We started our journey November 30. We arrived December 2 in Bahir Dar late in afternoon after a long journey of 12 hours flight and then a day and short night in Addis Abeba. A nice but 10 hours long buss ride took us to Bahir Dar.

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There were fantastic views especially the Blue Nile canyon.

DSC_4539sWe had a fantastic reception at the house where we are going to stay. Three of the students that Titti is going to have at the university had prepared a traditional coffee ceremony. Apart from our friends the dean of the department Titti is going to work at joined the ceremony. We were then invited to a farewell party for an Australian surgeon who had worked in Bahir Dar for 9 years in a fistula project. He is moving on to Tanzania.

Second day in Bahir Dar started with full activity for Titti at the university and I was sharply introduced to the medical reality.

Samuel Assafa had the day before been consulted about a newborn baby that during the delivery had been traumatized with an open mandibular fracture in the mid line. We went to the hospital Falaga Hiot and I could examin the baby. The fracture was very unstable but the baby feed well and she didn't seem to be in pain. We prepared for an operation later the same day.

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On the way out we were consulted about two other new manibular fractures.

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The situation is that at this public hospital everything is free for the patient if the hospital have the resources for giving treatment, if not the patient has to be referred to Addis Abeba and have to pay for the treatment. If the patient can't pay no treatment is given apart from bandage and infection control.

To collect insBrannskadatruments for the operation we went to the private surgery in Bahir Dar where Samuel sometimes have patients. There was also an interesting experience. After having got the instruments (Samuel's) on the way out we were and especially I consulted abut several cases in the head neck region. The question I soon realized is “can I treat or not”. They expect me to do what I think is possible even if it is far away from my speciality region. There were at least six patients I had a quick look at, no medical records and other paperwork.

When we came back to the public hospital later in the afternoon, just like what happens at home, we found that the operation was canceled due to misunderstanding in the booking and that the staff were going home. The operation will be on Monday instead. While being at the hospital there was another consultation about a peculiar swollen neck I never seen before. This seems to be the life of a surgeon if you enter a hospital.

Woke up early and had a shower in a thin water stream. The water pressure is almost non existent. One has to be patient and don’t be alarmed about the condition. Take it slow and one will be just as clean as at home.

Samuel knocked on the door, “we have to go to the hospital they are waiting for us with the baby fracture”. There we changed clothes as you do before you enter an operating theatre. The difference is that you do it in a corridor with a symbolic curtain. The surgeons look more like painters in their green clothes with lines and patches of different color, shading to white due to their use of chlorine for disinfection.

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It was decided to do the operation in local anesthesia. The baby was prepared with some inhalation gas, but I didn’t get the name of it. Since Friday the right part of the mandibula had rotated up and was in contact with the roof of the mouth. After the injection of Xylocaine with adrenaline I made an incision below the mandible in the anterior region. This was relative straight forward but then the problem started. I hadn’t realized that the blood suction apparatus was a foot pump operated by the anesthesiologist. This didn’t work in our situation. We had to relay on use of cloth compressors, drying blood in the operating field. Light and position of the baby was another problem. I felt left alone as the assistance doctor was very unfamiliar with the situation.

DSC_4617sDSC_4621sI struggled through and could quite quick explore the left fractured mandibula. Next surprise the burr felt like on meter long, but that is what we had, and I managed to drill a hole in the lower rim of the left mandible. Then to explore the other side I had great difficulty in seeing what I was doing. I had mostly to rely on what I felt. Eventually I could drill a hole on this side as well. Next surprise the wire that we had got, felt more like a piano wire than the steel wires we normally use. After a substantial long time I manage to get it through the holes and to twist the wire. Unfortunately, the wire broke and the bone next to the hole on the left side broke as well. I almost lost faith, but with a new approach and a new assistant that appeared on the arena, an interested general surgeon, I drill a new hole in a better controlled way. Luckily I found that Samuel’s last piece of wire from Sweden was a three parts twisted thin stainless wire. Now the fracture could be put in place and a wet Hans could leave the suturing to the general surgeon.

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Luckily we managed to get in late time for lunch with Titti and Fantu who were waiting for us at our local restaurant. They had started and we had to eat quickly so Titti would be in time to the university on the other side of town.

