Ethiopian Doctors

​ Travelers Health 
by Dr Getachew Feleke          
July 2019

Introduction
​
Millions of people travel globally every day. Travel from resource rich to resource limited countries can be associated with travel related illnesses. Most at risk are those who travel to their country of birth as they are more likely to socialize, stay with family and share food and drinks. These diaspora don’t necessarily feel they are at risk and are less likely to take precautions.
Risk of travel associated illnesses is related to where one is going, the length of stay, the time (month) of travel, activities during travel and the underlying health status of the traveler.
Travel associated illnesses can be prevented or reduced if appropriate precautions are taken. The goal of this presentation is to increase awareness of common travel related illnesses. Travel to Ethiopia is the focus of the presentation, but the information may be relevant to other destinations too.
Tips to all travelers
In long distance flights, getting up, walking or stretching every couple of hours to avoid blood clots is advised. Prolonged sitting may result in blood clot (deep venous thrombosis: DVT) which is a serious health hazard.
Travelers taking medication must carry enough supply of the medicines for the duration of the trip.
Mapping out available health service at the destination is advised. Travelers may also consider buying travel insurance. 
Getting pre-travel advice and immunization from an experienced clinician is advisable.

Common travel associated illnesses:
-Diarrhea
-Fever/chills: many infectious causes 
-Respiratory infections
-Other (bites, traffic accident, sexually transmitted infections, skin rash)
Causes of travel associated illnesses
-Contaminated Food and water: Poor sanitary conditions lead to contamination of the food and water with human excreta (feces). Human excreta contain germs .Eating and drinking germ contaminated food and drinks cause illnesses such as traveler's diarrhea, hepatitis, typhoid, amoeba and cholera
-  Ingesting raw foods such as eggs, milk and salad may lead to traveler’s diarrhea.
-Not washing hands and using contaminated utensils are risk factors for upset stomach/diarrhea
Poor sanitary conditions and poor hygiene can result from lack of knowledge, lack of clean water, crowding, lack of bathrooms/latrines (open defecation), or other environmental and cultural factors.

         Vector (Mosquito) bites: Infectious diseases such as malaria, yellow fever and dengue fever are transmitted by mosquitoes. 
Malaria, a most serious infection that affects millions of people is transmitted by the bite of an infected female anopheles mosquito. Yellow fever and Dengue is transmitted by a different mosquito. 
          Contact with contaminated hands, utensils, environment: Infectious diseases can be transmitted from person to person through contact. Unclean hands, utensils, environment, etc play an important role in this regard. Diarrhea, vomiting, influenza are examples.
          Airborne (Breathing contaminated air): Infectious agents(germs) maybe floating in the air we breathe. For the most part, these bugs come from infected persons nearby who cough and sneeze without covering mouth and nose; Measles and tuberculosis are spread this way. 
 
The germ causing meningitis is spread similarly but requires close person to person contact
            Blood/body fluids exposure: Serious infections such as HIV, Hepatitis B. and hepatitis C are acquired from blood or body fluids of an infected person. This occurs via contaminated needles, sharps (blades, surgical instrument), unprotected sexual contact and rarely transfusion. It is important to note that these infections are not transmitted through hugs, handshakes, eating together, etc.
             Bites; scratches; cuts, puncture wounds Rabies is a deadly disease that results from the bite or scratch of a rabid animal, mainly dogs. Bats and raccoons are important carriers in the US
 Accidents that result in open wound can predispose to tetanus, a serious preventable infection 
Traffic accidents can present serious health risks to travelers 
Prevention of travel associated illnesses. 

Many travel associated diseases are preventable!
Preventive measures include:
1) Vaccination: vaccines are available against: Hepatitis A. Hepatitis B, Yellow fever, Influenza,
Rabies, Typhoid fever, meningococcal meningitis and cholera. Pre-travel consultation regarding vaccination is advised 
It is important to be up to date with routine childhood and adult vaccines.  (Measles, mumps, rubella, polio, tetanus, diphtheria, pertussis, hepatitis B, influenza.)
2) Mosquito avoidance: These important measures include
-Staying indoors at dusk and dawn. Malaria transmitting Mosquitoes bite early evening (dusk) and early morning (dawn).
-Cover as much exposed skin as possible, 
-apply insect repellents to exposed skin
-Use bed nets preferably impregnated with insecticide
3) Chemoprophylaxis (Using drugs to prevent infections) .
-This mostly applies to malaria. There are effective drugs that can protect from malaria.
-Taking the pills start before the travel date and continued during and for a few days after travel.

