A large part of my work now entails more than just capturing the still image. I am often asked to collect video and professional sound so that the content can be edited into small video stories or other applications. Here are two examples from my work documenting Hamlin midwives in Ethiopia.
I enter the room cautiously, not wanting to disturb the family. They motion for me to come all the way in, and when I do, I see beaming faces and hands outreached, scrambling to make contact. I am only the photographer, not a doctor, but their joy and appreciation are boundless: Degie has lived through an obstructed labor and childbirth, and the baby is thriving. I look at Degie, and her smile is wide, tears are in her eyes. I grab her outreached hands and shake them like a mad woman. I too am thrilled to see such a difference in her well-being. I can also detect concern regarding how she will comfortably make the long walk home.
She slowly uncovers the tiny baby boy next to her, her first-born child, and the cool air makes him stir. Lips plump, tiny fists pumping the air, he opens his eyes and makes a sucking sound that makes us all laugh. He is content. I motion outside for someone to come and translate for me, and I tell Degie that I think she will make a wonderful mother. I also tell her that I have never seen such devotion from an extended family, at least three members sitting at her bedside around the clock, waiting to see if she needs anything.
In rural hospitals, the family must provide basic care for the patient. They feed them, bathe them, and sometimes even administer simple nursing tasks. Degie’s sisters, brothers and grandparents have provided exceptional care for her. It is not always like this. At times, there is no family support. These perhaps are the most difficult situations to witness. When a person comes in great crisis, and they have no one to support them, most likely they have no means to pay for services and they reluctantly must turn away. It is heartbreaking to watch a very ill woman, laboring with a child, have to leave the hospital grounds based upon inability to pay the fees. Once again, our souls reach out to her and want to pay the fees, but the hospital administrator strictly advises us that this creates more problems than they can handle once we are gone.
What do they do? Where do they go?
This is simply a way a life here in rural Ethiopia. Our minds turn to how we could possibly make the payment of fees sustainable. An on-going fund for destitute patients? A plea to the government? We don’t know these answers.
But Degie is fortunate in that she has many brothers who sold cows to pay for her surgery, and have taken time from the fields to carry her home. They gently walk her to the makeshift stretcher, and tenderly move her down onto it, covering her with a gabi. A chaotic flurry of hands dip into injera and food is passed around. The men are fed quickly so that they have strength to make the arduous walk over rock strewn terrain back to their village. After a bit more clamoring as they decide who is in front and who is in back, they reach down and pull up on the stretcher, lifting Degie’s body high onto their shoulders. The sisters pack up the food and scurry behind, barefoot with gabbies flowing in the wind.
I watch them turn away from the hospital and walk together down the rocky road toward their village, their feet hitting the ground in rhythmic unison. And as they disappear into the horizon, I see the faint outline of a group of men carrying a woman toward the hospital.
She stands in the doorway, shoulders slumped, hair in tangles from not being washed in a week, shirt stained with blood, tears streaming down her cheeks. One hand is in her lab coat pocket, the other fumbles with the keys that mysteriously no longer work in the door to her sleeping room. Four women walked in with dead babies today alone, with several mothers struggling in other beds; it’s been a difficult day.
She longs to quiet her mind, to place the images of death in perspective with the job at hand. She signed up for this, with full knowledge of the difficulties. A diversion please. Shower? There is no water. Chocolate? Gone. Music? Too much of a reminder of home. A nice note of encouragement via our CDMA internet connection? It’s 3:10am back home, so no news. Like many Ethiopians who are hungry, worn or troubled, she reaches for sleep. But in this place, on this day, it does not come. Tossing and turning, stomach in knots, a fever arises and she whispers: “This is hard.”
Death is a part of the fabric of life here in Ethiopia. The people have come full terms with the likelihood of its occurrence. According to World Health Organization figures, 10,000 babies and 1600 mothers die from childbirth complications every day. Here at Mota Hospital, the director responds to the question regarding what is the most difficult aspect of midwife retention with the words: “We see death of our mothers and sisters every day, on our doorstep, and we have little supplies to help them.”
The problem is quite complex, as many intertwined issues exist in Africa. When a girl or woman labors at home, she may not even be aware that there is a health center nearby. Hospitals have a desperate need for doctors, which are first priority, and they rarely have money for outreach and education. Even if she does know about the hospital, often a woman will suffer in silence and not want to bother her husband, father, brother who toil in the fields all day. By the time she musters the courage to say she thinks she is in trouble, it is often at such a late stage that the baby and mother are well headed toward death.
