Elena Phoutrides is an MD/MPH student at OHSU who is a visiting researcher working with us for part of the summer. Today she is sharing some of her experiences here in Ethiopia, and a bit about her project.
It’s mid-morning: somewhat watery sunlight lighting up the bougainvillea, the appealing smell of fresh-roasted coffee in the air. Just about time for a coffee break here in Mekelle town in Tigray, Ethiopia.
I am fortunate to be working this summer with Healing Hands of Joy (HHOJ), a non-profit, nongovernmental organization based in Mekelle. HHOJ works with women who have experienced obstetric fistula; this condition occurs during prolonged obstructed labor, which creates a hole between the uterus and the bladder, the rectum, or both. The direct result of this injury is urinary or fecal incontinence. Indirectly, many women who experience fistula are traumatized and socially isolated as a result of the smell that accompanies obstetric fistula.
Ethiopia is one country where obstetric fistula remains relatively prevalent, due to a lack of easily accessible emergency obstetric care. The good news is that women who experience fistula can be surgically repaired at one of the six branches of the Hamlin Fistula Hospital, which works almost exclusively in fistula repair. However, the social issues that accompany fistula can’t be managed in an operating room, and despite successful closure of their fistula, many women continue to suffer from social isolation within their communities.
In this context, HHOJ trains women who have experienced fistula as Safe Motherhood Ambassadors, who work in their home communities to educate women about safe pregnancy, labor, and delivery. Ideally, their programs will impact both the experience of women with fistula as well as the community at large. HHOJ has done an excellent job of prioritizing monitoring and evaluation as a part of their program management, especially with regards to their program’s impact on fistula survivors.
My work this summer will help assess how HHOJ’s programs are affecting community-level maternal health knowledge and practices. This is a basic evaluation; untangling the question of how, exactly, a program can change how a community thinks about the health of mothers is a complex question. However, I am excited to be a part of HHOJ’s work and the challenge of evaluation. I’ll be spending most of the next two weeks in rural health centers talking with people impacted by HHOJ’s programs is hopes of understanding how best to assess impact on a larger scale in the future.
Big thanks to both HHOJ for the opportunity to work with them this summer and to my faculty mentor, Dr. Rahel Nardos. In addition to her encouragement, guidance, and logistical support for this project, her work with OHSU’s Global Women’s Health Initiative (GWHI) is what first piqued my interest in fistula. GWHI’s project in Ethiopia supports maternal health by providing training and surgical support, community outreach, and educational partnerships with local hospitals, health centers and students.
Check Out the New Blog by Catherine Fraser
Our new research lead, Catherine Fraser, is blogging about her work with HHOJ. Click on the link in the sidebar to visit her blog and get updates on her work and life in Ethiopia. Here is a little bit about her in her own words.
"I’m originally from (born in) Vancouver, British Columbia, and have lived all around North America: Moscow, Idaho; Portland, Oregon; San Francisco, CA; Queen Charlotte BC; Prince George, BC; Kingston & Ottawa, ON; even Puerto Rico. Those moves, plus two geography degrees, avidly reading my mother’s tropical medicine textbooks at age 8, being a slightly neurotic over-thinker – all of these things have very deeply shaped who I am and how I think.
I really can’t explain myself properly without telling you about the amazing people, books and experiences that influenced me and opened my eyes to the realities of life and struggle in the developing or colonized world. When I was younger, I was obsessed equally with Nancy Drew, and with the Young Indiana Jones series. As I matured, I started reading non-fiction (thank goodness) about those distant places and adventures I’d dreamed about and had (let’s be honest!) utterly romanticized.
I was (and am) particularly influenced by Dr. Paul Farmer’s efforts in Haiti with his organization Partners in Health (captured by Tracy Kidder in Mountains beyond Mountains, and in Farmer’s later work Pathologies of Power); and by Dr. James Orbinski’s book “An Imperfect Offering” which details his work with Medecins sans frontieres (Doctors without Borders). I adore the poetic (and often poetically-brutal) writings of Eduardo Galeano on the colonial experience in Latin America, especially The Open Veins of Latin America. I can’t get enough of the gritty, honest and thoughtful writing of journalist Nicholas Kristof (of the New York Times).
I trained in health geography and worked in health informatics/epidemiology/population health in Canada, after earning my Master’s degree at Queen’s. Combined with my lifelong obsession with international health and medicine, it’s amazing to see now how each of these experiences and positions and interests have intertwined to equip me to help HHOJ perform their monitoring and evaluation work, and hopefully to help them expand their programs and capacity in the Tigray region.
I’m so privileged to be working with an organization that is making a life-changing difference with Ethiopia’s most vulnerable and outcast women. Have an idea for a post? Let me know!"
Isaiah 58 6-11
“Is not this the kind of fasting I have chosen:
to loose the chains of injustice
and untie the cords of the yoke,
to set the oppressed free
and break every yoke?
