Toward Emergency Department Integration in Ethiopia

In the dark of the night, our plane descended. A galaxy of yellow and orange house lights swarmed below, drifting closer to my pocket of airplane window. Twenty hours of travel (including two brief layovers) was nearly over. Complimentary glasses of red wine (for the circadian adjustment) had done their trick, and our wheels skidded down on cool Addis Ababa tarmac like a reunion of old friends.

Just three years previously (in November of 2011) I made my first trip to Ethiopia, as part of a multinational study assessing medical and nursing students� migration intentions. At that time I partnered with senior educators in Addis Ababa University�s School of Medicine and worked closely with senior and junior students alike, making quick and close friends at all levels. Ethiopia had felt a strange and unfamiliar place to me then�far different in culture, climate, history and language than any sub-Saharan African place I had ever visited. Now three trips later, however, it was almost a second home, my friends here some of my dearest, and the culture and customs no longer new.

As I waited in line for a renewed visa, watching disembarking passengers bolus past outnumbered Ebola screeners, excitement and impatient apprehension both swelled as I began to unlock the mental list of immediate �to-do�s� needed to jumpstart the upcoming three weeks of work. No longer studying health professional student migration (as I had my first two trips) or working clinically in the Emergency Department (as I had my third trip), my goal this trip was to forge a network of Ethiopian Emergency Departments in order to aid in multicenter data collection and analysis, and national and regional policy reform.

As elsewhere across sub-Saharan Africa (and, in fact, throughout low- and middle-income countries), the importance of emergency care is growing. And while most Disability-Adjusted Life Years (DALYs) in sub-Saharan Africa are still lost to lower respiratory tract infections, diarrheal disease, HIV/AIDS, and malaria (by Global Burden of Disease data), the burden of traumatic injury and acute presentations of non-communicable ailments is rising.

Ethiopia, in particular, finds itself in a unique situation. With the 13^th highest population in the world (second in Africa only to Nigeria), it also has both the largest proportion of rural inhabitants (80%) and the highest rate of urbanization (5%) of any of these most populous countries. But that�s not all. Among these most crowded nations, Ethiopia continues to boast one of the highest per capita GDP growth rates. In other words, Ethiopian cities are growing faster than in any other most populous nations (urbanization rate). Additionally, they will likely continue growing for longer than anywhere else, given the proportional and absolute size of the rural population, and they are filling with people who now have somewhat more money than they did, say, a decade ago. This money is often sufficient to afford slightly less healthy lifestyles (diet, cigarettes, etc.)�but not ample enough for medications to control the corresponding resulting chronic diseases. While these trends are familiar across Africa, it is in Ethiopia where a �perfect storm� of demographic and economic realities have rendered them most pronounced in both absolute and relative terms.

 For Ethiopia, the encroaching high tide of emergency care need represents both an immense crisis and an unprecedented opportunity. For a nation so historically rural, the urban health system capacity�including its emergency care capacity�must be rapidly expanded if it is to have any hope at absorbing the influx of demand. But precisely because so much growth is needed all at once, there is great advantage to undertaking it in a coordinated fashion. Indeed, it is in hopes of helping coordinate the emergency care data collection systems that I return to Ethiopia.

My first few days consisted of logistical essentials: buying a phone, buying a SIM card, buying a second SIM card when the first SIM card didn�t work; checking into a cheap hotel, moving to a second hotel with more reliable internet and closer proximity to the hospital; scheduling meetings, preparing documents for said meetings, rescheduling meetings, defaulting to back-up plans when rescheduled meetings fell through�. And finally came the opportunity to sit down with the Head of the Emergency Department (one of the hospital�s busiest men)�in a small hidden conference room tucked behind three bustling ED rooms. I handed him my proposal. We talked. Our meeting was brief; it didn�t need to be longer. We saw eye-to-eye�our mutual appreciation for the importance of this task fueling each other�s excitement. Without delay, he introduced me to an individual who would become over the next several days one of my closest collaborators�a young nurse

manager (A.Y.), recently trained in emergency care and critical care nursing and now working to coordinate referrals between Addis Ababa�s government hospitals.

As week 1 came to a close, I had spent many long days venturing with A.Y. and his team to all of the city�s government hospitals (as they coordinated referrals between them), confirmed data recording systems at each one, and developed a plan with A.Y. to standardize inconsistencies going forward. It was time for the next important meeting�with the Ministry of Health.

Over aromatic black Ethiopian coffee, we sat and pored through an intricate spreadsheet I had assembled on my computer late the previous night, summarizing the full week�s findings. The cool morning air bowed to midday sun, and we switched tables to keep talking. The lunch crowd came, then left. And still we talked through further details. Reviewing variables, considering how to improve collection of still others, discussing which additional ones might even be added going forward�and how, logistically, in a network of government hospitals with universal paper charts, to accomplish these tasks. Our work, at last, was finished. A team was formed. And week 1 in Ethiopia was complete, far more successfully than I could have imagined, thanks in large part to the Partners Centers of Expertise Global Health Grant.

Dave Silvestri, PGY-2

Department of Emergency Medicine

Massachusetts General Hospital

Brigham and Women�s Hospital