We all know that Vitamin D is important for bone health. Lately a lot of attention has also been focused on Vitamin D’s effect on numerous major diseases, namely cardiovascular disease, diabetes, cancer, immune disorders, as well as muscle strength, weight and even long term mental acuity.

Vitamin D level is measured in our blood as a 25-hydroxyvitamin D. This represents the conversion of provitamin D to previtamin D in the skin during exposure to sunlight emitting ultraviolet radiation. Previtamin D is then converted in the liver to 25-hydroxyvitamin D.  About 40 to 50 % of circulating 25-hydroxyvitamin D is derived from skin conversion. We also can get some vitamin D from food sources. (Usual amounts are between 100 and 200 IU’s or international units a day.) I know this all sounds a bit confusing, but in a nutshell (and nuts don’t have a lot of D, but if you are out there harvesting them in the sun, your D levels will benefit.) serum 25-hydroxyvitamin D is the best indicator of our overall Vitamin D status. It reflects the D from nutritional intake and sunlight exposure. The latter is of course dependent on latitude (less in northern latitudes), the season, clothing, sunscreen use and local weather conditions. Then there is the issue of pigment…the darker a person’s skin the less she or he will absorb the requisite UV rays. Levels of 25-hydroxyvitamin D are lower in blacks than whites who live in the same environment. Body mass also seems to matter; heavier individuals typically have lower levels than their svelter counterparts. Other conditions  that can also result in low 25-hyroxyvitamin D levels include: poor dietary intake of Vitamin D together with negligible sun exposure (this probably represents many of us), malabsorption due to inflammatory bowel disease, gluten intolerance, gastric surgery, liver disease, intestinal overgrowth (of bacteria) use of anti-seizure medications and long-term use of steroids.

So what is a normal D level, and what should we do to ensure that it is high enough? Currently “frank” Vitamin D deficiency is considered to be less than 10 ng per milliliter; Vitamin D levels between 10 and 30 are “insufficient” and “normal” D is defined as blood levels between 30 to 79 ng per milliliter.  Alas, when this range is used, the estimated prevalence of Vitamin D deficiency includes 50 to 80% of the general population!

A case vignette which highlights Vitamin D levels and need for supplementation appeared in the January 20, 2011 New England Medical Journal. In this article the author described a healthy 61 year old white woman whose  level of 25-hydroxyvitamin D is 21 ng per milliliter; she is not overweight , has never had a fracture and her bone density at the hip is -1.5. What should she do (if anything)?

The first concern that the article dealt with was her current and future bone health. Most of the studies that the author cited suggest that calcium plus vitamin D (and not Vitamin D alone) is marginally effective in reducing the risk of fracture in older patients compared with no supplementation. But he didn’t feel she was old enough or at sufficient risk to require high doses of Vitamin D supplementation. (See the end of this report.)

He then addressed Vitamin D’s “other health effects”, and that “observational studies in large cohorts have shown significant associations between low levels of 25-hydroxyvitaminD (i.e. below 20 ng per milliliter) and an increased risk of metabolic, neoplastic (cancer), and immune disorders such as type1 diabetes mellitus and multiple sclerosis. …That two conditions often connected with low levels of vitamin D are atherosclerosis and diabetes mellitus.”  But then the author goes on to state that “there are not enough data from large, randomized, controlled trials to assess whether Vitamin D supplementation reduces the risk of chronic diseases other than osteoporosis.” (Please don’t be turned off by this, nearly every study that is published, especially if it does not include the entire diverse population of the US followed for their lifetime’s ends with this statement.)

The article then deals with “areas of uncertainty”, which basically include all other medical disorders and diseases and the potential benefit of Vitamin D supplementation to prevent or diminish their occurrence. The author once more refrains from advocating Vitamin D to ward off disease, writing “data are lacking from large randomized, controlled trials designed to determine whether Vitamin D supplementation reduces the risk of other major diseases, such as colon cancer.” (For which there are observational data suggesting a reduction in risk with supplementation).