Is it not to share your food with the hungry
and to provide the poor wanderer with shelter—
when you see the naked, to clothe them,
and not to turn away from your own flesh and blood?
Then your light will break forth like the dawn,
and your healing will quickly appear;
then your righteousness will go before you,
and the glory of the Lord will be your rear guard.
Then you will call, and the Lord will answer;
you will cry for help, and he will say: Here am I.
“If you do away with the yoke of oppression,
with the pointing finger and malicious talk,
and if you spend yourselves in behalf of the hungry
and satisfy the needs of the oppressed,
then your light will rise in the darkness,
and your night will become like the noonday.
The Lord will guide you always;
he will satisfy your needs in a sun-scorched land
and will strengthen your frame.
You will be like a well-watered garden,
like a spring whose waters never fail.
Views from Ethiopia: The Life of an Intern
Incredibly, these weeks are flying by – the staff has involved me in various activities at the HHOJ Center as well as fieldwork. Ethiopian hospitality is most memorable, and I’ve come to the conclusion that the best aspect about Ethiopia is its people. Chaina, our Finance Administrator, invited the staff to his house for a delightful dinner meal prepared by his family. It was nice to relax and get to know the staff members outside of the office and learn more about the Ethiopian culture. I am also learning to enjoy a slower pace of life as time works differently here in East Africa. The staff also treats me as one of their family. It truly is an honor and blessing!
Staff taking a quick coffee/tea break before evening activities begin.
We are in the midst of our extensive monitoring & evaluation process, which includes travel to the 10 woredas (or districts) where the health centers are based. Our SMAs also come from these 10 woredas, and the vision is to eventually expand to include all the woredas in the Tigray region. Traveling to Samre and Gijet were both interesting and valuable learning experiences. We have around 40 SMAs in Samre, which represents our largest community of SMAs. Beriha, our first SMA, also came from the Samre region. It was nice to observe and gain a better understanding of both the background and living context of our SMAs.
Traveling to the Samre Health Center.
Zewdie and I interviewed 10 women from Samre and spent time with them to understand the challenges they face on a daily basis. Some of these challenges include lack of a better road infrastructure or even transportation options. One of our SMAs traveled 6 hours by walking in order to make it to our workshop! With our vehicle, we were able to drop her in her hometown on our way to Gijet.
One of our SMAs that we interviewed – as a talented connector, she
has educated many pregnant women about fistula in her community.
Another challenge faced by SMAs in Samre (as each district is varied in their situations) is the lack of running and clean water. Water security is a major concern throughout Ethiopia as the terrain is mainly an arid, desert environment that sees the rainy season for about 2 months of the year (July/August). These two months are vital in order to begin the sowing process, since being an agriculturally based economy, many of our SMAs subsist off their land and rain is an important resource to these people. In many ways, it is a blessing when it rains, especially for communities that see rain as a gift from God. Sometimes, when traveling to a new region or town, one will ask as a greeting, “How is the rain?” Even in churches, the people will gather and pray for rain. So when it rains, people are overjoyed!
Our own water collection and storage system at HHOJ Center
– we also rely on the rain.
After our workshops and M&E in Samre, we traveled to Gijet for another community engagement event. Fortunately, it thundered and poured a ton of rain, encouraging more people to come in and watch our film, “Fistula is not a curse”, as they shelter from the heavy storm. The timing was excellent because as soon as we were finished, it stopped raining! And we were on our way back on the road again.
Community in Gijet coming together in support to end fistula.
A hopeful, wistful look – this young woman seems to express hope in her
community that fistula will be eradicated for all mothers.
We also graduated our 24th class of SMAs and will soon be graduating another class. We look forward to celebrating their accomplishment and successful completion with our local partners who will be attending as special guests during our ceremonies. The staff is excited to empower our SMAs to change their communities and to share their stories with other pregnant women. It is encouraging to see the hope and joy in the eyes of our SMAs!
Overall, it’s been a wonderful cultural immersive and valuable learning experience here in Ethiopia. I feel blessed to be joining the team at Healing Hands of Joy this summer and seeing the impact of the organization for these fistula survivors. Stay tuned for more insights to come as I wrap up the remaining weeks here in Mekelle!
Children excitedly greeting us in Gijet.
This is Sharlene, currently based in the Mekelle office, and I am interning this summer as a Program Associate with Healing Hands of Joy. I arrived earlier in July and am already involved in quite a number of activities working alongside the hardworking and dedicated staff here at HHOJ. Everyone has been incredibly welcoming and friendly! My first impression upon arriving here is that Ethiopians must be some of the friendliest and warmest people on earth! For example, at the airport in Addis, strangers would come up to me and start a conversation. Sometimes they will even greet me in Chinese with a “Ni hao!” Ethiopians have a wonderful spirit of hospitality and are very caring towards their guests.
