Field-Testing Survey Methods and Thoughts on Health Care in Ethiopia
Very recently, I had the opportunity to visit a health post in the kebele of Kaliti, in the woreda of Ad’a, in East Shewa, Oromia in preparation for the midline evaluation survey of community-based newborn care, which will take place in August.
Ethiopia’s health system is organized in three levels to address the needs of the population. The majority of the population in Ethiopia is rural and has limited access to health services. At the kebele level, there are facilities called health posts, which are staffed by health extension workers (HEWs). At each health post, two HEWs work together to provide preventive and basic curative services to the population within the health post’s catchment area. HEWs are young women who are often recruited right out of high school, and participate in one year of training. After discovering that most of the deaths of children under five were among newborns, the government of Ethiopia in collaboration with NGO partners introduced a community-based newborn care component to the HEW training almost two years ago, but only in seven zones. So, our task is to evaluate whether this training component is actually helping to reduce newborn deaths in rural communities through conducting a midline survey in zones with the intervention and zones without the intervention (called comparison zones). It is called a midline because it’s taking place at least one year after the implementation. By having these comparison zones, we can measure the effects that the intervention is having so far.
The purpose of the field visit was to test some of the survey methods in order to see what works and what doesn’t (things don’t always go as smoothly as anticipated in monitoring and evaluation processes). Once this is accomplished, the protocol can be refined and standardized, which will allow the interviewers to have a clear understanding of the data collection process and obtain accurate, high quality data when the survey begins. Because I’m responsible for writing the field manual, I joined the team to take notes and observe the process.
The drive to Kaliti was rough. It was 30 minutes away from Debre Zeyit, a town outside of Addis Ababa well-known for its crater lakes. The four of us bounced along the muddy dirt road alongside cacti and soon-to-be teff fields, where men were busy plowing with oxen. Along the way, we picked up the HEW, who was also heading to the health post by foot. When we finally arrived at the health post, there was a mother waiting for us with her newborn child. Our team had contacted the community the day before to let them know that they would be visiting from Addis Ababa, and that a medical doctor would be present. The medical doctor therefore serves as both an incentive (doctors are hard to come by in rural areas) and an important part of the evaluation.
It was very interesting to see how the team evaluated the HEW. First, a team member observed the HEW’s consultation with the mother and child, and noted down her activities, advice, and diagnosis. Next, the mother and newborn met with the medical doctor, who performed a re-examination. Another team member examined the HEW’s records and conducted clinical vignettes, which present certain clinical situations and assess her knowledge and training. By comparing the HEW examination to the doctor’s examination (the gold standard), it is expected that the effectiveness of the community-based newborn care initiative can be measured.
When we were finished testing our methods, we headed to a restaurant in the larger town of Debre Zeyit for lunch and coffee, where we could relax, talk, and debrief. Yirgalem, the medical doctor, told me a lot about the state of health care in Ethiopia. Apparently, many of the well-trained doctors leave to practice in other countries, including the United States, where salaries are higher. This “brain drain” is really taking a toll on the health and productivity of the Ethiopian people. Most of the doctors that do stay in Ethiopia are concentrated in major cities and private hospitals. In the rural, poorer areas, people continue to suffer from diseases like polio, leprosy, malaria, elephantitis, and river blindness. The latter two are caused by parasitic worms – conditions I’d expect to see in nightmares or horror films.
Although it makes me sad to hear about the shortage of quality health service provision in Ethiopia, I know that many NGOs have stepped in to fill the gaps and have made a lot of progress in recent years, particularly in the prevention of malaria. Although I’ll be leaving Ethiopia before the midline survey begins, I intend to follow the monitoring and evaluation process of community-based newborn care once I’m back in New York. I’m already excited to read the report that details the findings, and know that I was a part of the effort to improve healthcare in Ethiopia, even if in a very small way.
A kebele is the smallest administrative unit of Ethiopia, sort of like a neighborhood. A number of these “neighborhoods” are contained in a woreda, which is similar to a district. A collection of woredas comprise a zone. The East Shewa zone is a part of the Oromia region, which is the largest and most populous region of Ethiopia, and primarily composed of people who speak the Oromiffa language.
The Running Farenji
Something happened last week that added a little excitement to my usual Ethiopia routine and made it more like my America routine: I went on my first run.