We will get future information with an ongoing study called the Vitamin D and Omega-3 Trial (yes it has an acronym…VITAL) which is a 5 year, randomized, placebo-controlled study involving 20,000 US men and women . The goal is to see whether Vitamin D supplements (2000 IU per day) with or without supplements of n-3 fatty acids helps prevent cancer and cardiovascular disease.

So should we wait until this and other studies have been completed….and will they be enough for “orthodox”, peer reviewed and New England Medical Journal published recommendations?  The answer may not give us an A on any medical exam but then neither do we want a grade lower than that D when it comes to our future health…

To continue this Vitamin D review: There are 2 kinds of oral D supplementation. The usual over-the-counter D comes in the form of D3 and generally is available in doses of 400, 1000 and even 2000 units.  A second type of D, called D2 is available by prescription. D2 has 1/3 the “power” of D3. Toxicity from overdoses of D3 is rare and generally will not occur with doses less than 10,000 IU a day. The Institute of Medicine (IOM) has recently set the tolerable upper level of daily Vitamin D (3) at 4000 IU.  One reason for their concern is that there have been recent observational studies that suggest that blood levels of 25-hydroxyvitamin D over 60 ng per milliliter may increase risk for pancreatic cancer, vascular calcification and death from any cause. Too much of a good supplement (or its associated blood level) may not be a good thing.

To complicate the issue … an international workshop on Vitamin D in 2007 agreed that most of the world’s population is not getting enough Vitamin D to maintain healthy bone and minimize fracture risk. In 2010 the International Osteoporosis Foundation recommended a target blood level of 25-hydroxyvitamin D of 30 in all elderly persons, stating that vitamin D intakes as high as 2000 IU per day may be necessary to attain this recommended level.  But to make this more confusing to “D attentive” physicians and patients, the IOM has recently stated that, based on observational studies and recent randomized trials, a serum level of 20 ng per milliliter of 25-hydroxyvitamin D would protect 97.5% of the population against adverse bone outcomes such as fractures and falls.

After considering these conflicting studies, the author of the NEJM recommends that the woman in the vignette maintain an exercise program, make sure to have a total calcium intake of 1200 mg a day (though food and supplements) and since she is not at high risk for a fall, take just 600 IU of Vitamin D a day.

Having looked at this article (and many other studies that I will not burden you with…) I suggest that my patients take 1,000 IU to 2,000 IU of D3 a day and would suggest that the woman in the vignette do the same.  My preference is that we all reach a blood 25-hydroxyvitamin D level of at least 30 ng per milliliter.  But of course neither I, nor any physician can promise good bones or disease-free health through Vitamin D supplements.

Most of us had chicken pox as children (and a few unfortunate adults got it from exposure later in life). It’s caused by the varicella zoster virus. Once the initial chicken pox illness has passed, the virus stealthily remains in our system “housed” in the roots of large nerves where it can remain in an inactive form for decades. It may later come forth and multiply along the nerve to the area of skin the nerve supplies, causing an extremely painful vesicular (blister) rash. The reactivated varicella viral activity is the culprit for an outbreak of herpes zoster or shingles. It can result in disabling pain that may last for months, or even years. (If the pain persists for more than a few months it’s known as postherpetic neuralgia.) Unfortunately, one episode of shingles does not prevent recurrent reactivation.  Approximately 1 million episodes of shingles occur in the US every year.


Reactivation of the varicella virus and development of shingles is most likely to occur when the virus is not “kept down” in its inactive state by an individual’s immune system.  Our natural immunologic defense is weakened with age, disease and medications that cause immunosuppression.