After leaving her there, we went back to the hospital to collect Samuels instruments, drilling machine and see the little patient. Everything was all right and she was lying on the bed with her mother and her twin sister.

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One thing I found is that you can’t just leave. You have to socialize first with the other doctors. It is nice but time consuming. And of course have a patient consultation, this time in the hospital cafeteria.

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Then we went to Samuel’s clinic. Samuel had several consultations that he could manage quite well. Ranging from swollen nose to fractures. There was one case of an impacted premolar that he wanted me to operate tomorrow and a case of intense pain over the right temporal madibular joint region. After local anesthesia in the joint region we could eliminate the joint as the cause of the pain. Then the question was what it can be. The patient had been to x-ray the day before and had with him two films and a suggestion of a cystic lesion in the joint. That was nothing we could confirm ourselves. Suddenly my mind came up with the hypothesis of a Temporalis arerit. After discussion we decided to start a treatment for that.

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As the patient was in quite severe pain Samuel arranged to get a bed at the small private hospital. To think that you should let a rheumatolog or another medical doctor take over is out of the question as there is no one. If you are in a medical profession you are expected to do everything that is possible if you think you know what you are doing. We ordered erythrocyte sedimentation rate. Prescribed Perdisolone 30mg * 3 and Petidin. Tomorrow we will evaluate and hopefully the diagnosis can be confirmed.

This is almost all for today!

We are beginning to find our routines and how to get around by ourselves. Took a badjha (the small three wheel motor car) to town and I got off at Samuel’s clinic and Titti continued to the University including change of badjha because they run in kind of bus traffic in defined routs. You have to tell the driver where to get off so one has to know where and that is not so easy in the beginning.

I started off with an operation of removing a cystic lesion with a retained premolar in the mandibula. To assist me there was a nurse from the private hospital who did a wonderful job. The equipment was working wonderfully. It is nice to have a working suction facility.

Then we had different consultations and it was interesting to se how well Samuel handled those.

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At the end of the day we were called from the private hospital. A boy about 20 years of age had been in a fight and got a right mandibular fracture. He had come a long way for treatment about 100 km and he had his family with him, 5 together. There was a quite big fragment in the fracture making the fracture rather complicated. We planned for an operation the next day in general anesthesia. Operating time was set preliminary in the morning. After this Samuel drove me home. Titti was already home because she I suffering from a cold although she had been to the university and tried to make the best of it. We were too tired to have dinner so we had some beer and went to bed early.

Next day in the morning Gulilat, Titti’s partner at the university came to offer a ride to the university but we were still in bed as Titti had been having a bad night with coughing. Then Samuel called and said that the operation had been canceled because they didn’t have the money for the operation. Samuel was rather upset about it but couldn’t do anything as he has no operation facility of his own. It is difficult to accept this as a Swede.

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Titti had her first meeting at the university at 10 so we could take it a bit easy. We went together with a badjha to town and I went to the clinic for the normal consultations with Samuel.

This morning Samuel had a patient with luxuated front teeth’s in the upper jaw. Fantu assisted as a fully qualified nurse.

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At lunchtime we went home to Samuel and Fantu. Titti and Gulilat came by his motorbike and joined the lunch.

In the afternoon Samuel had some consultations. A patient with a root that was left after wisdom tooth extraction had been having trouble for half a year. Samuel though it this was a case for me and gave the patient an operating time tomorrow afternoon.

I became a bit worried as there is no operating light in the clinic apart from the sun. The fiber optic equipment that Lasse Ahlner and Björn Franzén had set up when they were here in February had stopped functioning because the lamp broke. I was eager to fix it but to get a spare part in Bahir Dar was out of the question. I started to go to a computer shop in the same building to see if they had a lamp for a projector that we could use. No luck, but at a shop for car spare parts I found a 100w lamp that looked like a possible solution. By using composite filling material and some wires that I got at the computer shop I succeeded in replacing the original lamp with this car lamp. Hopefully the fiber optic devise will work when I will try to remove the small left root fragment tomorrow.

Titti has not recovered from her cold but she struggles on. We went for a short walk in the neighborhood before I took off to the clinic. I started off to check the fiber optic light. Found out that one of the cables was too near the lamp so it started to melt. I did some adjustment and I could in satisfaction wait for the operation. Samuel came and so did the nurse but no patient. She was either too nervous or could not find the money for the operation. This is not unusual Samuel says.

