Saturday

I could write a long chapter in a book about each of our days in Harar. This, our first full day begins with breakfast at the guest house of coffee or tea, and a unique “pancake” for lack of an adequate description and with fresh honey to put on it.  Actually very good.

I want to go to an ancient Muslim cemetery which is somewhat outside the old city, but first, after wandering a little we stop for a large glass of fresh papaya juice which Daniel and Sierra have grown to like.  Sitting next to us are two men, probably in their thirties actively communicating in sign language.  

We finish and walk perhaps a half mile in the presumed direction of the cemetary and one of the  deaf men comes upon us.  Daniel communicates with him by gestures and typing on his phone and he begins leading us to the cemetery.  It is quite a long walk and very hot.  We finally see the cemetery and some men in the distance.  Turns out they are building a gravestone.

We watch them for a while and then begin to ascend a steep hill through a very large field of recent gravestones, then somewhat older, and then very old and deteriorated stones.  All the while Daniel continues to communicate as I have no interest in this otherwise very nice fellow.  I assume he will want to be paid at the end and I am thinking 100 birr.

We walk quite a distance, climb over a 5 foot stone fence and jump down 7 feet to a road. Take  a Bijaj to the market with its essence of spices and coffee,

and ultimately I head back to the guest house for a nap.  I give Daniel some money because our companion stuck to us like glue, obviously wanting to obtain a fee for guiding us, even though we neither engaged him nor wanted him.  Sure enough as I am nodding off to sleep i hear him in the courtyard arguing with Daniel. He wants 500 birr (a ridiculous amount for an unwanted companion). Daniel ultimately gave him 250.

Went for a long walk and ultimately to dinner.  I lingered by myself for a while and encountered a group of 5 young people from Italy with whom I compared travel notes.  End of another wonderful day.

Friday

Today is a travel day. but first we go to the hospital for morning report.  This is followed by a “seminar”.  One of the residents gave an excellent presentation on neuroanesthesia.  This was followed by another superb presentation on trigeminal neuralgia.  By prior arrangement I supplemented this with some intra-operative photos of the treatment of this condition, as well as a review of all the available treatments.

In early afternoon we fly from Addis to Dire Dawa.  Took a minibus from Dire Dawa to Harar (45 miles in 1 hour for 22 birr = 75 cents). Harar is an ancient Muslim town with an old walled city, and the "new" city outside the old city walls.

  Bijaj (3 wheeled vehicle) to near our guest house and walked the rest of the way.  Primitive old traditional Muslim house on a narrow alley. 

They have only one twin bed room for Daniel and I, and a room up some very steep stairs for Sierra.  There is a bathroom across the small courtyard which is clean but primitive.  Today there is no running water whatever, apparently a common problem in Harar.

We have not eaten in many hours so we head to Fresh Touch, the primary recommendation in town.  Nothing fancy, but good food.  At dusk we head to see the hyena man.  This is a unique experience in all the world.  We hire a Bijaj to take us there for 40 birr.  I witnessed this several years ago and it is clear that the vehicle is not taking us to the place I had been.  Furthermore a native jumps in the vehicle with us and we are soon to learn that he is a “guide” to get his cut of an outrageous fee that is asked of us.  We are the only ones there and I am thinking this is a sham; the guide is asking 200 birr from each of us.  I am now convinced that this is  sham, but try to bargain (unsuccessfully) for 100 birr each.  We direct the driver to take us back at which point they agree to 100 birr, and many other people begin to arrive.  Turns out this is hyena man 2.  It is very dark, and the hyena man motions for some of the other tour cars to turn on their lights.  He begins calling the hyenas by name, and one by one they slowly emerge from the surrounding forest until there are 14 in all.  He begins throwing meat into the air and they move quickly to eat it.  He throws the meat closer and closer until one of the hyenas is eating from a stick he is holding and finally from his hand.  Sierra is one of those brave enough to take a seat on a rock next to the hyena man, hold a short stick and proceed to feed a hyena.

When all is done, we take our waiting Bijaj back to the main town square where there is a chat market in progress under the dark of night.. 

Thursday

Morning report as usual and amazingly only one trauma case last night.  This gave me an opportunity to ask questions regarding how all of our operated patients were doing and amazingly some very difficult surgeries thus far are all doing well.

After rounds I demonstrated the use of a lot of the surgical equipment that I brought this year.  One of the items is an electric drill with many bits for drilling burr holes, turning a skull flap, and carrying out spinal surgery.  It currently takes an hour or two to open the skull and finally get to the brain problem.  This should shorten this to 15-30 minutes.  Actually the chief asked if I would scrub next week and show them how to, in essence, get to the meat of the case much quicker.

Our surgical case this morning was a three year old with an enormous tumor, probably a low grade and potentially curable cystic astrocytoma.