I don’t do gyms. I’ve tried, but I really don’t like them. In April, I started running at Astoria Park about two times per week, where there is an outdoor track. I kept it up until I arrived in Addis, where I thought I might join a gym, but I just couldn’t bring myself to waste money on something that I don’t like very much anyway. So when I got home from work Wednesday, I was wanting to do something active other than a yoga podcast on the rug in my living room, so I decided to go for it.
It took me four weeks to attempt running outside here, for a few good reasons. The first reason may be a bit obvious because I’ve written about it before: the altitude and the air quality. After a month, I felt like I was well adjusted. Secondly, I finally felt like I had my bearings, and could make a 2-3 mile loop around my neighborhood without getting lost. Lastly, I had to mentally prepare myself for the people. I don’t see many local people training outside here, so based on prior experience, I figured a white woman running along a busy road around rush hour would get a few reactions. This is why I decided to put my ear buds in and tune everything out with music. Maybe it was a slightly dangerous decision because it diminished my ability to hear the erratically cars driving nearby, but I figured the music would be motivating and familiar, and therefore keep me going. It did indeed, and there were no close calls. I am happy to say that I arrived home later in one piece.
When I used to go running in rural Lesotho (which was very occasionally), children would shriek with joy and run alongside me for as long as they could. I would cringe at their bare feet pounding along the rough gravel road that ran through my village as well as the idea of that they were probably depleting the few much-needed calories they had consumed that day. Mothers and older women would look up disapprovingly from washing clothes, brewing beer, or other household duties, and I imagined they were thinking something like “what the hell are you doing and why would you want to waste your energy?” It was the same exact “look” I gotten when I had played in the snow. The men were surprised to see a white lady running around in leggings, fancy running shoes, and a t-shirt and would mostly just stare.
So when I decided to go running in Ethiopia, where people are well-known for their running abilities, I figured I had experienced the most extreme reactions already and that perhaps it’d be a little less weird to the modern city people of Addis Ababa. As I ran through the back roads of my neighborhood, people looked up from their conversations to watch me pass by. In one area where there were a lot of taxi drivers, shops, and children, a few of the bystanders stood on either side of the road and clapped their hands, as if I were running in a marathon and they were cheering me on to the finish line. Someone pointed and laughed when a moth flew in my eye and I couldn’t get it out, all while huffing and puffing up a huge hill. Once I got to the Sarbet roundabout (comparable to a large intersection) from the back roads, I continued downhill along a main road I know well, where there are many shops, cafes, and pedestrians. I was halfway there, on the home stretch back towards my home
There are moments when I have felt so out of control and helpless here in Addis. It’s difficult to describe how happy and powerful I felt as I ran down that busy sidewalk, as fast as I could, dodging and blasting past all the people, including the usual men who always shout “Hello! Sweet!” and pester me although I obviously want none of the attention. Towards the end of this long stretch, two young men joined alongside me for a while as they rushed to catch a bus. They were smiling and laughing, and waved goodbye to me as I turned onto my street. I got back home with a huge smile on my face. Running in Addis was actually unexpectedly enjoyable, in my neighborhood at least. I still will never be anonymous or blend into a crowd here, but that’s okay. I’m a farenji (foreigner).*
*Note: It appears that I am also known as “China” to some small children and “Sweet” to young and middle-aged men, which I don’t expect to ever really understand.
Cost of Living
When I came to Ethiopia, I knew I would spend less money than in the United States, but I didn’t realize just how much less. I’ve lived quite modestly for as long as I can remember. I spent my teenage years in a single parent household and have spent the last eight years relying on student grants and loans, or in the Peace Corps. Money is usually something that creates stress in my life, especially now that I live in New York City, one of the most expensive cities in the world.