After a while the ordinarily consultation patients dropped in. Before the day was over we had seen patients ranging from tonsillitis to heavily infected lesion. One of them had come 100 km and was prescribed antibiotic and given time for operation tomorrow.

We were also able to test the X-ray that I had managed to get through the customs. This story should be told by it self.Samuel had got three films from the hospital and we made exposers on two of the patients. 101209rtgTo develop them we vent to the hospital were we with anxiety waited for the result. We were very happy when we saw that they came out nicely, a little under exposed. We also saw the baby with the mandibular fracture. Tadela Gode (the bay’s name meaning lucky and her fathers first name Gode meaning good) was feeding and looking very healthy together with her twin sister that hadn't got a name yet. The wounds were healing alright. Of course there was some socialization before we went from the hospital, but no consultations for a change.

Samuel came at 8.30 and off we went for the container that was shipped from Sweden in 2006. 101210containerThere are quite a lot of things that has not been used for the clinic and is meant to be for the new clinic that is under construction. To find what is inside the container we had to take a lot of things out. I was very eager to see if I could find my father’s operating lamp and transformer because it was the reason why we went there. I was not sure that the transformer was there because I think Björn and Lasse had looked for it. We looked in every corner and eventually I found it. This made me very happy because an operating lamp is really something that is missing at Samuel’s clinic.

It is quite encouraging to find so many things in Africa that my father Gösta and partly I had at our clinic in Stockholm. Some of the things recall good memories from the time we worked together at Riddargatan 12.

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Back at the clinic I had an operation and then Samuel invited to lunch at an Ethiopian kind of hamburger restaurant. But first he arranged to collect Titti so she could join us. After lunch we went to the university with Titti and then to the clinic. Not much happened there but we got time for planning how the operating lamp should be put in place. Then the sun started to go down and the working day was over and Samuel drove his staff home.

We have now entered a kind of routine state. We now know how to get about and things tend to get less unusual.

On Saturday 11 we went about 50 km north along the lake Tana on the east cost. Our goal was a very exiting an unusual community called Awuraamba. It is an Ethiopian group of people living together and taking care and supporting each other in every phase of their lives. At this community I tried a small piece of injera with some kind of tomato souse. I should not have done that. I was sick all night and didn’t get much sleep.

On Sunday 12 we were invited to one of Titti’s colleague’s mother in law and we were going to meet Biset in town at one a clock.
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Before that we went on a walk to explore our surroundings. We passed the hospital and found that there are different kinds of medical educations for nurses, pharmaceutical and laboratory training right near it. There were also several pharmaceutical shops. On the way towards the main road to town center we passed a village, well organised but rather poor. When we came to the main road, we were to take a bajaj or a “taxi” to center of the town. but all of them were filled with people coming from church. So we had to walk all the way, which wasn’t too troublesome.

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We arrived a bit late but it didn’t seem to trouble Biset and his mother in law when we arrived after a taxi journey to the far east of town. A taxi here is a blue mini buss (like a Volkswagen bus) that picks up people along the road.

We had a wonderful traditional lunch and we also met Bisset’s 1,5 year old son. Biset’s wife attends pharmaceutical education and had class even on Sundays, so we did not see her..

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On the way home we passed a Muslim wedding ceremony. The men were dancing around the bride and everybody seemed to enjoy themselves. The bride and the bridegroom didn’t look that exited, but may be they were nervous.

Monday 13 started in the general way and there was no sign of a Sancta Lucia. I met Samuel and Fantu at the clinic and with them they had their neighbor, a technical guy. I went with him in Samuels car to his former workplace which bankrupted a week before. Our mission was to lengthen the roof console for the operating lamp with half a meter, as the room height is much higher than were my father had it in his “garage” clinic. We managed to take the consol apart and to find out the length and dimension of the needed pipe. Then away to town to try to get a pipe. I think we went to at least six shops were they sell used metal. You could call them mini scrap yards. In the end we went back to the first one where they had a pipe with the right outer diameter but a bit thinner than the one were to lengthen. Now it was time for lunch and after that car ride to town and then back to the workplace were we had the pipe welded and we were ready for the next step. At home you would have everything needed but here you have to get and buy the pieces needed. That took the rest of the day.

