intro: Welcome to the Peds Ethics Podcast, where we talk to leaders in pediatric bioethics about a hot topic or current controversy. And now here's your faculty host from the Children's Mercy Bioethics Center in Kansas City.

Stephanie Kukora, MD (Host): Welcome to the Pediatric Ethics Podcast series sponsored by the Children's Mercy Bioethics Center at Children's Mercy Kansas City. I'm your host Stephanie Kukora. I'm a Bioethicist and Neonatologist here at Children's Mercy, and today I'm speaking with Dr. Bethlehem Kassa. Dr. Kassa is a Critical Care Physician with expertise in Bioethics.

She is a graduate of the Children's Mercy Bioethics Center Certificate Program last year. Up until recently, she cared for children at Black Lion Hospital in Addis Ababa, Ethiopia, and recently relocated to Kansas City. She's been collaborating on ongoing projects with the Bioethics Center in Global Pediatric Bioethics, and continues to work with her colleagues closely in Addis.

Thank you so much. I'll call you, Betty, because that's what I tend to call you. Thank you so much, Betty, for speaking with us today.

Betty Kassa, MD: Thank you for having me, Stephanie.

Stephanie Kukora, MD (Host): All right, I want to begin just by asking you a little bit. Also a side note for listeners, I actually have done a lot of work in Ethiopia in the past and have been a number of times, so I'm a little bit familiar with some of these things, but excited to learn more. I know, Betty, that Ethiopia has a really rich history and culture from the times that I've been there. I'd love if you would just begin by telling us a little bit about Ethiopia so that the listeners can understand some of the things that make it such an interesting place.

Betty Kassa, MD: Well, Ethiopia is a very interesting place in that it is one of the oldest nations in Africa, next to Egypt and Nubia. It is 3,000 years old and it started in the civilization of Damat. It has been occupied by the longest reigning dynasty in Africa. And it is also a birthplace of the human race, basically, and currently it is a melting pot of around 80 different ethnicities with around 80 languages.

And the country is largely a temperate environment where the highlands of Ethiopia are cold and there's also the area where in the lowlands, it's really warm. Ethiopia has been a place where the African pride has been shining since it has not been colonized ever. It is one of the two countries that hasn't been colonized by the Western powers.

And currently it is a place where people are tolerant, the majority Christian and Muslim living together and respecting each other's culture, basically.

Host: Thank you for that overview. So tell me a little bit about the medical care system there and what being a practicing pediatric intensivist is like in Ethiopia.

Betty Kassa, MD: Well, it is a low and middle income country. So in our country there's an issue of a very underdeveloped healthcare system because it hasn't been given the due focus that it needed. So currently in Ethiopia, although we've had huge strides in the last 20 years towards preventative medicine and primary healthcare, things like high level care regarding critical care, neonatal care or complex surgeries have been largely neglected. So working in this environment is very frustrating and challenging because the patient care is suboptimal and for physicians having to decide on a daily basis really difficult decisions like resource allocation or who gets to be treated and who doesn't. So those things are really frustrating and it is really difficult to practice medicine in that regard.

Host: You spoke a little bit about some of these challenges with the limited resources. Can you speak a little bit about specifically the ethical challenges that you face and how culture plays into some of these situations?

Betty Kassa, MD: Oh yes, because in our country, it is really complex resource allocation or giving proper health care, not only because we don't have enough resources, but because of the cultural nuances that we have to follow through starting from the basics, basically, you don't have enough ventilators, so you have to pick which child has to be put on ventilators, or which children need to be admitted to the hospital sometimes. And, you have to say, oh, this child might survive or is more likely to survive. So I will take this one instead of this one. So making these kinds of decisions as a person weighs down on your conscience. And also you don't have that ethical backup that tells you, okay, what we're doing here under the circumstances is okay, because there is no ethical framework.

Basically, physicians have to make up their decisions as they go along and whatever they feel is important or right, they have to make the decisions themselves. Aside from that, also, interactions with family is based on that cultural and economical situations have to be taken into hand.

For example, if you have a patient and you know the parents cannot afford the care that you're supposed to give them, like if he needs the dialysis or something like that; talking about this with the parents, sometimes it's like you don't know how to do it because you haven't been given the practice, or the education to deal with these kinds of communication with family, and at the same time, family does not want to know everything, we assume, because how can you tell someone, oh, I know how to cure your child, but it just happens to be that you cannot afford what I can do for the child. So, having this communication with parents, it's really difficult. And then, sometimes, decision making itself. Do I do the decisions? Do the parents make the decisions? Considering the fact that I have a very constrained resource limitation, how am I supposed to deal with these things? All those things are very difficult and that's something that we have to deal with on daily basis and navigate.

Host: Yeah. I mean, that sounds so challenging to have to, as an individual clinician, make some of these decisions at the bedside, looking at one patient and saying, is this a good candidate? Do I prioritize this patient over another one, not knowing who else might come in and who else might need those services, and thinking about things like parents ability to pay, and especially you said that there aren't really formalized ethics committees, for the hospital the way that we have here in the U.S. So, how is ethics education provided in Ethiopia if clinicians are facing these challenges? Is it sufficient for the clinicians there to deal with these? Like, what are some of the opportunities that there might be there?