Coffee ceremony with our 24th class of SMAs where they courageously
share their personal experience with fistula.
Surprisingly, the first week is already over and went by incredibly fast – with all the activities, events and occasions we experience together this week. We had our coffee ceremony, led by Frewaini and Senait, with the 24th class of Safe Motherhood Ambassadors (SMAs) where each woman shares their personal struggle and experience with obstetric fistula. Many of these stories are quite personal so I admire their courage in sharing and hope they will continue to share their stories with the pregnant women they meet along the way and in their communities. The coffee ceremony is also a fun bonding time with the ladies, and whenever they get excited or happy, they will clap their hands and cheer loudly. We also enjoy freshly roasted coffee, which is brewed right in front of us. Before enjoying the first cup, we all get a whiff of the fresh roasted coffee beans as it goes around in a circle which makes one more excited to try that first sip. Ethiopian coffee is one of the best in the world, right after Brazil.
I also got to visit the city of Mekelle with Chaina and Zewdie for the first time and see it in broad daylight. The city comes alive in the morning with the hustling and bustling of the markets, shops, and cafes along the streets. People are walking everywhere and some are just relaxing, enjoying another beautiful day in the sun. It also happens to be the rainy season (July and August) in Ethiopia but so far, the rain seems to be holding back. The staff and I get around town riding Bajas, which are similar to chai wallahs in India. They are these fun 3-wheel miniature blue taxis that can take you wherever you want to go in the city. It makes for a unique and novel experience, and after some time, you get used to riding around in these vehicles.
Traveling around town in these Bajas is actually a lot of fun!
We also head out for our first community engagement event of the week. The staff has a lot of energy and enthusiasm that they bring to these community engagements. I can sense the passion they have in bringing awareness and educating the communities about obstetric fistula. During that first evening, after several hours of traveling through mountainous, windy roads, we make it to the district of Kelte Awelado at Agulae Tabia and settle at the health center.
Visiting the Health Center for a community engagement.
Tesfu, the counselor, grabs his microphone and starts making announcements for people to come watch a film. The purpose is to start collecting people and it takes some time before we have enough of a gathering in order to show the film screening. Pretty soon, the venue is almost filled and the film runs smoothly without any problems. But then the lights went out due to a power outage so with quick thinking, the staff quickly gathers and has everyone light up candles as we all make a declaration to see no more cases of fistula, “We will support our mothers and safe delivery at health centers for a fistula-free community.”
Tesfu and one of our SMAs sharing about fistula in front of the community.
The crowd gets pumped up by this time and it’s quite amazing to see all these candles light up, and I would imagine empowering for the women who already suffer or have suffered from fistula to see a community come together rooting for them.
Frewani, Program Director, reunites happily with one of our SMAs.
Fortunately, the lights come back on and the film continues on with no technical problems. The community seems to enjoy watching the film and also appreciates the raffle drawing that closes the evening where prizes may include umbrellas (useful for walking and in bright sunny days), beautiful handcrafted HHOJ scarves, and t-shirts.
Celebrating our partnership with World Vision Ethiopia.
Overall, it was a very successful evening in engaging the community, and the staff heads home, satisfied that it all went well. Another community is empowered to fight fistula with the HHOJ vision to see a fistula-free community, not only in this district, but also in every district and community in the Tigray region, and eventually Ethiopia.
Declaring a fistula-free community for our mothers.
Meberat is a beautiful young woman who lives in Tigray, Kileteawlalu wreda, Tabya Agulae, which has infrastructure like tap water and electricity. She was married at the age of 14 and gave birth at 15. After five days of prolonged labor, she delivered at home and developed fistula. At that time, she knew nothing about fistula and did not know how to share this problem with her parents. Meberat lived with fistula for four months, experiencing partial paralysis in her legs. After a long four months, her family encouraged her to go to the Mekelle Hamline Hospital where she received her first treatment on the journey to cure her fistula.
While stuggling with the embarrassment of fistula, Meberate felt guilty, unlucky, and like she had been cursed. She said “I cried and ask to God, why did I become likes this? What did I do?” Unlike many young women who develop fistula, Meberat's husband was beside her through the entire process. He encourages her every day and takes care of her needs. Her relatives and community have also been a major support throughout this difficult time.
“Life after surgery is very pretty! I planned to lead my life properly and my husband becomes very happy and passionate, my relatives and the community wishes me best and welcomed me” she said. She was screened by Mekelle Hamline Fistula Hospital to join Healing Hands of Joy. She is very happy and feels lucky to train with HHOJ for one month.
Meberat now has her own corrugated metal home and 2 hectors of land for agriculture. She has her own business raising four chickens and one ox. Meberat is currently in grade 6.
We are so blessed to have been able to work with Meberta and see her life be transformed. We cannot wait to see what the Lord has in store for her and her husband.
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