After working hours we had a meeting with Midroc’s chef architect and planner in Bahir Dar. We went to the new clinic and looked around. He said that he will have deeper look on the project and he will suggest certain changes especially connected to drainage and water situation in the area.

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In the evening we invited to a Santa Lucia celebration with Swedish Glögg (Glü wine) and ginger biscuits. Midroc’s chief architect (from Philippines), Samuel, Fantu, Gulilat, and his wife Masteval joined the party. We had a Lucia picture on the computer.

Tuesday 14
Woke up with a sore throat in the middle of the night, first warning, But in the morning it wasn’t so bad. Were to meet Samuel at 9 and I was there at time but not Samuel. They showed up later with a brand new impact drilling machine.

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Happily we started to drill holes and the first and second went well, but then the problem started. Something that would have taken half an hour took all day. The cheap stuff is to blame!!! A lot, almost all things imported are of bad quality and we learned the hard way to get the right stuff like quality drills
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In the evening Titti and I had a muslin dinner at another of Titti’s colleagues. Adem and his wife Hayat are living in a flat that is quite a new way of living in this region. We had a very nice dinner served the Muslim way on the floor. They have a very cosy home and their little boy went asleep on a cushion in the corner.

Wednesday 15
During the night I got aware that I was getting influenza but in the morning I felt not so bad.

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Went to the clinic and now Samuels technical guy quite easy could put up the remaining fixtures in the roof. He had also made a piece that was missing from Sweden. We were very happy but next disappointment came. The hole for the electrical power was too small.

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We found a way to fix it and then we were able to connect the cables to the transformer and fix the cables to roof and wall in a nice way. Suddenly there was light and everybody clapped their hands.

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In the evening we were invited to our landlady Orit and had a wonderful dinner the Ethiopian way. She showed us some photos and talked about here family. Her husband is living in Addis and so do her children who mowed there as grownups. Here husband don’t come home so often but next time at Christmas. We showed her some pictures from Sweden on our laptops. We had a nice evening.

Thursday 16
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During the night the influenza really got hold of me. I had to call Samuel to tell him that I must stay in bed although he had planed some operations for me. This was not a good day. In time for the next night I wasn’t feeling at all better.

Friday 17
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In the morning Guliat came with some special drink or soup in a thermos. This is good for you he said. I don’t know if it was Gulilat’s drink that made me feel better but I picket myself together and went late to the clinic.

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I didn’t do much useful there. We had some case discussions.

In the afternoon I met Titti and Haimanot, a teacher at the department of gender and development studies.

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She invited us home for dinner and we had a very nice evening talking about different situations in Ethiopian press media and country especially women’s situation. Her master thesis (May 2010) was about a small community in Bahir Dar, Negede Wayto. They live by traditions going back to Moses and are extremely poor. Their religion is looked upon as threat to both Muslims and Christians. They are radically different in language and religion compared to any other Ethiopians. They are a discriminated and socially oppressed racial group and assigned the lowest status in their region. It was interesting to hear about this and one wonder why and what makes it possible for a group of people to keep their traditions for such a long time.

Now another week has gone and we enter our last week here this time.

genet_sAndrew_vDr Asrat Genet head of the Health Bureau of the Amhara Regional State invited/persuaded Dr Andrew Browning, an Australian surgeon, Samuel and me to go to a countryside hotel in Chagni about 120 km southeast of Bahir Dar. The mission was to show a hotel that the owner wanted to convert to a hospital. Dr Andrew has been running a fistula center in Bahir Dar since it opened in 2005 and is now moving to Tanzania. Dr Asrat wanted to persuade him, as an alternative to Tanzania, to think about starting a hospital alone or together with Samuel and me. We were picked up early in the morning by Dr Asrat with a chauffeur in what I think was the Health Bureau's Land Rower type of car. The first part of the way was on a good road and we cruised at quite good speed.