They have asked me to give two lectures to medical students next Tuesday and Wednesday, which I always enjoy.

We left a little early this morning to have an early lunch before a very special afternoon.  Dr. Medoff, his wife Debi, and their son Sar from Greensboro, NC picked us up and we all went to the world famous Hamlin Fistula Hospital.  Their son Sar is in the last year of an Emergency Medicine residency at Emory in Atlanta, and has a one month elective rotation in the emergency room at The Black Lion where i am working.

The Fistula Hospital is a remarkable place.  Google it, or read "The Hospital by the River" by Cathrine Hamlin, or go to YouTube and search for "Oprah and Hamlin".


On the way back to our guest house they dropped me at the Telecom office.  I am running low on data on my cell phone and could not figure out how to add more.

Tomorrow I will be giving a conference, along with one of the residents,  to neurologists and neurosurgeons on trigeminal neuralgia, after our morning conference.  We are then leaving early to fly to Harar for the weekend.

Wednesday

After morning conference I elected to make rounds with the residents on all the neurosurgery patients.  I like to do this at least once a week.  We saw probably 30 or more adults and another 15 children.  A neurosurgical museum all in one morning.  Conditions I never saw in 40 years of practice and other more mundane problems but taken to the extreme.

Surgery today was a giant acoustic neuroma and a thus far undiagnosed huge tumor in a 40 year old woman (insert photos)

Waited for a minibus, but in the fashion of the Shanghai subway, locals kept edging us out so we took a taxi back to our guest house.  There is a new cafe practically on our door step, “Step Up” that turned out to be our best lunch yet.   A huge tray of Lasagna and drink for $3.50,

Had been talking for the last few days with Camilla, an academic from Sweden who comes to Ethiopia once or twice a year and is doing research at ASU (Addis Ababa University) having something to do with the “greening” of Ethiopia; i.e. efforts at environmental improvement. We invited her to join us for dinner and we decided to try a different restaurant.

Turns out that a 5 minute walk from our hotel are three outstanding spots: 1) Le Grand Reve; a Belgian restaurant where we actually had an excellent dinner.

Dinner at Le Grand Reve

2) Immediately next door to it is a new modern casual place, Savoy, where we had some gelato after dinner. 3) Just around the corner is perhaps the fanciest restaurant I have seen in Addis (not including the many new westernized hotels), Attica. An Italian restaurant that gets outstanding reviews. In the course of findings these I have also learned about “Five Loaves” that i am going to try next week.  In summary, a lot of my previously favorite restaurants have been closed, but some new wonderful restaurants have opened.

Addis has been undergoing enormous change in the past five years.  You cannot go anywhere, look around you, without seeing at least 3 new skyscrapers under construction.  There are at least 30 new hotels just in the last few years.

Tuesday

Usual morning report reviewing 5 emergency cases from last night.  I then announced that I would like to have 2 of the junior residents with me for my clinic.  Very junior, indeed.  They began their residency yesterday (January 1 — not New Year’s Day in Ethiopia).

A good opportunity for me to recall basic neurosurgical interviewing and examination skills.  A number of very interesting patients, a few rather mundane.

After clinic we walked one mile uphill to the Piazza for lunch.  Mediocre.  Took minibus a long way back to our area of town, then 1/2 mile walk to our hotel.

Went exploring with Daniel (one of the students) looking for a favorite French restaurant from years past.  Walked and walked some more and never found it.  On returning to our guest house, Google maps found it right away.  Will try it in the next day or two.

In the meantime went to a Yemeni restaurant that I like, though it was clear the students were unfamiliar with Mediterranean type food (much less Yemeni),  I was not very hungry so had just  Tabouli with a lot of the wonderful Yemeni bread.  Daniel made friends with the owner and he brought us some hummus “on the house”.

Monday

Off to morning report.  The residents present all the emergency cases over the weekend, about 15 in all.  A whole huge batch of residents (42!) and I know hardly any of them.  All the fellows I trained are now attending, and I am very impressed with them.

Took the students to see their first surgery . . . an enormous sphenoid wing meaningoma.  

The residents assisting, and doing the entire opening exposure were both women.  They have a new state of the art Leica $250,000 microscope recently donated by the Norwegians (The neurosurgery department at the University of Bergen has for many years aided the residency program).  However, in typical Ethiopian fashion they are unable to obtain funds to buy drapes for the microscope so as to preserve a sterile field during surgery.

Leave it to these clever guys.  They did extensive research and came up with a protocol for  exposing the scope to formaldehyde gas for 24 hours.  They then operate directly using all of the controls of this very sophisticated scope without an occasionally cumbersome vinyl drape.

Surgery began at 10am and concluded at 10pm with near total removal of this enormous tumor (we were not there for the entire operation!).

Did not eat lunch until 3pm and had a very late dinner after a very interesting day.