1. Plotkin, Gretchen MS, RN, CIC

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Ermias called to me as I was making rounds in the pediatrics ward. It was the end of the rainy season, a time when the hospital admitted many people suffering from severe malnutrition, and he had just seen a five-year-old boy so malnourished and dehydrated that any foods or liquids he took in resulted in vomiting and diarrhea.


It was 1998, a few months into the academic year that I spent as a volunteer teacher of pediatric and obstetric- gynecologic nursing at Jimma University in Jimma, Ethiopia. Clinical work was at Jimma Hospital, where tertiary care for much of the southwestern section of the country was provided despite a staggering lack of resources: medications, supplies, and sometimes even soap and water were scarce.


At 42, Ermias was one of the oldest of my 26 students. He had few friends, and many of his relatives had been killed in the civil war that ravaged Ethiopia. Ermias, however, never discussed his losses. Like all of my students, he conversed freely about religion, politics, and health care, but avoided any talk of personal feelings. (When an Ethiopian colleague told me about his two sons who had died in an accident, I offered sympathy. With tears in his eyes, he shrugged. "These things happen," he said, abruptly ending our conversation.)


I followed Ermias to the boy's bedside. Nearly a week earlier, his father had abandoned him at a local orphanage. Left under the shade of a tree, the boy was already too sick to speak. Nobody knew his name. Although he'd been hospitalized for three days, no ivs had been ordered and he'd lost 0.8 kg in 24 hours. I suspected the doctors weren't providing aggressive care because he was an orphan. Ermias and I decided that he might benefit from "kwashiorkor milk," a milk solution enriched with protein and fat. We decided to give him one teaspoon of half-strength kwashiorkor milk every three to five minutes by mouth. Although he was too weak to raise his head, remarkably, he took in some milk.


We stayed with him for about an hour, until he was able to keep the solution down. As I left, Ermias promised to talk to the staff about starting an iv for hydration, then helped Mihret, a petite 14-year-old girl who'd accompanied the boy from the orphanage, reposition the child and instructed her regarding continued feedings. While I'd previously noticed his tendency to be brusque, I was moved by the gentle way he touched the boy and conversed softly with Mihret.


I suddenly remembered the holiday back home. It was the third Thursday in November: Thanksgiving in America, but a regular clinical day for me here. I was suddenly struck by the discrepancy between a starving Ethiopia and an overfed America. How many Americans will be overeating and suffering indigestion while this boy and so many others like him starve? According to the United Nations World Food Program, an estimated 11.3 million Ethiopians are in need of emergency food assistance. Until that moment, I'd been strong and upbeat, caring for children suffering from tuberculosis, malaria, and AIDS. But this anonymous child, lacking the strength to move or communicate, was the most desperate I'd seen. For the first time I wondered whether anything I could do here would make a difference. For the first time I understood my students' silence in the face of monumental sadness.


The following Monday, Ermias sought me out before class. He had visited the boy over the weekend, making the trip on his own time. He spoke with great difficulty. "Miss Gretchen, I don't want to make you sad," he said, "but the boy has died on Saturday." In America, I would have cried and shared my feelings of helplessness with colleagues. In Ethiopia that isn't done, and I stifled the urge. Ermias remained silent, but watched me closely. I could see the empathy in his eyes. Although he'd seen so much more tragedy than I, he'd acknowledged my pain by reaching out in his own quiet way. I was humbled and strengthened by his effort.


That night, I wrote in my diary, "In my professional life, it's rare that I am the one who is cared for." To my students in Ethiopia, this 56-year-old American with a white head of hair was an elder as well as a teacher, and that year I felt listened and responded to in a way I hadn't before. Yet while I was their teacher, they taught me to provide care despite deficiencies. Their work exemplifies this wisdom of Jewish lore: Look ahead. You are not required to complete the task. Neither are you permitted to lay it down.