A shingles vaccine called Zostavax has been developed by Merck pharmaceutical company and was licensed by the FDA in 2006. Inoculation with this vaccine has been recommended for healthy individuals aged 60 and older by the Advisory Committee for Immunization Practices. But before this vaccine is universally accepted and becomes part of routine care, scientists and physicians would like to demonstrate its effectiveness in “the field”, i.e. the general population. This was done by the CDC division of Viral Disease together with the department of research at Southern Kaiser Permanente. They published their results in the January issue of JAMA.


This retrospective study included 130,415 person-years from January 1, 2007 through December 31, 2009. The patients were Kaiser members who were 60 years or older, many had a variety of chronic conditions. (Remember person-years represents the years a person has been followed, so if 100 patients are followed for 2 years, they study period is 200 patient-years.) Unvaccinated individuals with similar birthdays to those who received vaccination were matched at a ratio of 3:1 to the vaccinated group. (To be exact, there were 355,659 unvaccinated “controls”). In order to ensure that the vaccinated group and controls were similar, the researchers also eliminated immunocompromised individuals. That meant that they excluded individuals with HIV, leukemia or lymphoma or those receiving immunosuppressant agents within a year of the onset of the study.


The results: The vaccination was associated with a 55% reduction in the incidence of herpes zoster. This reduction occurred in all age strata (those who were 60 and those much older) and among individuals with chronic diseases. The authors state that “Not only might the patients experience a very large absolute reduction in their relative risk of herpes zoster, but for the oldest group, this could result in a very large absolute reduction in the disease because they bear the greatest burden of herpes zoster and post herpetic neuralgia and are also especially vulnerable to these disabling conditions.”


An earlier study adds to their conclusion. The Shingles Prevention Study which included over 38,000 participants aged 60 and older, showed that those who received the immunization but nevertheless develop herpes, had less pain and discomfort than those who had not been vaccinated. Moreover, the incidence of postherpetic neuralgia was reduced by 66.5%.


The shingles vaccine is administered subcutaneously (just under the skin) in one dose. It consists of a small quantity of live virus, which promotes new immunity to herpes zoster. Because it is a live virus, it has to be stored at 5 degrees Fahrenheit and then reconstituted with special fluid (diluent) within 30 minutes before injection. Not all physicians have the vaccine stored in their office so call to check to see if they (or a pharmacy) have the vaccine in stock.  The vaccine is expensive…  (The cost is $220 in most pharmacies). Medicare part B will not cover it but part D will. There are no significant side effects that have been reported with vaccination. Rarely, a recently vaccinated person can infect a child who has not had chicken pox with actual chicken pox, but not shingles. If you were born in the US you are considered to have had been exposed to or been infected by varicella (chicken pox) and there is no reason to check for varicella antibodies before you receive the shingles vaccine


I wish that the vaccine had been available 9 years ago. A year after her open heart surgery my mother developed a horrible case of shingles. She suffered from agonizing pain for months. This ubiquitous viral reactivation is not fatal but it’s now almost preventable. As soon as the vaccine was available, I gave it to my Dad (and frankly to my husband and myself!)


Bottom line: If you, a friend or family member are over 60 (and even way over 60) consider getting the shingles vaccine. It’s effective in preventing or diminishing that “damn pox”.

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In last week’s newsletter, I quoted the elder from a village in the north of Ethiopia: “This allows our children to free themselves from the bondage of poverty”. I had not yet written about my visit to the Save the Children School in Shafat where we were given a very emotional welcome by the students, villagers, PTA and local leaders. I’ll continue my description of the Ethiopian trip this week. (And I promise to return to my more traditional medical articles next week.)

It was Day 3 of our visit: We gathered at 4 AM in front of our hotel in Addis to drive to the airport for a flight to Mekele in the north (798 kilometers away). The flight would take less than an hour, but we had to pass through 3 security checks before we were allowed to board the plane. We arrived in a sprawling city surrounded by arid fields from which endless rocks had been removed (and mostly shoved near or onto the road) in order to utilize every inch of land for cultivation. It was the dry season, and dust was everywhere. The grain had been harvested and was piled in pinnacles that were neatly stacked on the fields as well as on roofs of stone walled huts.

