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Walking in the Shadow of Death with Courage and Hope: Experiences from a Trip to Ethiopia
I just finished 3 whirlwind days through Ethiopia on a learning tour on the challenges of saving the lives of mothers and their new babies. The tour was hosted by CARE–USA’s President (and a longtime friend) Helene Gayle and included good friends Christy Turlington Burns and Jenna Bush Hager (doing a story for NBC). It also included new friends Deb Derrick of the Gates Foundation, which funded the trip, and Representatives Aaron Shock (R–IL) and Laura Richardson (D–CA). All of us – old friends and new – bonded as I did with friends in medical residency, not just as companions, but as those do who have walked together the shadow of death, and who come out of the shadow with an abiding sense of hope, even of joy. We met extraordinary, courageous young girls ages 4 to 18 in Addis, the capital city. Many of the older ones had run away from their rural homes to avoid becoming child brides – but now worked as ”domestic help” for slightly better–off Ethiopians, working 16 hours a day7 days a week, for $6 a month. They were able to escape to the Center for 4 hours a week to learn to read and write and to be with the only friends they have known for many years. When asked what they wanted to do, most said that they wanted to help young girls to avoid their own fate. While there was a sparkle in their shy eyes, they shared a sense of subdued spirit that comes from a lifetime of hardship. The younger girls’ classrooms were raucous and full of cheers and smiles. Although Ethiopia has increased primary school attendance from about 30 percent to more than 90 percent, higher among girls, some still do not attend because their families cannot afford uniforms and books (school itself is free). Yet they hope to be doctors, teachers and, amazingly (since they have never seen an airplane) pilots! That’s imagination and its constant companion – hope. We also saw the devastating health effects of early marriage and pregnancy – an awful affliction called fistula. Girls as young as 8 can be forced to marry and to try to have children. Because their pelvis has not had time to grow, the baby cannot get through the birth canal and the uterus can be badly damaged, which leads to an opening to the urinary track and the bowel. Not only does the young girl have to deal with the trauma of losing a child, she will constantly leak urine and feces, causing a a foul smell that results in total rejection by her husband, friends and even family. But early marriage isn’t the only cause of fistulas – any obstructed delivery can do it and most of the 130,000 cases of fistula worldwide are in Africa. A relatively simple surgery that costs only $500 including a 2 weeks hospital stay – less than [!] the cost of a visit to the emergency room in the US – usually cures the problem. In Addis, we visited the Hamlin Hospital, an oasis of love for society’s unlovable, that has performed 30,000 surgeries and recently started a midwife training center so that obstructed labor is managed. The Government of Ethiopia has declared early marriage illegal. By dealing with the social causes of fistula, there is hope that Africa can stop it as we stopped it in the US a century ago. We traveled to a health center in Doba, only 230 miles away, but involving a one hour flight and a 3 hour drive. Doba has 30,000 people, but goats not people filled the streets on the way to feasting tables to celebrate the overlapping Muslim and Christian holidays: Eid, which ends the fast of Ramadan, and the the Ethiopian Orthodox New year. In this town, Muslims and Christians clearly lived together peacefully – a shining example for the world. We met a young woman who had suffered for 9 years in disgrace and despair with a fistula. Now she glowed, giggled and said she would teach others not to wait, that they could lead normal lives if they underwent the 2 weeks surgery, provided free of charge. Her mantra was “take 2 weeks to save your life”. The health center is the referral site for several health posts. There are no physicians – the place is run by nurses and health officers (with 4 years of basic training) who can provide many services, including more advanced care for women with difficult deliveries. We traveled by 4–wheel drive SUV from one health post to the health center – it took over an hour. We then drove to the nearest advanced hospital with physicians and obstetricians who can manage the most difficult pregnancies. It took 3 hours. The long distances and expense of travel from health post to health center to hospital convinced the government that they needed to make higher quality services available closer to where people live. We learned about their aggressive effort to build more than 3,000 health posts and place more than 30,000 trained community health workers – 2 per village – in the last few years. This remarkable undertaking is being led by the extraordinary Minister of Health, Dr. Tedros. Ethiopia’s rapid completion of this goal is a clear demonstration of how U.S. aid and African countries really work together. Congresswomen Richardson described it best: U.S. support isn’t about being the “white knight” coming to save poor, uneducated people. It is about supporting talented, resourceful and courageous people to solve their