 General behavioral precautions:

-Wash hands after using the toilet and before eating or use hand sanitizer.
-Eat well cooked food while hot. Avoid cold foods. Food can be contaminated after it is cooked.  
-Drink boiled water, bottled water or chemically treated water 
-Fruits that you can peel are safe. Rinsing/ washing fruits, salads with water may not be safe as the water may be contaminated
-Avoid ice from tap water
-Avoid crowded places
-Avoid contact with animals
-Avoid unprotected sexual contact, unsafe body piercing, tattoos 
-If dog bite occurs, wash the wound with clean water immediately.

What can be done if one gets sick while travelling?

         Travelers’ diarrhea:  This is the most common condition a traveler encounters. Travelers’ diarrhea may be mild, moderate or severe. Fluid replacement is important.
Mild diarrhea: Usually self-limited. It can be self-managed with fluids and antidiarrheal drugs such as Bismuth sub salicylate or loperamide (lomotil). 

Moderate to severe diarrhea is best managed by health care provider. Self-treatment with   antidiarrheal drugs is acceptable. If there is no improvement in 2 to 3 days, a clinic visit is warranted.

Some travelers carry antibiotics ( ciprofloxacin ; azithromycin). In situations where no medical care is available, taking antibiotics as a temporary measure may be acceptable.
             Fever:   this may be caused by infectious diseases, that Include malaria typhoid and meningitis. Fever lasting over 24-48 hours must be taken seriously, and must be evaluated by a healthcare provider.   
Being vaccinated or being on preventive drugs may not be fully protective. Serious infection such as malaria, typhoid, and meningitis can be deadly unless treatment is started early.
Fever in the returning traveler Fever may be caused by many infectious diseases, Including malaria typhoid and meningitis. Fever lasting over 24-48 hours must be taken seriously, and must be evaluated by a healthcare provider.   
It is important to remember that being vaccinated or being on preventive drugs may not be fully protective. 
Fever in the returning traveler could be a sign of a serious infection. Malaria and typhoid are two infections that can present in a returning traveler. If these infections are not treated early they can be deadly. The returning traveler who has fever must seek medical treatment immediately. 
It is important to inform the doctor all the travel details (itinerary) including vaccinations and medications taken. It is preferable to consult with a doctor experienced in travel medicine. 

Summary

Travel associated illnesses are common. Diaspora visiting friends and relatives are most affected. Traveler's diarrhea, hepatitis, typhoid and malaria make up the majority of travel related illnesses.
These infections can be prevented with pre-travel immunization (hepatitis A; hepatitis B; Typhoid) or taking preventive drugs (malaria).

Behavioral precautions are important in avoiding travel associated illnesses. 

       -Eating well cooked food while hot, avoiding raw foods and drinking boiled or bottled water.
        -avoiding mosquito bites (staying indoors, covering skin, using insect repellent and bed nets.
Mild to moderate traveler's diarrhea can be self-managed by taking fluids and anti-diarrhea drugs
Fever can be a sign of serious infection .Consulting a health care provider is advisable.
Fever in the returning traveler must be taken seriously and warrants seeking medical help.

Selected vaccines for travelers
Hepatitis A –Transmission is via the fecal-oral route (by contaminated food or water)
                     --The vaccine is protective; two doses are required given 6 month apart
                     -- Vaccination is recommended for individuals who are not already immune 
                      -- The vaccine may be taken any time before travel.   
Hepatitis B: Transmission is via blood and body fluid exposure.
                     -The vaccine is protective; three doses are required at 0, 1 and 6 months
                     -Vaccination is recommended for individuals who are not immune
                    -Hepatitis B vaccine is currently included in as one of the routinely given childhood vaccines
Meningitis:  -Transmission is from person to person (close contact)
                      -The vaccine is single dose.  
                 -Vaccination is recommended for travel during the dry season (December to June)
                     -The vaccine is best given 10 days or earlier before travel. 
                     -Booster doses are required in 3-5 years.
Typhoid Fever: Transmission is via contaminated food and or water
                           -The vaccine is moderately protective
                          -Vaccination recommended especially for those travelling rural areas,
                         -These vaccine comes in an oral and injection form. The oral vaccine comes in 4 doses 
                          The injection form is a single dose. Protection may last for 3 to 5 years.
Rabies:          -Transmission is by bite or scratch of a rabid animal primarily dogs 
                     -The vaccine is protective.it is not routinely available.
                     - The vaccine is recommended for travelers at risk of coming in contact with animals              
                    -If a bite/scratch occurs immediate medical attention is warranted