Once in Mikele, we were driven to the Tigray Save the Children offices. Here the staff presented us with a detailed overview of their programs: The region of Tigray (Mekele is the capital) has its own language, covers 53,623 square kilometers and has a population of 4,422,317 (how’s that for Save staff exactness!). Children under the age of 14 comprise 43.7%. More than 83% of the population is dependent on agriculture. Many areas had no schools or inadequate structures. The enrollment rate was under 58%. Girls were required to walk tens of kilometers to wells to fill Jeri cans with water for use at home, which prevented them from going to school. Moreover, if the girls did not have separate latrines, families were afraid to allow them to attend school for fear of molestation. Much of the rural population lacked access to basic services including safe water and health. There was constant food insecurity made worse in years of inadequate rainfall.

Then we received the organization’s “it-can-get-better” news: Save the Children has been operating in Tigray since 2005. It currently has programs in ten Woredas (counties) addressing basic education, food security, school health and nutrition, access to clean water and sanitation, early childhood development and food by prescription for children and mothers infected with HIV/AIDS. Save the Children has built 33 new schools in these 5 years increasing gross enrollment in the areas that now have school access to over 100% (The “over” part is due to the fact that children who were not at grade level enter classes for younger students.) Save the Children also has helped provide school material, train and staff the schools with teachers, district education staff, and has even worked with communities to form PTA’s! The students are provided with Vitamin A supplementation, and given medication for de-worming (a major health issue causing life threatening diarrhea for these rural children). There were now as many girls as boys enrolled in these schools and girls even outnumber boys in the early education classes for 5 and 6 year olds. But that’s not all! Save the Children has also helped the population with food security. Farmers can apply for micro loans to purchase water pumps, manage livestock (cows, sheep, bee colonies, poultry and my favorite, shoats, a combination sheep and goat…I was intrigued by these wooly-eat-anything animals; whenever we passed a group I would point them out to the others in our car… to diminishing enthusiasm.) Food security not only helps prevent childhood malnutrition; families who are “secure” are able to enroll their children in school. The goal of Save in Tigray has been to mobilize communities and help them create a sense of ownership Once a project is implemented the plan is to hand it over…not take it over. The challenge (as usual) has been funding, especially if the funds are granted for a limited time. (This is where donors and foundations can help).

The local staff of Save the Children in Tigray ended their PowerPoint presentation to us with a large “Thank You”. I felt that I and the other board members in our group should be thanking them for their tireless efforts!

Now onto the rest of the day… We traveled for several hours via unpaved, rocky (and did I mention dusty) roads to one of the schools that Save the Children had built. As our three-car caravan approached, we were greeted by scores of women ululating and throwing popcorn. Hundreds of children followed carrying an Ethiopian flag and singing as they presented us with flowers. At this point, most of us were trying not to cry as we danced with the children and shook everyone’s hands. It took me a while to point my camera and take pictures, but I don’t need them… the image of those women and children will always stay with me, reminding me why I went to Ethiopia and why I support Save. (Please take a look at the pictures I have posted: click here)

We were introduced to the headmaster who modestly (!) told us that he travels over 10 kilometers by bike each way in order to teach at the school. There were 5 classrooms, a playground (apparently very unusual in any Ethiopian school), a separate building for the early education program, a well, an area for hand washing and separate boy’s and girl’s latrines. The students proudly showed us their books. The 5th grade class recited in unison (and English) “a better future through education”. We then filed into another classroom, which had been set up for us to meet and greet the community leaders and the PTA. They welcomed us with coffee and traditional Ethiopian food. Their spokesperson spoke first through an interpreter: “In my 80 years I never had the opportunity for an education; I am a little jealous but also overjoyed that my grandchildren and great grandchildren can now go to school and have a chance to overcome the burden of poverty and ignorance”. As we reluctantly walked back to the cars (way behind schedule, we just didn’t want to leave), the children surrounded us waving, and singing. This was undoubtedly the highlight of our trip.

