Moving to an African country for six months gives one plenty of reasons to be afraid. Besides the numerous unknowns in a strange new land, there is no shortage of horror stories and anecdotes from previous travelers that can make you scared to even walk out your front door! While many people fear kidnapping, mugging, or attacks by wild animals, my own personal nightmare-in-waiting was getting so sick that thanks to bad food or water I would spend hours and hours praying to a toilet bowl followed by a day or two of sitting on one. Unfortunately for me, my nightmare came true on January 2, 2011.
I had just returned from spending the New Year in the remote western Ethiopian region of Gambella, which shares both a desert scrub landscape and regional tribal culture with neighboring South Sudan. Because I had been working almost exclusively on the Carter Center’s Trachoma elimination program which treats millions of people in just one week, my boss here thought I might benefit from being exposed to an entirely different approach to neglected tropical diseases that is relentlessly focused on reducing under two dozen cases in the entire country to zero cases for the rest of time! Gambella is “ground zero” for Guinea Worm in Ethiopia, with all 21 cases in 2010 reported from one small Woreda named “Gog”, confined to an area of three ponds the Center has dubbed “The Great Guinea Worm Triangle”. After seeing the MALTRA program first hand and having just analyzed the results of data that revealed over nine million doses of Zithromax® dispensed and almost 90,000 anti-malarial treatments in one week, 21 Guinea Worm cases seemed so low I wondered what all the fuss was about. However, completely eradicating any disease, I learned, requires the complete absence of cases, year after year, until the disease has no more transmission vectors and ceases to exist. And that requires a tremendous dedication to disease prevention, identification, containment, and treatment along with huge grass roots education campaigns, all of which I saw evidence of as we traveled hours through the countryside by land cruiser and on foot.
While we traversed the region, we had to eat of course. Fortunately, there were plenty of small restaurants (I can’t call them “hole in the wall” since not all of them had walls, exactly). Unfortunately for me, the sanitation left a lot to be desired, and after a day and a half of driving back to Addis through truly spectacular scenery, I returned home and felt a strange rumbling in my stomach. I’ll leave out all that followed for the next three days, but needless to say I didn’t have to worry conceptually about my nightmare any more. I was in it. There is a phenomenon here in Ethiopia that expats call “Addis Belly”. I had become accustomed to its symptoms, which I can only describe as a background, aching pain in the stomach and a feeling that your digestive tract is “just not right”. When it got a bit worse in October, I took a three-day course of Ciprofloxin which helped for a couple of weeks, but it came back. This new bout of illness, however, required something more. Besides the cycle of Cipro, Lorena found me the Ethiopian version of Pepto Bismol (Peptica), as well as an anti-emetic to help keep food down. After about a week of feeling better, the symptoms returned, and I got to go back to a place we are getting to know really well here, St Gebriel Hospital, for a diagnosis. After giving them a “sample” (enough said) to bring to the lab, the doctor told me I didn’t have a parasite and then reprimanded me for taking only three days of Cipro. Rather than defend myself, showing him the Global Health Fellows medical sheet calling for a three day cycle and the same instructions on the bottle from my US pharmacy, I accepted his advice that “our bacteria are stronger here in Africa” and his recommendation (which matched WebMD’s) that I take a full five-day course to knock the bacteria back once and for all. Those who know me won’t be surprised that I took it for seven days 
For now, the symptoms are gone and Addis Belly has not returned. Fingers crossed that it may remain so!
Despite losing over a week of work to sick days, January was a busy month at the office. I had the task of finalizing the “MALTRA V Report” for the Carter Center and its partners, and the team allowed me to spend some time with my Macbook Pro trying to create a more aesthetically pleasing version for this round that would be a break from the typical “Microsoft Word” factual report and style. Thanks to a lot of photo contributions and repeated analyses of the (often updated) data, the final report is ready for printing in early February. I also pushed ahead on an idea to digitize the creation of “dosing stickers” to guide Zithromax® treatment in the field, purchasing samples from a vendor in the US and having local versions printed for comparison here. So far, it looks like the technique and approach are promising, and could allow the Carter Center here in Ethiopia to avoid a cumbersome and expensive process to repaint the thousands of existing metal sticks that are deployed across the northern reaches of the country. Though we had hoped to spend late January in the Simien Mountains of North Gondar to conduct a height/weight dosing study, due to time constraints and the difficult terrain of the zone, we were forced to postpone the activities until MALTRA VI in May. Some of the villages we were to visit were so remote that even donkeys cannot traverse the routes, so carrying the necessary digital scales and measuring devices would have been unfeasible. Back in Addis, a team of a dozen temporary workers have been furiously entering data into PCs from paper forms with the results of a trachoma prevalence survey that took place in East Amhara in December. The results will tell us how effective the first three years of Mass Drug Administration have been in reducing trachoma burden in the region, so we are anxiously awaiting the outcome! Seeing the effort required to manually enter tens of thousands of pages of data underscores the rationale behind the eSurvey proposal I put together for the Carter Center last month with the goal of digitizing the process of collecting this data in the field using new electronic tablet technologies. There is so much left to do, but so little time left.
As I write this, I have just five full days in the office remaining, and have been busily trying to wrap up my tasks here in Ethiopia, get started on the required activities for my transition back to Pfizer, and of course meeting with newfound friends to start the process of saying farewell. It is amazing how much you can learn about a place in just a few months, and we’ve been trying to pass on some of our experience and knowledge to some newcomers to Addis so that they can have some “free” perspective we had to learn the hard way! Ben Maxey (Global Health Fellow assigned to ITI) and I had the pleasure of taking some of the leaders of the local Lions Clubs out to lunch to express our appreciation, both personally and on behalf of the company; the Lions fund a good deal of the trachoma elimination activities in MALTRA campaigns, and included us in their “Sight First” work related to eliminating Measles as well. Lorena, who did some amazing volunteer work at a local hospital, and I were invited to a traditional dinner and coffee ceremony at the house of one of the midwives and it was one of the most special meals we have ever had in our lives. We also have been able to have S’mores – yes, S’mores – with our friends Jeni and Ray and hang out, and visit the silk spinners and weavers of Sabahar with our friends Dan and Nataly from the embassy. Incidentally, if you haven’t seen the homes of the state department employees on deployment, you’re missing out. It’s the ONLY way to live overseas! We were lucky enough to housesit for them to take care of their gorgeous Rhodesian Ridgeback, Sophie, and avail ourselves of Armed Forces Network, HD/BluRay movies, and (God Bless them) a crock pot to make slow roasted chicken! To prove we care about more than just our human friends, we have also spent some time helping our favorite neighborhood street dog, who gave birth to a litter in late January, raise and cuddle her puppies almost daily. Lorena even rescued the lot of them when they fell into the open sewer and were close to drowning, proving she is a better human being than I am (I’m not saying I would have seen them drowned, but I definitely would have had to think about sticking my hand in there)!
With so much accomplished, thoughts now turn to the future but not before wrapping things up the right way. There was a phrase floating around Pfizer for a while that comes to mind, “Finish with Finesse”. February will be busy, with a frantic week at the office in Addis, a week of vacation in the Rift Valley with friends, a long trip home (if we can get through Cairo, that is!), and a review meeting at the Carter Center headquarters in Atlanta. If you’ll excuse me, I better get back to finessing my way to the finish line!
SJ
