Resilience in Ethiopia

I’m in rural Ethiopia, a three-day drive outside of Addis Ababa, with a field team investigating a cholera outbreak. The primary pipeline that provides water to this community was destroyed during ethnic conflict over a year ago and it has not been rebuilt, leaving the community without a safe and reliable source of water. Private citizens are trucking in water from 70 kilometers (roughly 43 miles) away and selling it at an inflated price in 20-liter plastic cans.

 Community members who cannot afford to buy water are collecting it from unprotected wells or streams. With limited sanitation facilities in the community, the cholera outbreak promises to intensify once the impending rainy season hits.

As a Columbia Public Health student, I’m working with the Ethiopian Public Health Institute (EPHI) for my summer practicum. I’ve been assigned to the Recovery and Resilience Directorate within the Institute, a new division of EPHI, whose existence partly reflects the current trend to study and promote resilience in health systems. Building resilience means ensuring that a health system is able to adapt and recover from unexpected events and continue serving the population. A lot of discussion about health system resilience focuses on health care facilities and the personnel who work within them. It’s an important concept, and this trip to the field has been giving me a lot to think about in terms of what resilience in health systems really means in practice.

After a week of working in this Ethiopian community, our team’s last task is for the microbiologist to collect samples from different water and food sources to analyze for cholera and other microbes in a lab. It’s a crucial step that will help to show us where the outbreak is coming from and how it might be spreading. The results will inform the way the Ethiopian government responds to the outbreak, and where resources are directed. But the samples need to get to the lab within 24 hours of collection in order to provide an accurate result, and the closest lab with the necessary equipment is three days away in Addis Ababa.

We go over plan after plan trying to figure out how to get the samples to a lab in the necessary timeframe. But they all come to the same conclusion: we won’t make it in 24 hours. It’s logistically impossible, something that is hard for me to accept from my American perspective and my “where there’s a will there’s a way” upbringing. My team and I can’t leave the town or take the samples late in the evening or early in the morning because there’s a curfew in place, prohibiting movement after 9pm or before 6am. The roads are also unsafe at night, and our driver refuses to travel in the dark, even outside of the curfew zone. We also can’t drive straight through, and if we can’t do that then we can’t make it to Addis in the allotted timeframe.

The only plan that can possibly work is to try to get our microbiologist and his samples on a flight out of the closest airport—about 300 miles away and over some rough roads. We need to collect the samples in the early afternoon, drive as far as we can before dark, and then wake up at dawn the next morning to finish the trip. This is the only plan that will get us to Addis in close to 24 hours. But we’re not in the clear yet. If we hit a checkpoint with particularly inquisitive soldiers, if there are more cows than usual on the road, or the car gets a flat tire, our microbiologist will miss the flight and all this effort will be for nothing.

As we set off with the samples packed on ice, we’re nervous and unsure the plan will work. But we sail through all the checkpoints, spot just few cows on the road, and we make it to the airport with time to spare. The microbiology team starts analyzing the samples 26 hours after we collected them and they’re confident that they can get a reliable result. The outcome will help guide the response to the cholera outbreak and instruct the priorities for water treatment and food regulation in the community.

As we make and execute our plan to reach Addis Ababa in the quickest way possible, I reflect on larger meaning of all this drama and the obstacles we faced. If our team, backed with the resources of the Ethiopian government such as a private car and funds to buy a plane ticket, couldn’t make it to a laboratory within 24 hours, what does that mean for the average Ethiopian citizen living in a community like this one who needs medical attention? When we talk about resilience in health systems, we should be talking about situations like this one, which illuminates the myriad of factors that affect the ability of a health system to provide services to communities.

If the only laboratory with the capacity to perform a cholera analysis is in the capital city, what does this mean for someone in a rural community who is very sick and needs a complicated analysis to determine their treatment? What does the strictly enforced curfew mean for the child with malaria who spikes a high fever in the middle of the night and whose parents can’t seek medical care? What do the unmaintained roads mean for the woman in obstructed labor who needs to be transported to a hospital? What does the ongoing ethnic conflict mean for the broken pipeline, which authorities hesitate to rebuild out of fear that it will just be destroyed again?

Resilience is a hugely important idea in public health, and it should encompass so much more than simply the provision of healthcare. We need to view resilience from a systems perspective and build it in a way that accounts for all the factors that influence health. This why the work we are doing at Columbia Public Health and at EPHI is so compelling. There is a long way to go and a lot of resources needed, but I’m excited to be part of the movement that is working on tackling these problems.

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Christina Kay is a second-year MPH student in the Heilbrun Department of Population and Family Health. She received her BS in Peace and Justice Societies from Tufts University. 

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