That afternoon we traveled for several hours to see a cow… Well it was not just any cow, this one had been purchased with a loan by Save the Children to help a family’s food security. The cow already had delivered a calf (artificial insemination is used for breeding), and its milk was sold daily to a local contractor. The proceeds were used to pay back the loan, help support the family and send the children to school. Despite their poverty (the 2 room hut was not much bigger than the living quarters for the valuable cow), the family had prepared bread, coffee, popcorn and yogurt to welcome us and they served that repast with ceremony and dignity. (I have to admit I didn’t drink the nonpasteurized yogurt.) We then continued the agricultural part of our visit via rock strewn rutted trails to another village where we peered into a bore hole well which, with the aid of a loan for an inexpensive generator, was used to irrigate gardens and fields in an otherwise barren area. (This is where some of us desperately searched for a bush to use as a field latrine.) The day ended with a journey to an amazing third century church built from red rock. It had beautifully preserved frescos of African featured saints. I was told that Queen Judith (obviously no relation) had tried unsuccessfully to burn it down. The view from the church was magnificent…I was reminded of monument valley. Once more, we got into our cars and headed (for another 2 hours) to a rustic lodge surrounded by imposing red rock cliffs where we spent the night. There were no mosquitoes.

Day 4: We traveled back to Mekele where we met at the government office with the president of Tigray and members of his staff. We gathered in a “formal” conference room where each of 20 participants spoke (often at length) about his (and one her) field of expertise. I was the one selected from our group to share our collective impressions; thankfully I had had some strong Ethiopian coffee that morning. The president (who apparently had been in the rebel force 20 years ago) spoke (in excellent English) of the need to educate the millions of children living in rural areas and voiced appreciation for the fact that Save the Children had built 33 schools in the region in the last 5 years. The minister of education was the only female representative there…she too spoke of their specific goals, especially primary schooling for girls. It was apparent from the male attendance (with the exception of the one minister) that female participation was needed. But they are doing some things right…the national parliament is over 35% female.

We were a lot less formal at lunch in a local hotel. The president joined us and after I rudely suggested that he appoint a minister of coffee (I guess I had had too much of this beverage), he smiled and offered to share his fish. (I was not eating my pasta…Did I tell you that Ethiopia had at one time been ruled by Italians and they left a legacy of Italian food? In this case it was way too spicy for me and I couldn’t eat it.) I guess one could say that relations between Save the Children and Tigray were improved by sharing bread, I mean fish!


We did have a serious discussion about women’s health (my comments on this subject were probably more cogent than those about coffee) and he suggested that I tour the Mikele fistula hospital. He offered his car for a brief visit to the facility. It was a small hospital with 30 beds; the doctor in charge (actually the only physician who worked there) gave the most coherent summary on the causes, therapies and prevention of fistula that I have ever heard. He had been trained at the renowned Hamlin Fistula Hospital in Addis. I’ll go into a brief discussion about this consequence of obstructed childbirth and the horrendous physical and social repercussions in my review of Day 5. We almost missed our flight as we rushed through 3 security checks to fly back to Addis.


Day 5: We were back in Addis and started the day with a briefing by the Save the Children country directors. Currently, Save the Children in Ethiopia has offices and programs that are administered separately by several countries including the United Kingdom, Sweden and Norway. Twenty eight global Save the Children programs have, in the past year, joined together in an International Save the Children Alliance. This Alliance partnership will then work together (and be more effective with less redundancy) to ensure the well-being and protection of children in more than 120 countries. (We’ve gone global!) Over the next year, the programs in Ethiopia will merge and become better equipped to administer many of the types of fabulous programs we visited.