    Yellow fever:-Transmission is via a mosquito bite 
                            -The vaccine is protective. It is a one-time injection with lifelong protection.
                             -Vaccination is recommended if travelling to endemic countries.
                             -Yellow fever vaccination is a requirement to enter some countries
  Tetanus: The tetanus causing spore (germ) is commonly found in the soil. 
                              -wound (cut, lacerations) contaminated with soil may cause tetanus.
                             -The vaccine is protective .It comes as a combined vaccine against tetanus, diphtheria,  pertussis (Whooping cough); it is one of the routinely given childhood vaccines
                               -Repeat vaccination (booster) every 10 years is recommended. 

Written by Richard Pankhurst   ​

Adapted from An Introduction to the Medical History of Ethiopia

​While diplomats, doctors, and other foreigners had been introducing modern medicine to ever-wider sections of the public, the first Ethiopian doctor, quite unknown to Menilek or anyone else in the country, had been obtaining his training abroad.
The story of this physician, variously known as Dr. Martin and Hakim Workneh, is most romantic. Born in October 1865 of a good family, he was not yet 3 years of age when his parents, along with other prominent people of Gondar, were seized by Emperor Tewdros and taken with their families to his fortress at Magdala. On the arrival of the Napier expedition not long afterwards, the child was found wandering away from his parents and was assumed by the British to be lost. He was therefore annexed by Colonel Charles Chamberlain, of the 23rd Indian Pioneer Regiment, who took him back with him to India and kept him at his home in Rawalpindi. The colonel died in 1871, after which the boy was dispatched to the mission school at Amritsar, the expense of his education being met by one of their number, Colonel Martin. The missionaries christened the boy Charles after the colonel who had brought him to India and Martin after the one who paid for his education.

Written by Dr. Girma Abebe   ​

Written by Efrem Alemayehu M.D   ​

After graduating from the Addis Ababa University Medical School, we (the present members of Hakim Workeneh and Melaku Bayan Society) left Ethiopia for North America in the late 70s and early 80s. We left our beloved Ethiopia to further our education because of political unrest and other personal reasons. We left Ethiopia during the rainy winter, or in the summer time, a season filled with plenty of sunshine and comfort. Global warming and environmental degradation have changed the climate of Ethiopia from what it was then. Many are dealing with harsh and extreme weather conditions. But I digress. We landed in various parts of the U.S. and Canada, in the scorching heat of the summer or in the bone-piercing cold winter. Because of the newness of the season, we accepted winter with excitement. Many of us who settled in areas with snow have winter stories to tell. Let me tell you mine, as it will give you a glimpse of my early life in Canada. ​

Written by Abebe Haregewoin, MD, Ph. D. ​

Every society deserves a character that is at the center of this story. Even the most conservative societies need someone who thumbs his nose at what is considered sacrosanct and sacred and out of limits to either derision or negative commentary from the vast majority. This is always a sign of a healthy society – magnanimous toward eccentricity and tolerance toward members of society who sing to a different tune and march out of sync with the most common beliefs of most members of their society. In some societies such acts can have severe consequences, which may include stoning, or some such unpleasant acts by the conventional hordes in the belief that this will ensure the favor of God or the King or even other members of their society who are inclined to nod in approval at their outrage against the unlucky ones who end up being the individuals on whom society has to prove its point of, “Thou shalt not…” In the modern age in the so-called enlightened societies the media may take its pound of flesh if such a personality is worth their time and ultimately their economic interest. ​