For the first time since I was a young child, I feel like I can live more freely. I didn’t realize just how much anxiety not ever having enough money caused me until I escaped it. Here are the average prices I’ve observed for some common items in Ethiopia, converted into U.S. dollars:
-macchiato, made with high-quality Ethiopian coffee: $0.75
-bottle of St. George lager beer: $0.75
-large, sharable meal at an average Ethiopian restaurant: between $2.00 – 5.00
-pack of Marlboro cigarettes: $1.75
-bottle of spring water: $0.30
-netela (traditional handmade Ethiopian scarf): $10.00 – 15.00
-shoe-shine or cleaning on the street: $0.25
-public transportation, in a minibus taxi to another part of town: $0.10 – 0.25
Although most goods and services are considerably cheaper here, I’ve noticed that a lot of imported items are quite expensive, especially packaged and processed foods from the Middle East and Europe. To my disappointment, apples are also expensive because they are not grown in Ethiopia and must instead be imported from Italy. I’d say about 95 percent of the fruits and vegetables sold in Ethiopia are also produced in Ethiopia and are grown organically. This includes many tropical items I eat less frequently in the U.S. such as avocados, papayas, pineapples, and limes, but also the staples I love like bananas, spinach, potatoes, tomatoes, and onions. I was happy to see that produce stands are everywhere, and everything looks dirty and imperfect – fresh out of the ground or off the tree, which is how food should be.
While they look uglier, I find that foods taste more flavorful, especially the carrots. Here, it’s much easier to have a healthy diet when most of the foods that correlate with chronic diseases and conditions like obesity are uncommon and expensive relative to whole foods in their original form. It’s completely the opposite in the U.S (especially in the south, where I’m from), where so-called “food deserts” are common. You couldn’t buy a head of broccoli for miles, but there is a McDonalds or KFC right around the corner. The calories are there, but the nutrients are not. The famine in 1980s Ethiopia is over, and indeed many people still suffer from malnutrition, but the U.S. population in general is also suffering from a different kind of malnutrition.
Although I am happy that I can live a comfortable life, eat well, and save some money this summer in Ethiopia, there are a lot of beggars on the streets of Addis Ababa that can’t afford the very things that I consider to be so cheap. I feel poor in New York, but I’m not poor at all compared to them. It’s a strange, dual feeling that allows me to better understand just how extreme the levels of inequality are in our world. The hardest thing of all is that I can’t do anything about it.
Walk to Work
It takes me around 40 minutes to walk between home and my office each day. I realized, after getting home with about an inch of mud and grass caked onto my sandals the other day, that I brought way too many shoes of the wrong kind, meant for easy-to-navigate, relatively clean sidewalks in New York. But here, sidewalks aren’t always available. Because it’s the rainy season, I frequently walk in mud or, during an afternoon downpour, an inch or two of water. Cars have the right of way in Addis. Throughout half of my journey, I’m walking on a dirt path adjacent to a road named after Mauritania. Parked cars or mounds of dirt dumped there block portions of it, and drivers hardly yield to pedestrians as they cross streets. It appears as if no one follows any traffic regime here, which requires me to always be very careful. Almost every time I cross a busy street, I consider the possibility of being run over by a car. Unfortunately this route is the most direct one to get to work by foot.
It’s not only the traffic patterns that are different but the smells too. Mostly, I smell the black, sooty exhaust from old engines that penetrates the air during morning and afternoon rush hour. While I knew it was the higher altitude that contributed to my labored breathing in the first few weeks and adjustments to a new environment that caused me to catch a cold, I could have sworn that the black stuff in the air was to blame for all of it.
And then there are the whiffs of shit and rotting animals. My first week here, I saw a dying donkey covered in flies in the middle of a sidewalk (indeed there was an actual sidewalk along this road) not far from the large Sarbet roundabout. Everyone just walked by this poor suffering donkey as if it was normal or they didn’t notice it. Last week, I passed what I thought was a sleeping dog but soon realized it too was dead and its eyes were not really eyes but poked-out black gaping holes. I always get a little bit startled and shaken up when I come across things like this, but I suppose everyone here gets used to it if they see it so often. If I see dead animals on the road a couple times a week, maybe I’ll get used to it too.
Despite all of this, there are still plenty of beautiful, tropical plants to look at, and the pleasant, occasional aromas of roasting coffee beans or maize that fill the air. At least I don’t have to take in any of those nasty, greasy fast-food smells that seem to fill a lot of streets in New York. Best of all, there are always the funny, friendly people I encounter, like the old man who hopped under my umbrella and walked along beside me for a good fifteen minutes to get out of the rain.