Next on the agenda was a visit to the Hamlin Fistula Hospital. We arrived at the entrance square where several women were squatting on low stonewalls. (We later found out that “stone was the friend” of women who suffered from fistulas…it’s easily cleaned and doesn’t stain.) At this point, I need to give a brief discussion about gynecologic fistula: It is caused by the tear and breakdown of the tissue separating the vagina from the bladder and/or the rectum and leads to urinary or fecal incontinence (or both). In Ethiopia, the most prevalent cause of fistula is obstructed labor. If the fetus is too large or poorly positioned it cannot pass through the pelvic canal; labor goes on for days and ultimately it dies. The remains loose fluid and eventually are passed. But the prolonged (and horrifically painful) obstructed labor results in tissue damage to the mother and may destroy the vaginal wall so that there is a single opening (called a cloaca) encompassing the bladder, the vagina and the rectum. These women are rendered incontinent… and because of this are divorced by their husbands, shunned by the village and often die of infection or commit suicide. Some are cared for in secluded huts by a relative but because of the incontinence (and nerve damage  during days of labor) may never walk, remaining curled up in a fetal position for years.


Over 90% of women, deliver at home with no care. Many of these women are young, malnourished and have poorly developed pelvic bone structure. Obstructed labor occurs in 1% of Ethiopian women, this number increases to 1.6% in rural areas such as Tigray. Dr. Hamlin and her husband (both gynecologists from Australia) were horrified by this tremendous obstetrical problem which they witnessed while visiting in the early 70′s. They remained in the country and opened a hospital to treat fistulas in 1972. The facility now has 150 beds and treats 2500 women a year. Over 30,000 women have had fistula surgery at the hospital with a success rate of 90%. In addition to treating infections and malnutrition and of course performing surgical closures of the fistulas, the hospital provides treatment for concomitant orthopedic deformities (Some women have been in a fetal position for years and cannot extend their legs to walk or even stand). The hospital staff also provides psychological rehabilitation and teaches the women basic reading, writing and work skills that enable them to return to their communities and sustain a livelihood. If they remarry and become pregnant, they return to the facility for prenatal care and subsequently undergo C Sections at a government hospital in Addis.


Dr Hamlin herself gave us a tour. She is 87 years old and still does surgery! She has trained numerous physicians and all those who staff the 5 satellite fistula hospitals in other regions (including the one I visited in Mekele). She has founded a midwifery school and trains nurse-aids, many whom have themselves been treated for fistula. She works with the government (as does Save the Children) to help increase training for extended health care workers who can provide prenatal counseling and help determine which women should be referred for delivery to clinics and hospitals before they go into labor. The Hamlin Fistula Hospital was built next to a river and was surrounded by beautifully manicured lawns and lush gardens. It was an oasis of peace and care for women who had been isolated and neglected since they suffered in childbirth and had lost their babies, families, dignity and health. Most of the patients we saw were in their 20′s. As we visited the recovery ward, children from the American school were singing Christmas carols.


Just before we left Ethiopia, we had one more outing; to a woman’s cooperative that produced pottery which was sold through NGO fairs. (This allowed them to receive direct payment for their wares). They created the most beautiful vases (without a pottery wheel), trays, candlestick holders, and small statues. I bought as many as my carry-on suitcase would hold to bring back to LA. Most made it without breaking.


I hope my description of the trip and my pictures have allowed you to share in my trip to this highly populated and beautiful part of the developing world. Seeing allows one to believe… that programs like those of Save the Children can make a difference in the lives of children, their families and the future of their country.


Next week, I’ll recommence my usual medical reporting.

 

“This allows our children to free themselves from the bondage of poverty.” A quote from an elder in a village in the north of Ethiopia upon greeting us at a school built by Save the Children.