Written by Dr. Zergabachew Asfaw  ​

It is a great pleasure to present Professor Edemariam Tsega as a pioneer in Ethiopian medical education. He single handedly introduced post graduate program in Internal medicine in Ethiopia and served his nation with great distinction for over forty years. He completed his primary education at Haile Sellssie I school in Gondar and his secondary education at Haile selassie I secondary school in Addis Ababa. He graduated from university college of Addis Ababa with bachelors degree in science in 1961 and then he joined McGill University where he got medical degree in 1965. He studied at London school of hygiene and tropical medicine in 1968. He did not want to stop there and even after becoming professor of medicine he eared PhD from Lund university, Malmo, Sweden. His qualifications are immense.
​

​Written by Fassil Teffera   

Many moons ago, I was assigned to work at Jijiga hospital. As it was customary at the time one GP is assigned to a hospital of whatever size, with some nurses and several Health assistants. I did the outpatient clinic daily and in patient rounds and minor surgery as well. I also did difficult deliveries though most of the deliveries were made by the competent Health Assistants who must have done thousands before I came to the scene.
I had a wonderful staff of Nurses, Health assistants, Lab and X-ray techs. We were supported by dedicated ancillary services and administrative staff. Of course, we had our dose of Political Cadres who carried their weekly indoctrination of the superiority of the Socialist mode of production over the Capitalist one.
One Friday, a giggling Health Assistant came and told me that a bride is coming to be seen by me, prior to her wedding night. I did not understand what it meant. She told me the Somali men bring their bride to the hospital prior to the anticipated wedding night. I still did not understand the whole idea. The Health Assistant noted my confusion and re assured me that everything will be fine and she will help me handle the issue as she had done with many others before.
Sure enough, there walked in a very handsome bridegroom and his beautiful bride with beaming smile in their beautiful weeding dresses. They got registered and the bride was brought to the OR by the nurses and Health Assistant, and undressed and put on an OR gown.
They all giggled saying that I will be the first man to see the bride even before the bridegroom. The lady was put on the table and the staff explained to me what to do. As it was customary in Somali culture all girls had sutures placed over their vulva thereby completely blocking the vagina except for a small whole for the urine to dribble thru. This was a protection from in inadvertent or deliberate pre marriage sexual performance.
After the lady was put on lithotomic position we figured out where the small hole was located, which was at the distal aspect of the vaginal opening which allowed only a small finger to be passed. The local lady sureon had done a good job of suturing the labia majora of a baby girl around the age of three and completly blocked and entrance or exit from the vagina.This was done to protect the girl and the family from future embarassment.

Written by Abebe Haregewoin   ​

​Written by Abebe Haregewoin   

​A very pretty teen age girl was brought to the emergency room at Fenote Selam Hospital in the middle of the night in a state of apparent uncontrolled shrieking alternating with strange gesticulations, shivering and writhing. Her hapless father with his eyes filled with terror was holding his daughter’s waist and trying to restrain her restless hands and fists from self inflicted injury. The poor man looked totally exhausted from his struggle from this sylph of a girl, who seemed to have endless and uncontrollable power of an angry lioness. There was also a rope tied to her waist and gripped by her father’s gnarled peasant fists, apparently to prevent her from running away and do herself grievous harm. It was apparent from the red and bleeding welts on her face and exposed chest that she has been scratching and beating her face and chest uncontrollably. A couple of scratches on the father’s cheeks and nose revealed that he has also been a victim of her tireless nails and fists. Her poor mother, a scrawny little thing herself, was weeping uncontrollably from blood shot eyes. She was also making her own scene, by wailing for her daughter as if she was already dead. Her heart rending funereal tunes which were only interrupted whenever she frequently blew her profusely runny nose was the only respite from the impromptu mother and child tragic opera and drama.The trio was surrounded by bedraggled, younger and older siblings of the sick child, uncles, aunts and villagers of all sizes and shapes. Some were weeping and all looked miserable. From the bags of supplies they were holding it was apparent that they had travelled from a long and harrowing distance to come to the hospital.

​There has been a health education program launched  at St.  Mary of Zion  Church located in  Yonkers, New York, attended by Ethiopians.  The program has been going on for the last one year. The purpose is to promote wellness and health  among the Ethiopian community.  The  teaching is given at least once a month by doctors and has professionals residing in New York. The topics covered include preventive health education and chronic diseases that include diabetes, hypertension, obesity, kidney disease etc. The program  is coordinated by Helena Yigezu RN and Fassil Teffera M.D.