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After about an hour we stopped for coffee or drink at Dangla, a small town on the road to Addis Ababa. The guest house where we stopped had an unexpected high standard in comparison with the surrounding buildings. 11°15'16.20"N 36°50'52.40"O

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We continued about 35 km, left the asphalt road and turned west on a stony, bumpy road. This was compensated by very beautiful sceneries from the road going uphill.
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We passed a village after another 20 km, where a lot of people had assembled on a field. They had many horses dressed with colorful harnesses. We stopped and took some pictures and asked what was going on. It was a funeral of a local nun and as she was an important person in the village, all members of the community came to the funeral. 11° 0'20.17"N 36°40'45.03"O

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Next stop after another 25 km was at the home where Dr Asrat was borne. We were invited inside in a quite big room where we were served fresh honeycomb.10°58'39.50"N 36°32'57.80"O

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Then we continued to the school he had attended as a young boy. Some of the buildings were built as part of a Swedish aid project during the seventies. There is nothing showing that they were part of the project but everybody knew that that was the case. The buildings are not outstanding in any way but seemed to be of a stable construction. 10°59'24.30"N 36°33'20.10"O
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After a few kilometers we arrived at the Tana Beles Hotel. It is embedded in greenery and had a nice outlook.10°56'53.40"N 36°31'10.30"O

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There is a main building with a small restaurant and 3 low long hotel room buildings. Over the beds there are mosquito nets to protect from malaria. There are some other buildings for different purposes like rooms for staff. To turn the hotel into a hospital would be nice and possible but the investment is substantial as everything like x-ray and laboratory has to be in place. The distance to supporting medical service is too far. Another thing is that it probably is difficult to recruit doctors and medical staff to this rather far off place.

We continued into the small town Chagni with a lot of traditional shops along the main road. There are about 30000 inhabitants. One gets the feeling of a town in a Wild West film.

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We went to the region's Health center. 10°57'26.10"N 36°30'17.30"O There are about 16 health workers giving service to a population of about 100 000. There are several buildings with rooms for different medical use and there is one for treatment of infectious diseases. Health officers have a BA grade from university, similar to physician assistants in US, and are the main resource at health centers in Ethiopia. They are primarily trained for preventive health care. Physicians usually are found only in hospitals.

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The Health officers are taking care of more health problems than they are actually trained for due to practical reasons as there are no doctors and there is a long distance to nearest hospital.

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We looked in a “log-book” for births that showed about 2-3 births a day. The death rate was low and when we asked about that, they said that if a delivery is complicated they didn't take care of the patient and she wasn't recorded in the log-book. The woman is referred to hospital and that is in Bahir Dar about 120 kilometers away. There is no ambulance service. A big problem is that people who have a car, takes advantage of the situation and demands a very high price. Women who can’t afford it are left to their destiny, very sad and almost impossible to cope with. And then one have to think about all those who live so far away that they can’t reach a hospital in 2 hours, which is the general limit for a started complicated delivery to be saved by a caesarean section.

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We went back to the hotel and had lunch there. On the way back home we stopped at the church where Dr Asrat's father had served as a priest. The church (Segadi Abune Tetemekemedehen) was just near the home we stopped at earlier. Dr Asrat's father was buried there. 10°58'36.20"N 36°32'57.50"O

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They put up small houses or sheds over the grave and Dr Asrat's father had a proper house (not shown here) as a priest near the church . I don't know if the habit to build houses over the graves is common in Ethiopia because I haven't seen or noticed it before. We could not go into the church as the Sunday service wasn't fully completed.

After the visit we vent straight home as Titti and I had a meeting with an old friend at four a clock. We were back in time for the meeting after a very interesting journey out in the rural area of Ethiopia. The country side in this region is nice and green especially in those parts at higher altitude.

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Tuesday December 21

We were invited for lunch to an old friend Assefa Taye from earlier visits to Bahir Dar. He is a jack of all trades. He is has been living in USA for many years. In the end his longing for his old country grew too strong so he went back to Ethiopia. He is now trying to introduce environment thinking in Bahir Dar the practical way.

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He has a small farm where he grows a lot of things in a variety mixture to avoid using pesticides.

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The farm is on the border to the Blue Nile where he can get water for his agriculture. He has also a shop in town were he sells gas and solar panels. One of them is a smart construction that has a built in radio and lamp so that customers in rural aria can have light for reading and the children can do their home works when the sun is down. The radio gives them a possibility to hear what happens in the world and there are some educational programs as well.