Most of us agree that 2010 was a tough year… one of natural and man-caused disasters, on-going wars, bitter political battles that were lost and won (depending on whose side you were on) and severe economic inequalities. As I prepared to go to Ethiopia in December with several board members of Save the Children, I worried that the trip would add to my sense of world instability and decline.  Ethiopia is not a “see-the-elephants-and-tigers” African destination. It’s an elephantless land locked country located in “a very bad neighborhood”. A quick geography reminder: to the East lies Somalia, to the West, Sudan (soon to be divided, with inevitable fighting and bloodshed), in the South there’s Kenya and in the North a country that has been at war with Ethiopia over land and Red Sea access, namely Eritrea. The only access to a port on the Red Sea is via Jjibouti, a place most of us cannot spell (or find on a map). The highway (termed the corridor) that goes from Addis Ababa, the capital, to that port is driven by sleep deprived, accident prone truck drivers who chew a mild narcotic called chat. These drivers also tend to stop and visit the sex workers at the numerous cafés, hostels and bars along the highway subsequently spreading HIV/AIDS to their wives and girlfriends. (I’ll explain why this has significance for Save the Children later.)


Sorry about all these facts and the following figures but I feel the need to go into greater statistical detail before I report on my visit and the programs I saw. So to continue… The official population of Ethiopia is 75 million (however most people I spoke to in the country said it’s more like 80 million… the difference in number would fill another country…I’m thinking of Israel!) The country has few (or no) natural resources. It ranks 157 out of 169 countries on the Human Development Index. The per capita GDP is 130 dollars a year. Life expectancy at birth is 56 years, maternal mortality rate is 720 per 100,00 live births and 123 out of 1000 children under the age of 5 die, a third within the first month after birth.  Many of the children in Ethiopia are either orphans (often because their parents died of AIDS) or “vulnerable”. Only 65.2% of children aged 10-14 live with both parents. Malnutrition is rampant: 52% of children are severely to moderately stunted and a third of children are wasted. In a good year, 10 million people are food insecure and require food assistance.


The ability of this country to get out of its “biblical life style” may depend on the basic health and education of its children. Currently, the mean number of years of schooling of adults is only 1.48 years. Although there is a 79% net primary school enrollment (the rate is lower for girls), the primary school dropout rate is huge…18% at 1st grade and 14% at 2nd grade. (In rural areas, the girls have to bring water home from distant wells and hence have no time to go to school).  Save the Children has been able to help address many of these issues.

 

Despite all these horrific stats, my trip to Ethiopia was actually heartening.  I witnessed the care and respect that the people of this country show for one another under extremely difficult circumstances. Their sense of responsibility helps ensure that an orphaned child is placed in a home with relatives, that a deceased person is mourned and buried by the community, that the opportunity for an education for any child is celebrated.  Save The Children has developed programs that enable women, communities and the government to improve the lives, health and education of its children. I felt honored to have had the chance to see all this. It made my year!


In order to relive and share my experience, I have downloaded a few of my hundreds of pictures (which you can view by clicking here). For those of you who want narration (or just don’t want to see the pictures) here are some excerpts: And because this description of my tour of Save programs in Ethiopia is quite lengthy (and I know many of you read my newsletter on your Blackberries or iPhones), I’ve divided the trip report into 2 installments. You’ll get the second next Friday.


I flew from Washington, DC (where we had our board meeting) to Frankfurt and then on to Addis Ababa where I checked into the Addis Sheraton. (This is a truly luxurious hotel and not representative of the rest of the trip.)

Day 1: It was Sunday, a day of rest (which I needed) in this mostly Christian part of the country.  The national museum was open and we went to see the exhibits. They were small and poorly lit but the crowd of teenagers from local schools who lined up at the entrance was fascinating.  All of the girls wore their Sunday bright white head shawls that glistened in the summer sun. I spent my time taking their pictures and showing them how gorgeous they were on my digital camera. (I’ve included a few pictures). That evening our group was invited to a Christmas party at the home of the Ethiopian program director. It was attended by directors and staff from Save, other NGO’s (non-governmental organizations), the American embassy, the World Bank, the African Union and the Ethiopian government. They were a fascinating group of highly educated and committed individuals…a virtual think tank of public health and global welfare.  All traces of jet lag disappeared.

