack of health care.

For the previous year while the Ethiopian, Eritrean, and Amhara regional governments were planning their invasion of Tigray there was also a plan to defund Mekelle University with reduction and stoppage of many routine payments such as for a routine repair of the MRI scanner and CT scanner.

Then following the Ethiopian Eritrean occupation of Mekelle in late November 2020 the medical supply, maintenance support, and even communication with Ethiopian Ministries of Science and Higher Education and Health were gradually completely cut off to the federally funded Ethiopian Mekelle University and it’s referral and teaching hospital Ayder Comprehensive Specialized Hospital.  

The acting President of Mekelle University, Dr. Fetien Abay, and Chief Academic Head of the College of Health Sciences, Dr. Hayelom Kebede,  went to see the military commander of the Ethiopian occupying forces in early December when the hospital’s supplies were already near exhaustion at Planet Hotel. He told them that the Ethiopian military and government had no responsibility to care for the civilian population. Subsequent discussions with Mulu Nega, the first appointed governor of the Tigray Interim Administration appointed by Prime Minister Ahmed to preside over the occupation, and then the Eritrean Abraham Belay, long time supporter of Isaias Afwerki, dictator of Eritrea and now the defense minister for Ethiopia who replaced  Nega he was too “lenient”. Communications with Belay were that Ethiopia had no responsibility to offer any civilian support or assistance because civilians were not supporting the Ethiopian government.

Since the occupation and extending even up to the recent few months intermittent conversations with Dr. Lia Tadesse by Dr. Hayelom  Kebede and others have proven failures. She has expressed regret in telephone conversations that she is not allowed to take any action to supply Ayder Hospital or the Tigray Regional Health Bureau because the Prime Minister has forbid it.

Almost two years ago I was consulting with a group working with multiple international nongovernmental organizations to propose a plan to help improve the function of Ethiopian government purchasing. This included discussions about joint ventures on producing medical consumables in Ethiopia. The plan was rejected after our presentation to the Ethiopian Investment Commission because the funder of a factory wanted to build it in Tigray. Out of this work came a discussion with high officials of the Korea Hospital that they had tried a similar goal  before and discovered that Ethiopia was selling some of the supplies it purchased at discounted price or partially subsidized price to other African countries at higher prices to get “hard currency”. It now appears that some supplies that were collected and meant to be shipped to Tigray since the onset of war may have been just given to Eritrea or instead sold as means to collect hard currency.

Remembering 300 days of sorrow and strife in Mekelle

300 Days ago the misery of Tigray began but now the Tigray Army is giving hope for 7 million suffering in Tigray

Beginning 300 days ago Mekelle University has suffered airstrikes, artillery bombardment, rifle fire, pilfering of its records and equipment. Today the halls of the university and the wards of its hospital are empty accept for refugees trying to survive. Many of our employees and staff have been killed not because they became fighters to defend Tigray but just for walking on the street or trying to evacuate their elderly parents from a village.

The whole of the city of Mekelle, capital of Tigray, was bombarded with artillery for 24 hours even though all TDF defenders had left the city

A year ago Mekelle University was teaching thousands of students from not only Tigray and Ethiopia but many surrounding countries. Ayder Comprehensive Specialized Hospital was teaching medical school to hundreds and training specialists in pediatrics, internal medicine, general surgery, pathology, obstetrics gynecology, otolaryngology, oral maxillofacial surgery, orthopedics and trauma surgery, forensic medicine, and neurosurgery. We were starting training in master anesthesia, MD anesthesiology, oncology, neuroscience PhD, and many other fields. Leading research was done in agriculture, veterinary medicine, engineering, medicine, and many other fields.

Even though we were a “Federal University” we were abandoned by the Ministries of Science and Higher Education as well as the Ministry of Health. As soon as the war started they pretended we did not exist. The Mekelle community shared what little food, water, and shelter they had with students from other regions and countries. All payment stopped to employees. All medical supplies stopped. With the encouragement of the the Ethiopian military Eritreans were allowed to rape students, ransack buildings, and take any war booty meaning computers, lab equipment, etc.  back to Eritrea.

It will take millions of dollars to rebuild the University and its services to the community. Unfortunately is is just a small part of the overall damage done to Tigray. Millions are still starving at the order of Abiy Ahmed and his hench man Isaias. But I can imagine it would be far worse now if the Tigray Army had not resurged and marched forward. It is not over but we pray God will guide them on their mission to find peace and eliminate the threat to the Tegaru from their man-made insufferable misery.
Psalm 18:39
“For You have girded me with strength for battle;
You have subdued under me those who rose up against me.”