If she is lucky, the husband, father, brother may then rally several men to carry her over the rock strewn and rugged terrain to get her to the hospital, walking for hours, sometimes days to get her here. And then, once here, they see the costs that are associated with care (most often less than $100) and they quickly realize that they will have to sell all of their cows in order to pay the bill. The pivotal decision must be made: get the care their loved one needs and become destitute, or turn away and go back home. At times, treatment will be started only to have the family run out of money and leave mid-treatment. And perhaps the worse situation is when a woman is carried to the hospital only to find that it is not staffed.
We often long to pay for services when we see that they could save a life. We are told that this is not sustainable for the hospital, as many problems arise when the hospital cannot pay for other villagers after we have gone. Money is best donated toward equipment and occasional free services where they deem it to be appropriate. So, we assimilate to this way of life, and now, here in this tiny village, the problems of Ethiopia become our problems. No longer are we a simple bystander. We feel the loss. We see the complexity. We are saddened by the pain these women and their families suffer.
And, we hold hope, just as the doctors do.
A new road is being built that will connect Addis Ababa to Bahir Dar. Mota will become a stop mid-way, and many believe that this road will create a demand for better services in Mota, such as desperately needed water flow. This will enable the old rusted truck ambulance be to retrieve patients from outposts. It will bring better telecommunications services. The doctors tell us that they have seen immense progress already in the few years that they have been here. I ask them what support they have to mentally keep going when they see so much suffering and death every day. Their answer is said with quiet and passionate devotion: “These are our mothers and our sisters. Of course we will work for them.”
I have often reflected on the eye contact that is present in Ethiopians. I have traveled to many countries, witnessed many rituals and interactions, and never have I seen such an intense and long-holding gaze as here in Ethiopia. A few weeks ago, an Ethiopian man said something to me when I asked about courtship here that plays out in my mind today. His words: “Everything starts and ends with the eyes. It’s all within our eyes. Words are never needed.”
Ethiopians are creative, full of wonder, and tender. They know and experience many things that most of us will never endure, let alone fathom that these situations even exist. When I look into their eyes, I see more than the current situation at hand. I see belief, hope and an almost father-like twinkle that tells me they see me as a child: innocent, comfortable and maybe even if I am lucky, endearing to them. They see through me, because my life, my world, is transparent and thin compared to theirs. Their heart beats hard every day, while mine has long periods of rest, boredom even.
I look at Dr. Philippa as she finally finds sleep, and I admire her dedication to enter this world and exchange information with the midwives, and to also bring us all into the equation of moving toward the goal of creating healing environments for anyone who suffers here.
It is now morning, and Dr. Philippa rises with vigor and purpose. She picks up her stained lab coat, grabs a piece of bread, and pushes the door open to go round on the patients. Before she leaves, she hesitates, looks over at me and starts to say something. She searches my eyes, and then without words, closes the door behind her.
By now, many family members are crowding the doors, becoming more desperate as time moves on. I try to ease their concern by saying “teru doctor” (good doctor) but they look past me. Crying turns to sobbing, as each family member finds a stoop to sit upon outside of the operating room that is maneuvered without running water.
By the time I have changed into scrubs, I see that the nurse anesthetist is already preparing Degie for her spinal block. I rush into the room, find a position that is far from the sterile field, and set up my camera. Within literally minutes, Dr. Philippa exclaims with excitement, “And…..WE HAVE A BABY!”. The room is filled with the glorious sound of the cries of a newborn baby.
Though extremely weak, Degie is now alert, and begins fervently looking about the room, her eyes tracking every move of where her baby is. I ask a midwife to bring the baby over to her so she can see it. He does so, and she stares deeply at the infant. I take a few photos of the baby, and exit the room. I can’t take my scrubs off fast enough to make my way outside. I show the family the photo of their newest addition and say ” konjo baby” (beautiful baby). The sisters and brothers press against each other to get a peek at the photo. The grandfather shouts for joy.
Degie’s parents are both dead, but she has a wide circle of support with her many brothers and sisters and grandparents. One young man looks particularly shy, and stands apart from the group. I move away from the crowd and show him the back of the camera. A slight smile starts at the corners of his mouth, and he looks intently into my eyes.
“Degie husband”, someone whispers. I turn to try to say something to him, but he has moved away. He now stands in front of the doorway, trying to get a glimpse of his wife.
Degie is curled on her bed, her body is still. Her breathing is shallow, and her eyes can’t seem to focus. Her tattered gabby cloth swirls around her body, and one bare foot is dangling over the side of the bed. I look at her for a long time, wishing I could help her. I hear a voice, and see that the woman in the bed over in the corner is also watching her.