 

 

Day 2: This day began with a briefing at the Save The Children office. We learned that the Ethiopian programs serve over 3.7 million beneficiaries. The programs are developed and brought to capacity by over 600 staff in Ethiopia and help ensure the well-being and protection of children. The ultimate goal is to bring immediate and lasting positive change to the children’s lives.  These programs include training and support in fields of reproductive health, maternal and newborn survival, nutrition, livelihoods (translation, helping women and their families develop skills and jobs so that they can feed and educate their children), food security, prevention and treatment of HIV/AIDS, care for orphans and vulnerable children that are affected by this epidemic, education (building schools, educational materials and training) as well as emergency response (particularly in times of food insecurity, otherwise known as famine) as well as education and child protection in refugee camps that have been created in the south of the country… I was overwhelmed!


With all this as background, we commenced to see some of the programs for ourselves. The first was a PC3 program in Addis (OK there will be acronyms….this one denotes Positive Change: Children, Communities and Care).  Women from the community who have fostered orphans and vulnerable children were learning a trade. We were introduced to a group of about 40 women who were busily engaged in sewing and embroidering pillows and table coverings (I bought a few) so that they could better support these children. The adjacent room provided child care for their young children who were not in school. There was also a community kitchen that provided food for many of the vulnerable children in the city.  What impressed me was the fact that these programs were organized by local communities; Save the Children was there to lend them support, not take over their programs.

We then traveled for several hours on a two lane asphalt road to the town of Adama in the “lowlands” (Addis is at 7546 feet). This was the only area we visited in which malaria was endemic. I started using my DEET. The first stop was a “food by prescription” program which provides women and children who have HIV/AIDS with high caloric nutrition to help combat their disease. (The more malnourished the woman or child, the more likely she will succumb to secondary infections such as malaria and tuberculosis.) Those who were severely underweight received packages of plumpy nut (a special peanut butter paste packet containing 500 calories). This is a new program that has already shown significant results.  From here we visited a nearby TransAction site. This is a program that helps prevent the transmission of HIV/AIDS. It targets sex workers and drivers along major roadways. We watched a women counselor leading a group of 15 women, showing then pictures from a book that helped explain how to use condoms (yes there was a picture of a “practice” banana on which a condom was appropriately unrolled) as well as graphic images of  penile STD’s. (Condoms are also supplied at all the “driver stops”.) Next we visited a reproductive health center which certainly did not look like my office. Yet in an area that encompassed 4 bare rooms with 2 tables, health care workers inserted IUD’s, performed sterilizations, occasionally did D&C’s, gave oral contraception and counseled women on reproductive health.

 

That evening we went to the circus! Yes there was an Adama circus, but it was unlike any circus I’ve ever seen. (Years ago, my husband directed a movie about circuses and we have circus posters and paintings throughout our house.)  It was actually part of a PC3 Save the Children program in which orphaned and vulnerable youth are taught gymnastics, music and dance as after-school activities. We were welcomed (with flowers) to their performance. There were 200 children with their parents and foster parents sitting in bleachers to see the show as well as to welcome us. The music, gymnastics and especially the traditional dancing were extraordinary. Sitting next to me in the audience were several 3 and 4 year olds who stole my heart. We shared our flowers. I’ve included several pictures that will help me remember this evening in the years to come.

 

 

We spent the night in a local hotel…. and as I opened the window of my room (there was no air and it was hot) I discovered that there was no screen. I slept under a mosquito net and sprayed DEET over my entire body. DEET also removes nail polish.


Day 3: We flew to Mekele in the north of Ethiopia. I’ll describe this part of the trip and my emotional visit to a school that was built by Save the Children in my next newsletter. I’ve quoted the elder who spoke at the school reception for our group in the beginning of this newsletter. It sums up much of what Save the Children does…

 

 

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