What I learned and hope to return to at Mekelle University Ayder Comprehensive Specialized Hospital

Ayder Comprehensive Specialized Hospital campus of Mekelle University

In building neuroscience and neurosurgery at Mekelle University I experienced great happiness in serving the people and training future neurosurgeons and scientists.  My seven year experience at Mekelle University serving the people of Tigray and surrounding areas as well teaching neurosurgeons and neuroscience gave me a new perspective on what is true career success. I now recognize there are three phases.

When I first came to Ayder Comprehensive Specialized Hospital in 2015 my initial goal was get a good neurosurgery service going. They were really the only government hospital capable of developing this goal outside Addis Ababa, the capital of Ethiopia, as well as being some distance north so it would offer chances to treat patients who would otherwise go untreated. The University and hospital were committed to building not only quality and quantity of good health care for Tigray and surrounding regions but also to medical education. 

Initially I helped teach neuroscience and clinical neurology/neurosurgery to medical students and general surgery residents (young physicians who have graduated from medical school now doing specialty training) basic neurosurgical skills involving mostly traumatic injuries. My goal was to create a neurosurgery training program as well as a neuroscience research team. 

Teaching medical students about head injury

After about a year working with Ethiopian Ministries and some good collaboration from the Ethiopian ministries, World Federation of Neurosurgical Societies, and Mekelle University faculty we started a five year training program and a three year fellowship program. Up until the Tigray Ethiopian conflict we had grown to 18 trainees, doing 1,500 operations  year, and published internationally recognized research with our multidisciplinary research team on neural tube defects which occur in a high incidence in Ethiopia.

Our research team meet with the World Health Organization

Going through this experience made me reflect on what has been important in my career. When I was a college student at Texas A&M, then a medical student at Harvard, and finally a resident at the University of Miami I was mostly focused on personal achievement and perhaps also personal recognition. Through out that experience and subsequent practice I saw my career as having two phases. Learning to be a neurosurgeon and then becoming a great neurosurgeon. However it was my experience at Mekelle University and Ayder Comprehensive Hospital that taught me there was still a greater accomplishment which was to train great neurosurgeons and neuroscientists. 

Senior neurosurgery resident is supervised to remove a brain tumor

At first it was struggle. The hospital had little experience with neurosurgery. As a 60+ year old guy I was in the hospital every night doing surgery with young general surgeons and then residents with whom we had to start from scratch. Still they were eager to learn. With help from Indian and the few Ethiopian neurosurgeons we got up to date textbooks for them to read. Even though English was their second language they became proficient. At the end of the first year they knew more than I did at their level some 40 years ago. 

During surgery they have to learn about anesthesia, positioning, hand control, to make movements less than millimeter which could mean life or death, how to control bleeding, how to do a 12 hour operation, and much more. We began to have weekly seminars on very complicated ideas where they absorbed the concepts so well I was learning as much they were.  We were organized as most neurosurgical services in a sort of military style hierarchy to which the residents responded to well. Very quickly good and close relationships developed not only with those that were Tigray but also with others from other Ethiopian regions and other countries in the program.

I formed strong relationships with the research bodies of Mekelle University and we created a strong multi-disciplinary research team on neural tube defects which lead to meeting with government and World Health Organization officials, international NGOs, and a finally the beginning of a nationwide plan for prevention and treatment.

Before the  Ethiopian occupation and blockade shut the neurosurgery training program down we had operated on more than 5,000 patients from not only  Tigray but also Amhara,  Eritrea, and occasionally Addis Ababa to Gambella. This week far away from Mekelle I had been doing the “paper work” for my first graduates. I wish we could have had a formal ceremony but I had good voice communication provided. Now I have learned that the best phase of a neurosurgeon’s career is seeing his trainees carry on and expand what I started. 

Holiday dinner with my neurosurgery residents and fellow

I pray God will see fit to facilitate Ayder Comprehensive Hospital and myself to return  to its service, teaching, and research missions once again.

Ethiopia denying health care, education, basic human resources function is Tigray genocide

The Ethiopian Federal government is committing intended genocide robbing the future of the young people and the Tigray society by denying any funding for basic infrastructure, education, and health care in Ethiopia.

Ayder Comprehensive Specialized Hospital was a site for training medical students and residents as well as being the tertiary hospital for over 7 million

The National State of Tigray had 9 government owned college and universities and 11 privately owned. The number of students attending all these institutions was likely in excess of 60,000 students. The flagship university was Mekelle University, a Federal facility, that was the second largest university in Ethiopia enrolling students in undergraduate and graduate programs from not only all the regional states of Ethiopia but also Somaliland, Kenya, Somalia, South Sudan and Djibouti. Within Mekelle University are the following colleges: Dryland Agriculture and Natural Resources Management, Natural and Computational Sciences, Law and Governance, Social Sciences and Languages, Business and Economics, Veterinary science, Health Sciences and Ayder Comprehensive Specialized Hospital.

