“The hospital turned into a ghostly place with few nurses and a resident wandering around the wards.”

I’m a psychiatry resident from Somaliland, a self-declared territory that unilaterally seceded from Somalia in 1991. Previously I lived in difficult situations and complex emergencies like the civil war in Somalia and also during field work with Medecins sans Frontieres in places like Nigeria¹. I moved to Addis Ababa in late 2019 and I was in Addis Ababa for 4 months when the outbreak started here in March 2020. This contribution is a psychiatry resident’s diary during the global Covid19 pandemic, full of personal reflections and observations from an African setting.

Photo by Djibril I.M Handuleh – Landscape

March 2020

Ethiopia announced its first coronavirus cases in Addis Ababa. The first case was a foreign national travelling from West Africa². That month, I was doing my inpatient and emergency psychiatry rotation at Emmanuel Hospital in the city³. The hospital is the largest mental health hospital in Ethiopia where residents take rotations. This was a daily attachment to male and inpatient mental health wards and weekend shifts at the emergency outpatients. Africa including Ethiopia followed the world in reporting the Covid19 global pandemic which was very close when the World Health Organization declared the virus a global public health emergency and a pandemic⁴.

Before Covid19, the hospital was crowded with many patients. Both outpatient and inpatient wards were full with patients. Different departments were in full capacity including ECT and the pharmacy. Due to the huge patient load, many patients were on a waiting list. Outpatient wards were full by the morning and the afternoon with more and more patients. However, this had to change within days after the hospital had to respond to infection control measures and safety issues for workers and the patients alike.

This is the first time in my clinical life experience that I was working as a physician in a pandemic era. Being in a foreign country where my language skills were limited this seemed to be a hard time to reckon with. Nevertheless, I decided to stay on studying and working in the hospital. Suddenly our morning sessions, where we present cases, stopped. Outpatient follow-up slowed down and inpatient wards were to be emptied to reduce contact with patients. This was unprecedented and difficult for both clinicians and patients alike. The hospital turned into a ghostly place with few nurses and a resident wandering around wards. I was progressing the notes of three patients who remained in our male adult psychiatry ward and who waited in patience. When I walked in one of the rooms one patient came to me, speaking in English, asking me if I could call his family members. It seemed that patient knew that something unusual was happening in our hospital. I told him that I could not call anyone myself and that I myself was equally frustrated to have forgotten my mobile phone at home. He seemed to acknowledge my own personal confusion when he said “ok, doctor”, and he added: “Would you think I can be in the ward which you can see that it’s empty now?”

I myself felt isolated, confused and not able to reckon with being a resident. I replied in a low tone “I will do my best to assess your condition in my daily progressive notes and will work with our nurses and definitely your family when I get in touch with them”. He was recovering from Schizophrenia. His illness was improving and he was engaging with me. We both sat on a coach in front of our ward not knowing what to say after this brief encounter. Within minutes of silence, he went back to the ward. That day in late March, I was able to assess patients and I planned the next day with a fellow resident who took over from me. Every resident had to come one day, do rounds with patients and go for outpatient assessments. If someone coughs or sneezes people could run away from that person without saying a word. I would hear people muffling in buses if someone coughs. Some people were using their hand sanitizers more compulsively. One would think they would harm their arms.

Shops had ropes separating the shop keepers from the public by 2 meters. They seemed to be not panicking as they were working. Life in Addis Ababa continued as many laborers would be seen going to their jobs as usual. Khat, which is a substance common in East African countries, could still be seen in empty streets. One could observe those customers paying for it and rushing in a hurry. They used to chat, smile or laugh a lot but the pandemic made this less frequent in the streets. Khat shops are still operational but less crowded than before. Sometimes, music from the streets could be heard including a health promotion song discussing safety from Covid19 at a distance. As the streets were emptier in the first month, I could hear those voices more clearly.

The public transport changed in the first days of the pandemic. Addis Ababa’s traffic jam went down dramatically with less cars and people on the street. I could see panic in people’s faces, public buses became less available. People wore face masks in public, one could see frequent hand washing or use of hand sanitizers. The personal distancing in long lines for buses and less people in buses were visible within days. Streets were becoming emptier day by day. As a resident, it was becoming difficult to focus and my daily journal was in disarray. However, the classes and the number of days in hospital were less, this gave time to study and write several manuscripts I was preparing.