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We were invited for lunch in his house,

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built in the traditional way with mud walls that are very strong and works very well in the African climate.

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Assefa also let young people from rural areas stay at his house to give them a better chance to get god education. At the same time they learn how to interact with nature.

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After lunch we went to his coffee hut to have the traditional coffee ceremony.

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Samuel have had for a long period discussions with Midroc Ethiopia about a collaboration in building the clinic. Samuel and his contact at Midroc were convinced that they would take over the project. His contact at Midroc thought it was time to move forward and lift the discussions to the top level in the company. Samuel wanted me to come with him to Addis for the important meeting. He decided that we would fly there on Wednesday in the morning an back the same day.

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Where ever you go Samuel knows people

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We went there and at Addis airport a friend of Samuel was waiting to take us to the head office.

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We came just before lunchtime so we had time to go for lunch at a Chinese restaurant near the head office.

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The meeting didn’t work out the way we wanted and a important reason was that Midroc’s plans for a hospital in Addis had been delayed and that the top level strategies the had become a bit uncertain. Anyhow the meeting was nice with a lot of discussions but no further promises for our project.

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We went home with a great disappointment. A new strategy for the project must be set up including the possibility to radically change it and perhaps sell the plot and building if no capital can be raised

There was no sign of Christmas. In Ethiopia they have different calender. It is based on the older Alexandrian or Coptic calendar, which in turn derives from the Egyptian calendar. Ethiopian calendar has thirteen months, twelve of 30 days each plus five or six epagomenal days, which makes a thirteenth month. Now it is 2003, which began on September 11, 2010. Their Christmas day is on January 7th or Tahsas 29th of the Ethiopian Calendar.

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Titti's colleagues invited her (and me) to a farewell party as this Friday was her last working day at the University.

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They had chosen a restaurant at the Sematat monument. At the entrance there are military guards and the charge is 20 birr for tourists and 2 birr for locals. They shouldn't have tried to point out Titti as tourist. She talked about equal rights and discrimination with the military. They didn't win the battle, surrendered in the end and let us in as locals.

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There is a nice view over the outlet from the lake Tana into the beginning of the Blue Nile.

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The food wasn't served for all at the same time. When they arrived after a long time with Titti's dish, it was not what she had ordered and far too spicy.

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She was without anything but some bread and beer and took it as a whole woman. Apart from that we had a nice evening.

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In the morning we had a walk i town and went round at streets where "normal" people live.

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On the way to get a bajha there were one they packed in a sheep and three passengers.

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We were invited for lunch at Samuel and Fantu. Fantu had laid the table with a red cloth to make it a little Christmas like. The food was excellent and we had a nice time. We didn't miss the Christmas and were rather happy avoiding all the fuss that is connected to celebration.

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After the lunch we took a walk to Samuel's and Fantu's former maid Genet who now is married and got a 7 months old baby.

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She lives together with another family we met at our previous visits and it was nice to see them all again.

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Genet's baby (Jeimy) is absolute adorable and Titti gave her a little bear that she first got afraid of but son began to play with.

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We packed our things in the morning and then had lunch at our local restaurant. Gulilat came to join us. We didn’t feel at all ready to go home and would like to stay.

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Our journey home to Sweden started at Bahir Dar Airport at three in the afternoon. Samuel and Fantu drove us there. We said goodbye and thanked for a wonderful stay.

Our plane left for Addis at half past five and our flight for Sweden started at twenty minutes past midnight. We landed in Stockholm, Arlanda nine in the morning and then we went to Täby and my brother and sister were vi had our car parked. We went by the ferry to Gotland in the evening and got home in Visby at half past midnight December 28. (About 22 hours from Bahirdar)

There was a almost traumatic experience to come home in the middle of the night at a temperature of seven degrees below zero. We had to dig away almost half a meter thick layer of snow to get into the house and to be able to park the car.

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These pictures are taken the next morning when we completed digging paths through the snow in our garden

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We celebrated the new year 2011 and just after midnight after leaving the old year I took these pictures . We had a show storm in the evening and now it had stooped.

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The exposing time is quit long and the camera was fixed on a tripod.