“She sick. Very sick,” she says in broken English. I nod silently in agreement.
Degie is tiny. Her rail thin body is listless, and her mouth gapes open as she tries to take in each breath. I try to find a midwife to ask about her, and as I start to move away, Degie screams out in agony. A midwife rushes into the room, followed by our medical team. She has been in labor for a long time, no one knows for sure exactly how many days it has been. A few family members are sitting near her bed, and as the day progresses, more brothers and sisters trickle in, having heard how sick she is. Many are openly crying.
In rural Ethiopia, family members are expected to fill in as nurses and to provide other items of support such as food and bed sheets, but it is apparent that this family is here because they love her dearly and they are deeply frightened.
This is Degie’s first pregnancy, and she is near death due to this long labor.
The midwives administer Pitocin, and wait for her contractions to come more frequently. Once they do, they ask her older brothers to carry her into the labor room, and they comply in a stoic manner. It is not hard to see the concern on their faces. Degie continues to contort her body as each contraction comes, yet she is so weak she can hardly breathe, let alone scream during her pain. The midwives ask Degie to start pushing. They try everything to get the baby out, but it will not move.
Degie is suffering from obstructed labor, which often results in death for both the mother and baby. If a woman does live through obstructed labor, she frequently develops a fistula, which has devastating physical, social and psychological effects.
After two hours of pushing and an attempt at delivering the baby with a vacuum, one midwife, Selam, asks for visiting obstetrician Dr. Philippa to return to the labor room. Once Dr. Philippa arrives, she agrees with Selam that Degie’s tiny pelvis will not accommodate the birth of this baby and the baby can only be delivered by cesarean section. When they ask for Degie’s consent, she shakes her head no. She is scared and is worried about the money: less than $100. The midwives tell her brother that both Degie and the baby will die if the baby does not come out soon. Degie’s brother assures Degie that they will sell precious cattle and do whatever it takes to find the money. He pleads with her to say yes.
Degie gives her permission, and is swiftly transported to the operating room where a team of midwives, a nurse anesthetist, Dr. Philippa and Physician’s Assistant Darlene have assembled. They are ready for her.
In our fury to obtain water and find sources of clean vegetables and resolve the insect biting problem and find the latest irrelevant lost object, we sometimes forget why we are here in this dusty, remote village of Mota. Bekaset’s story is a jolting reminder of the desperate need for help in this region.
Bekaset’s pregnancy progressed normally until she went into labor. As she labored, her pelvis was too small to deliver the baby, and the baby became wedged in her birth canal. She knew something was terribly wrong, but she lived far from any health care and there were no midwives in her village who could help her. Her labor became obstructed, and the contractions forced the baby lower and lower into her birth canal. The relentlessly intense pressure eventually tears her uterus open, and the baby quickly dies.
Had Bekaset not heard good reports about Mota Hospital, had she not made the decision to leave her safe and comfortable home in her village of Debrework to try to find help here, had she not felt physically able to make the long bus and foot trek to Mota Hospital, had the men in her life not supported this journey by carrying her as she labored, had she suffered in silence like so many Ethiopian women do, she would be dead today. This would have left her children motherless and her weary, loving husband, who toils all day in the fields, uncared for. It is apparent in the eyes of her husband, Niguss, that he is desperate for her to live. He looks at her tenderly, his fingers slowly stroking the edge of her blanket. Words are unnecessary at times such as these, and cultural differences disappear. His pleading, yearning, silent eyes say everything. They will haunt me for life.
Instead, Bekaset is now under the care of skilled midwives and our medical team. A decision is swiftly made to remove the dead baby and her uterus, so she does not perish. Her surgery proceeds without issues, and her recovery is quick.
Days pass, and it is now time to go home. Her husband and father, who have been patiently caring for her and bringing her food during her days of recovery, are there to walk with her to the bus terminal. Her face is drawn; she has lost the baby she had come to know within her, and she also realizes that she will never bear another child. Yet, there is a deep respect for those who helped her here at Mota Hospital: she is alive, well, and able to return to her other children and household duties.
We give her a pair of donated KEEN shoes to make her walk home a bit more comfortable, and I watch as her family take tiny steps behind her to ensure that she is supported. The love is so apparent, more so than I have witnessed in many recent years of observing my own culture. They know what Mota Hospital has done for their lives, and without words, we all know why we came here.
Eyes speak, hearts leap, hands join.