Ramadan, the Muslim month of fasting arrived in mid-April 2020. This organized my time with fasting and reflection. The fasting reduced my stress levels but it was tiring as the spring days were hot and dry in Addis Ababa. I had to attend class with face masks given the reduced drinking and food intake, it was sometimes suffocating for me. In the buses and in the street, I saw people adjusting to life with face masks which was until then not common in Sub-Saharan African cities like Addis Ababa, where the level of air pollution is not a problem compared to many Asian countries. Face masks were an operating room asset. Some people wore face masks made of clothes or commercial company masks. During the sunset, when the fasting people ate, I could meet people eating their meals and having happier faces. Some would discuss the pandemic and would signal a concern and many would be just happy be fasting. Emotions were always mixed among them.

In the first month of the pandemic I was at the Emmanuel Hospital mainly doing inpatient, outpatient and emergency psychiatry. Those days included working days and weekend shifts, the hospital work became very different. Admissions were limited to emergency cases with most of the patients going into outpatient care. The patients were not able to come in the hospital in big numbers due to restrictions of transport, as some areas were in lockdown. Patients and their relatives shared their stress about Covid19. It seemed the same for everyone facing the pandemic, including foreign residents like me.

Despite the pandemic, I maintained good spirits, joggled in the morning and had frequent calls with my family members around the world. Some were in total lockdown in several countries and some in ease depending on places of residency. I could read my notes and sometimes life became stressful. The daily tallying of the global and national Covid19 cases were some of the daily stressors for me. I had to develop my daily journal recording my body changes including hotness, cough and other symptoms and signs of Covid19 infection. I had to cook indoors or, if buying meals, I used either home delivery or take away. My connections with the public went down as I was staying indoors more and more. Normal routines like going to the library or going out for dinner stopped abruptly.

Despite this difficulty my life was well and continued. I could see people on the streets, walking by themselves or two by two. Coffee shops, which are common in Ethiopia, had fewer guests though. Some days I could not find morning coffee which is my favorite.

In the second month of the pandemic, I went back to work at my training hospital where I did outpatient psychiatry practice. This time, I did not do inpatient practice, with the exception of consultations for other hospital wards. The daily commute to my hospital, Saint Paul Hospital, a general hospital, was the same as the commute to the main psychiatry hospital I had worked before. I had to travel to the hospital daily to see my patients. Restaurants around the hospital developed social distancing measures which helped me to dine and drink with fellow residents, all keeping appropriate distancing.

I live in a touristy neighborhood in Addis Ababa. The economic impact of Covid19 was apparent in the streets as restaurants, hotels and other hospitality industries like air traffic was low. Due to my proximity to the airport, I heared the noise of fewer airplanes which meant quieter nights to me.

In the last month, my stress-levels went down significantly. I was adjusting to the life of the Covid19 era including distancing, daily temperature measurements and normal life. I was able to observe people’s faces, seeing less panic but the continuation of life.

Interestingly, in the fourth month of the pandemic, I observed a few people trying to meet in big numbers or walking in the street with no face masks. Public transport was less strict with lining for buses or offering hand sanitizers compared with the first month of the pandemic.

When I look around me, I find my fellow residents energetic and more motivated to study. We are back to online Zoom classes and some of us are sending their case notes for assessment to their respective mentors. The level of commitment from training physicians seems to be as strong as ever before.

Spiritually, mosques are daily routine places I would visit for prayers. This was not possible since Covid-19 hit Ethiopia. As a preventive measure, crowded places had to be closed for public safety measures. This meant home prayers and reflections. I have mixed feelings towards this, as I am missing the crowd and relaxation of the prayers and the others, but I am safe and thankful for every day. If the trend continues as it is, I would be more likely to work in Covid-19 triage and an inpatient ward at our teaching hospital. That would be another story to tell. The pandemic seems to have disrupted our residency training and now we observe patients who are getting distress from the psychological effects of the global pandemic. Covid-19 will be remembered as a difficult time as a physician.

References

1. MSF Nigeria program, org/nigeria accessed on July 24, 2020
2. Confirmation of first Covid19 case in Ethiopia, https://www.afro.who.int/news/first-case-covid-19-confirmed-ethiopia accessed on July 24, 2020
3. Emmanuel Mental Hospital, https://www.ethiovisit.com/directory/amanuel-mental-hospital/1262/ accessed on July 24, 2020
4. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed. 2020; 91(1):157-160. Published 2020 Mar 19. doi:10.23750/abm.v91i1.9397