For almost 7 years I have been Professor and Chief of Neurosurgery, teaching medical students, residents, and fellows as well as Faculty for what was the first Neuroscience PhD program in Ethiopia. Even before the events of November 2020 which plummeted into armed conflict between the Federal government and the National Tigray State there were problems brewing with the Ministry of Science and Higher Education which oversees universities as well as the hospitals they own. Whereas before we were welcome partners at discussions on the national level about educational development the Tigray region was shunned. Although the COVID-19 crisis had resulted in prolonged shutdown and budget cuts there were additional steps taken to restrict Tigray Universities.

After the conflict began in every woreda and kebele schools were ransacked, teachers killed or raped, and books used for toilet paper by occupying Eritrean, Amhara, and Ethiopian National Defense Force Soldiers who often took over these facilities to be used as barracks or even worse centers of abuse. Universities and hospital underwent artillery barrages and air strikes even while they were treating innocent civilians.  Many faculty and staff have not been paid for many months (bank accounts are frozen) , physical plants have no ability to do even maintenance  Supplies and equipment were stolen and often sent to Eritrea as war booty.  The African Studies Association which is the largest African scholar group has condemned the action of the Ethiopian government. To rebuild and replace these losses will cost millions of birr.

After the occupancy of Mekelle by the Interim Administration of the Federal Government we were told that schools and universities would remain open and not to send the students home. However minimal funds and resources were sent to sustain the physical plants, the faculty, or even the students. Basically the Ministry just seemed to pretend we did not exist. Ultimately when the new budget was done for the coming year which normally starts in September to correlate with the New Year on the Ethiopian calendar we have learned that absolutely no budget at all was made for education or health care in Tigray. Even though the Federal Government says we are still a part of Ethiopia in reality we are being denied any funding of vital functions in society as if we are not a part of Ethiopia.

Mekelle Unarmed Civilians Brave Defense of Their Beloved Hospital-Ayder Comprehensive Specialized Hospital

drone view of Ayder Comprehensive Specialized Hospital
Shows Ayder Hospital and the streets lining it where a brave protest took place. Pictures I had of the events described were erased by Eritrean patrols that would search me everyday I went to the hospital I will never forget the bravery of the people in Mekelle who unarmed defended their hospital. This picture shows the streets around Ayder Hospital where it all happened.

This is the story I witnessed of the brave unarmed civilians peacefully protesting and blocking invading forces from ransacking Ayder Comprehensive Specialized Hospital in Mekelle, Ethiopia in November of 2020. I had been performing neurosurgery, teaching fellows, and medical students at Mekelle University  in the Tigray region of Ethiopia since 2015 in a federal university and hospital.  As such I was present in Mekelle from the onset of the war between the Tigray Defense Force and the Ethiopian/Eritrean forces from the onset until my evacuation near the end of December 2020 at the behest of international influence and my family which was three days of driving through multiple checkpoints and unstable areas until we finally arrived in Addis Ababa.

Following the retaking of Mekelle by the Tigray Defense on June 28, 2021 there has been a mixture of sadness and joy. For sometime I have wanted to tell the story of what I think was the most heroic thing I have ever seen in my life which was the unarmed defense of Ayder Comprehensive Specialized Hospital in Mekelle. Prior to this time I felt telling it would result in reprisal to the citizens of Mekelle. Now that Mekelle is free it is important to tell it.

For almost 24 hours on November 25, 2020 the city of Mekelle was attacked constantly by artillery, rocket attack, and airstrikes even though the Tigray Defense Forces had left the city to only civilians.  In my own immediate neighborhood just a few blocks from the Mekelle University hospital, Ayder Comprehensive Specialized Hospital many homes and buildings were destroyed and many killed. A market and home for elders was directly hit killing and wounding many.

About 200 yards from my house, a home that housed a large extended family suffered a direct hit that sent shrapnel breaking my windows at about 6:30 in the morning. I ran over there to find a young woman in the street with a severe bleeding wound in upper leg but that was just the beginning of the horror. The walls of the house had been destroyed on two sides and the rest looked like a Swiss cheese with many perforations. On the ground was a motionless young woman who had only a red spot on the ground where her chest was supposed to be. Her lifeless arms were extended with each one holding toddlers. The children where crying. When I pulled back their hair I found that hundreds of small munitions fragments had penetrated the scalp of both children although the eyes seemed okay. There was nothing we could do for the mother nor her mother who lay beside her dead as well from penetrating shrapnel. Remaining family members rushed the sister with the injured leg and the children to Ayder Comprehensive Specialized Hospital. 