Betty Kassa, MD: Regarding ethics education, I feel like it has been largely overlooked. We're too focused on what I call survival teaching, where we're just teaching people the basics of how basically, to treat a patient's disease and not take the patient as a whole. So in that regard, you know, like ethics would be the first thing that would be overlooked, which is exactly what happens.

In medical school, usually, students might get a few lectures of ethics, which is largely focused on research ethics instead of specific patient care, clinical care, and ethical dilemmas where students might face in the future when they become physicians, and how to equip them better to deal with the situations or the things that they're going to see.

When you come out of school, you assume everything's going to be just like the textbooks, but reality is completely different. So these things would have equipped students, when they actually need this kind of information or resource, but really, these are not things that you get educated on, even when you get ethics classes.

So, by the end of the day, most physicians, when they come out of school, are largely unprepared for what they're about to experience. And we have done a survey on pediatricians in the country and asking them about whether or not they feel like they're confident in their knowledge of bioethics, pediatric bioethics, or their difficulties and things like that, or do they need any supplementary education, and around 89 percent of them say, I don't feel like I know enough to navigate the difficult situations I see day to day and that I need more support, I need more education.

So that tells you how much of a gap there is basically in our educational system.

Host: I agree wholly. And I think, I was part of that study and it was really shocking to see that the vast majority of folks felt like they didn't have enough education in this area. So what would you like to see for the future to improve some of these gaps in the ethics education, and support in Ethiopia? What are some ways that you think that they could be addressed either on the individual, institutional, national level.

Betty Kassa, MD: Well, I feel like we need to focus on two different things. One is to educate and empower the physicians that work in the centers. For the students, we need to have a structured educational system that focuses on clinical ethics. And for the physicians that are already practicing, I feel like we need to have multiple trainings to empower their decision making abilities.

And we can do that by creating sim centers where they learn how to communicate with their patients or learn to navigate difficult decision making. The other thing that we could do in a wider scale would be to actually have a structured, ethical organization, basically an ethics committee or something like that in each and every hospital. That can only be rolled out by a national change basically.

So I feel like we need to work on exposing this problem to the healthcare system, to the government, and at the same time we need to work on educating our students and empowering our physicians.

Host: Excellent. So, do you think that it would be challenging to disseminate ethical knowledge and practice across the country? Like, what are some of things that are unique to Ethiopia that might be helpful or what are some things that might be barriers to making it extra challenging.

Betty Kassa, MD: I feel like it is something that we can do. The one thing that I would tell you that would be in support of disseminating knowledge would be the fact that everybody's curious and ready to learn and ready to improve, starting from physicians to nurses and any other health care professionals currently working in the system.

So the fact that people are curious and determined and they want to understand is, I feel like a huge plus for us to work on it. And at the same time, knowledge can currently be disseminated not only through face to face practices, we can do online teaching, online sessions of communications and things like that, that would really help and support our community.

And there are organizations that actually have that means set up. So the societies in the country, like the medical society, the pediatric societies, and all the other ones, so I feel like they're more cooperative. They're willing to work with us, and I've had a few conversations with some of them, and that's a huge plus.

 The diifficulty, I would say is some places are harder to navigate. You would not be able to go in person because of access issues. And those are the physicians that we can reach through online teaching and online online trainings and things like that. So I think it is doable. And I feel like there are people in positions of power are more likely to hear us now because, the country is trying to go towards change, and I feel like that is something that we could do.

Stephanie Kukora, MD (Host): I couldn't agree more with your first point that the folks in Ethiopia are so engaged and excited to try to make care better and to do everything that they can to improve the situation. I know that that's a lot of why I do so much collaborative work with you and your colleagues there. And it always makes me feel so energized to hear about all the initiatives that folks are trying to work on and I'm really excited about some of the work that's being done now in pediatric bioethics. Are there any other points you want to tell us about the pediatric bioethics in Ethiopia and what it's like to practice there?

Betty Kassa, MD: Well, it is really a very new idea to us. It's something that we're getting to explore and discover very recently. And the interesting thing for me is how people have responded to it. We tried to create an ethics committee in one of the hospitals, the one that I worked in and the amount of feedback that we got and the interest that we've seen, the cases that we've been presented in the short time that I was there trying to work on it was very incredible to me. I feel like it is time for us to start seeing our patients as a whole and care for them with the dignity and respect they deserve.

And at the same time, I feel like it is time for us to protect our healthcare providers that are being burned out and completely neglected. I feel like this is the time to address these issues and I think we are the people to do it.

Host: Well, thank you so much for sharing all of your knowledge and expertise today. I think it's so interesting to get perspective on what it is like to practice in a setting that's so different and especially a setting where the ethical challenges are so, so big and so serious and so common. It's so interesting to hear about this kind of work that you've done and that your colleagues are doing over there now. I want to thank everyone for listening. If you want to find out more about some of the global work that we are doing in the Bioethics Center with our international colleagues, you can find more on our website as well as now, very recently, a funding page to try to support more international students to be part of the certificate program, and to do more collaborative work with us in the center.

So, thank you so much. Thank you, Dr. Betty.

Betty Kassa, MD: Thank you, Stephanie.