Starting my Internship
My second week in Ethiopia was overwhelming, but busy and exciting. Here are some highlights:
- attending a live reggae music event (featuring Haile Roots, a famous Ethiopian musician) that turned into a dance party with a DJ
- having my favorite cross-body “going-out bag” cut off of my body from behind my back on the way home from above-mentioned music festival (don’t worry, I had a local ninja friend with me who reacted like lightning, and no one got hurt)
- Gaining internet access at home
- Cooking delicious, healthy meals with my housemates
- Starting my internship at JaRco Consulting and bonding with my colleagues over long lunches and plenty of macchiatos
I’ve spent most of my time this week at my full-time internship, from 8:30 am – 5:30 pm on weekdays. I am currently interning with JaRco Consulting PLC (links included in case anyone’s interested) an Ethiopian-based international development consulting firm. I am assisting JaRco and the London School of Hygiene and Tropical Medicine in the monitoring and evaluation process of community-based newborn care, which is a government-led initiative to increase newborn survival in rural areas by improving the quality of interactions between health workers and families. In Ethiopia, approximately 90 percent of births happen at home, and for every 1000 live births, around 37 babies die before they are one month old. Community-based newborn care therefore aims to improve access to health services in rural areas (where around 80 percent of the population resides). It does this through providing training to individuals in these regions so that they are better able to identify sick newborns, refer them to health centers, and if necessary, treat them on their own. There is a ton of work to be done, since the midline survey will take place this July. Basically, we have intervention zones (where the project was implemented over a year ago) and comparison zones (where the project was not implemented) throughout Ethiopia. By conducting interviews and various other forms of data collection, we can see measure the effectiveness of the community-based newborn care program and scale it up.
To be honest, I had an information overload in the first few days and had to do a lot of reading and research. In order to do my work effectively, I need to understand local government structures, the health system, and how this project is working to fill in healthcare gaps. I’m working with epidemiologists, which is a completely new experience for me, and I certainly am glad I went for that minor in biological sciences during my undergraduate studies. Now that I have a solid background and better understand the context, I feel like I am better prepared and have been enjoying the position much more. I was also sick with a cold the first few days, which likely affected my attitude and productivity. Overall, I expect to gain experience in sampling, qualitative and quantitative data collection, and program evaluation. I also hope to have increased knowledge about best practices in maternal and child health as well as the connection between health and economic development, particularly in Sub-Saharan Africa. I’m probably not going to have as much free time as some of the other New School interns in Ethiopia, but two months is short, I enjoy being busy, and I really value this work experience.
First Impressions of Addis Ababa, Ethiopia
When traveling to a new place, I do my best to keep an open mind and my expectations minimal. Other than what I had heard from Sim, our Amharic teacher in New York, and others who had previously been in Ethiopia, I had no idea of what it would be like here. After being a Peace Corps volunteer from 2011-2013 in Lesotho, Southern Africa, I was excited to return to the continent to live in a different country – this time for two months instead of two years. I expected that living in an urban area with the luxuries of electricity and running water would make this experience quite different than my last.
Although Ethiopia is very different from Lesotho, I’ve noticed some similarities. The small shops on the sides of the road made out of sheets of metal and other random materials, the minibus taxis stuffed full of people, and the conspicuous reactions to foreigners are just a few things the two countries seem to share. While my house has the luxuries I mentioned above, the electricity goes out periodically and the water isn’t always hot for my morning shower. I’ve also already washed clothes by hand, just like the good old days.
Like the people of Lesotho, I find the Ethiopian people living in Addis Ababa to be quite open and friendly. From my experiences, Africans are far more welcoming than a lot of Americans or Europeans. They are very willing to help and explain their culture to outsiders. I also love how excellent they are at sharing, whether it’s coffee, a meal, or an experience, without expecting anything in return. Although their lives are far more difficult than ours, seldom do I hear them complain. This I greatly admire, and I feel as if I learn a lot from spending time with people like this.
When I first stepped off the airplane last week, I was surprised to see a lot of traffic, hear so much noise, and smell new, strange odors. It seemed very disordered and dirty, but already it’s starting to feel normal. The city is more difficult to navigate than I anticipated and all of the various parts of town look almost the same to me. I hope that in the next few weeks I will be better able to distinguish them and travel between them with ease, especially since the IFP Ethiopia participants are living in different areas.
Overall, I find the city and people very intriguing. The food is also delicious. I am in love with Shiro Wot, a dish that’s made from powdered chickpeas and spices, and served with injera. I am very anxious to integrate further and find a comfortable routine here, but I know that this will not happen overnight, and it also requires better language skills. By the time it’s time for me to leave, I will probably feel more at home. But I am very happy to be back in Africa, even if it is for a shorter time.