At the hospital emergency room there was wave after wave of ambulances and private vehicles bringing those hit by the attack who were all civilians. Some could be helped but many were beyond hope. We were able to save the children and their aunt from the attack near my house. Although we would sometimes previously do mass casualty from bus accidents in the past this was a much greater magnitude as we saw more then 120 patients in the first few hours. 

Before the invasion of the city, we had been receiving civilian causalities,  Tigray Defense Force causalities, and also Federal/Eritrean causalities. We treated them all the same. The local people even brought food and blankets for the all the groups. However after the invasion the tenor of the invading force changed. Many patients were just suddenly whisked away to parts unknown and we were not allowed to inquire.

The next day on November 26, 2020 at which time Federal Ethiopian armed forces and Eritrean forces invaded unopposed the city of Mekelle.  For the next few days in Mekelle there were Ethiopian and Eritrean forces looting, shooting, robbing, and harassing civilians all around the Ayder area where I lived and the hospital was located. The hospital was occupied by Ethiopian army regulars, then Special Forces from Oromia, and so-called Federal Police. Then suddenly for about half a day they disappeared.

Rumors where flying in the city that Eritreans where ransacking public utilities, schools, etc. The hospital had always been a source of pride and necessity for not only Mekelle but all of Tigray. The local population of civilians began to put tires, logs, and stones to block trucks or other vehicles in the streets surrounding around Ayder Comprehensive Specialized Hospital, the main teaching and tertiary hospital for Tigray, fearing that the hospital which was highly valued by the city would be destroyed or looted. Special Red caped soldiers showed up and began harassing the locals more and more. 

The locals did not back off. They gathered by the thousands and began to surround the hospital 24 hours a day. Many times semitrucks and smaller trucks driven by Eritreans which were empty tried to make it to the hospital to loot it but where physically blocked by protestors standing in their way.  At one point a group of young men were shouting about ten feet in front me to the soldiers. Suddenly the soldiers fired at them killed one and injuring two others. At that time there were tires burning all around the hospital with thousands of protesters. The soldiers were scared and I feared the worst was going to happen. It was tense until morning. Finally the lined up trucks driven by plain clothed Eritreans were told to leave by the invading forces. The two that survived to be treated were hauled off from the hospital by the invading forces and have not been seen again as far as I know.

Pictures I had of the event were erased by Eritrean patrols that would search me everyday I went to the hospital but I will never forget the bravery of the people in Mekelle who unarmed defended their hospital. 

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.

 

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.

Reflections on the Age of Limits in Healthcare Resources

The academic new year at Mekelle University for residents (doctors who have graduated from medical school and now will undertake several years of specialty training) is just a few weeks away. They will transform from the theoretical and observing from the sideline to actually being involved in medical care to improve the quality and longevity of their patients. A part of the new experience will be their discovery that there is a limit of resources even in the richest countries and of course more severe in the developing countries. This same thing is happening not just in Mekelle, not just in Ethiopia, but around the world in all the teaching hospitals.

Although we like to pretend otherwise there is no escaping the inevitable fact that we are mortal and will at some point suffer significant illness followed by death. An Ethiopian diaspora calculated based upon the year 2000 that the per capita lifetime medical expenses where $316,000 in the state of Michigan (USA). Most of the cost occurs in the first year of life and after age 50. Women were more than men because they live longer. About one third occurs in middle age and about one half in the senior year of life.
It is hard to put a measure on the value of human life.

When discussions occurred about the use of dialysis as to whether should be payed for by government, analysts determined that spending $50,000 to give an additional year of quality life was worthwhile. This same measure was applied by several governments world wide. The actuarial value of a human life in developed countries is put somewhere between $ 500,000 and ten million dollars by actuarial experts. It is much less in developing countries where the economic output of an individual is much lower often less than a few hundred dollars a year.

The most recent budget for healthcare in Ethiopia was 1.4 billion dollar equivalents which cames out to about $14 per person for the approximately 100 million Ethiopian population. If you count out of pocket expenses it increases to about $24 per capita. This is of course much less than than the $4000-$5000 you see in European countries and the almost $10,000 in the United States. Yet even in these rich countries there are cries that funding is insufficient.

This means that physicians and the policy makers whom they advise have to learn to do more with less. They have to spend resources where they will have most impact. How are these decisions made? Medical ethicists talk about years of productive life as a reasonable way to compare, for example, spending money to help newborns versus the elderly. But not all cultures would agree with this concept totally. There is often a belief that older citizens should be rewarded for their service to society. Note the creation of Medicare and Social Security and its equivalents in the United States and many other developed countries.

Good medical care even in this age of limits is possible. It requires a sound knowledge of likely outcomes, compassion, and realistic communications with the patients and the community at large in both developing and developed countries. The inevitable consequences of our mortality and economic reality of limits leaves no room for anything other than truthful sincerity.