problems. I agree. When I worked in the Bush Administration, President Bush called for an end to the era of paternalism in development and its replacement by a new a new era of partnership. The the Obama Administration has embraced this strategy and is building on it. In the Health Minister and the Government of Ethiopia, the American people have an exceptional partner. The partnership extends down to the village level. We met with several community health workers. They are nearly all women and are paid by the Government. The Government specified that these healthworkers should be women, so that girls and women in the villages would feel free to talk with them about their health issues, including helping them avoid unlooked for pregnancies. These workers perform an extraordinary number of crucial tasks. They help women learn the danger signs of delivery, encourage them to deliver in a facility (in rural areas now, less than 10 percent of women do), work with traditional birth attendants to teach them the signs of complications and when to call for help, and assist in delivery. Why is increasing the number of deliveries in healthcare facilities important? Nearly half of deaths in childhood could be prevented with cheap and relatively simple interventions for bleeding and high blood pressure – but women need to get to facilities in time to receive care. On the other hand, unlooked for pregnancies are even more easily prevented. One third of deaths related to childbirth could be avoided with inexpensive injectable contraceptives that last 3 months. But there is an even better innovation – an implant that lasts 3 years allowing for birth spacing – and it can be removed if family plans change. Health extension workers have been trained to place them and 1.6 million are already in use. With just 3 cheap, simple interventions for bleeding, high blood pressure and unlooked for pregnancies, 80 percent of women who now die in childbirth would live. The community health workers are the backbone of a network to help ensure pregnant women receive the services they need. But they are each supported by as many as 25 volunteers – about half men. Without the involvement of men, the health of girls and women will not be fully optimized. We met with leaders of a local kabela (of village) – all men. The head said that the health workers had become an important part of the community and that demand was growing for better services. As a result, the leaders felt more accountability to their people for improving healthcare. We had the sense that the tide was turning at the grassroots level. That is transformative. That gave us a strong sense of hope. The hope we felt was not only for the people of Ethiopia. I think we also felt a very strong sense of hope for the United States – a sense of what has made us a great country and that our greatness will endure. Many of the programs we saw were supported by the American people, including the US President’s Emergency Plan for AIDS Relief begun by President Bush and being carried on by President Obama. Everywhere we went, from the Minister to the village, people asked us to thank the American people. Compassion and generosity, a belief in the dignity and worth of every human life and opportunity for all are at the core of who Americans are and what our country stands for. On this trip, we saw the values that have made our country strong building the strength of Ethiopians and Ethiopia while enhancing our own strength and greatness. On a personal note, I saw America’s greatness in my fellow travelers, all with a deep commitment to service and profound compassion. Helene Gayle has spent decades contributing to global health and has proven to be a fantastic leader of CARE USA. Christy Turlington has turned her own experience into a passion for improving maternal health worldwide. She’s made a moving documentary No Woman No Cry, which has communicated her own passion to thousands of others, and has become a leading advocate for the health of girls and women. But it was our youngest companions who gave us all great hope for our future. Jenna Bush Hager (and her sister Barbara) inherited a big heart from her mother and father, but she has made it her own through service as a teacher in a SEED school and a volunteer abroad. She is already an accomplished advocate as a reporter and a writer – she is writing a book which will tell Anna’s HIV. Representatives Richardson and Schock demonstrated the promise of bipartisanship and that people who disagree can do so with an open mind and heart. Their commitment to join the trip during campaign season and in the midst of difficult financial times showed us that we can be generous at home and abroad at the same time. It was a great privilege to be in their company and we are grateful to them for keeping the fire of hope burning in us all.
Ambassador Mark R. Dybul is the inaugural Fellow in Global Health at the George W. Bush Institute. He plays a key leadership role in the Institute’s Pink Ribbon Red Ribbon campaign. From 2006 to 2009, he served as the United States Global AIDS Coordinator, leading the implementation of PEPFAR, the President’s Emergency Plan for AIDS Relief. Launched by President George W. Bush, PEPFAR is the largest-ever international health initiative for a single disease.
Dybul received his medical degree from Georgetown University.Full Bio