Hiberet Tessema Belay, MD, MRCPsych
Ethiopia is a country located in East Africa with a diverse population of around 113 million people. As such, there are variations in the cultures of the different regions of Ethiopia. This article by no means intends to be representative of all ethnicities, cultures or religions, and will show a culture from Addis Ababa, the capital city of Ethiopia.
Death and dying is an accepted norm of life globally and also in Ethiopia. While little is discussed about dying and caring for the dying; a dearth of practices and norms and elaborate funeral processions occur nationwide in the country. These are also documented in various articles and journals.
According to the CDC, the common causes of death in Ethiopia are neonatal disorders followed by diarrheal diseases, lower respiratory tract infections, tuberculosis and ischemic heart disease. The life expectancy at birth is 67 years. Terminal illnesses, cancer and age-related deaths, are now surfacing, as the country’s economic status is slowly increasing. Palliative care services are not widely available or extensively established. To my knowledge, there are no formal palliative care services in Ethiopia. While researching this topic I came across a hospice foundation in Ethiopia, a voluntary organisation that has been set up in 2003 and provides limited but much needed hospice care.
In the absence of a medical model of palliative care services, death and the dying are by and large managed within communities. It is common, and almost diagnostic of impending death, when relatives are informed to ‘take the patient home’. This phraseology is locally understood to imply that all healthcare has been exhausted, and the patient is dying.
Care of the dying
It falls to the immediate family to look after the dying at home. There are no nursing homes, no palliative care services, and no community health care professionals visiting homes to provide support. Recently with an increasing number of private medical and nursing colleges, private home care is available for hire at what may locally be considered expensive rates, at least in the capital city of Addis Ababa.
Families and neighbours by and large provide care to those beset with illness and nearing the end of life. Sometimes, the decision to inform impending death rests with close family and relatives, who may take a stance to support the dying, and usually withhold from breaking the bad news of informing the ill, of their impending death. This is done in a spirit of ‘sparing’ pain and agony for the dying.
Once the decision to take the ill person home is reached, families may take a number of options ranging from taking the dying person for a second opinion to a different health facility to consulting local healers to acceptance of impending death and nursing the dying at home.
At home, the dying person is typically kept in a separate space in the house. For example, (if there is a bedroom space, this will be dedicated to their care) and looked after by close family members and elders who might have had prior experience in looking after the dying. Food is offered to the dying and encouraged and supported to eat, if consciousness allows. Pain control is not common practice, nor is it practical. Typically, there is one person attending the dying person’s side, perhaps monitoring for life to end to alert the elders who diagnose the finality of life.
By and large, families come together to provide care for the dying and provide supportive care. What is striking is the extended fibres of society, neighbours and relatives, even those that one may not normally get along with, who put their differences aside and come and visit the dying person and give encouraging words to the family in an attempt to keep them strong. Typically, a brief see and greet will be conducted of the dying person, and guests stay in separate area. If available, the living room or outdoor space will be used to stay with the family and offer supportive words and share the family’s worries and stress.
Almost all Ethiopians are members of an Eder in their own localities. An Eder is a social association akin to funeral insurance. As an Eder member, one pays the allocated membership fee (usually affordable and small amount) monthly. Typically, the funeral day and the first 40 days after one is deceased are earmarked as a grieving period, following which normal life continues for those close to the deceased. Eder members give and receive practical support for the funeral.
Most Eder’s have in store all that will be needed for catering and practical items to the last detail such as plates, cups, pots etc; which will be needed after the burial of the deceased. With these they prepare food for the guests that will come to give their respects for the dead and for the family of the deceased. This will ease the burden of accommodating the guests by the deceased family. Anecdotally I have recently also heard of stronger Eder’s that have managed to raise enough funds not only to bury the dead, but also build property that generates income for Eder members.
Regardless of the time of death, the Eder trumpet announcing the death of the person who passed will be blown by the Eder trumpeter in the wee hours of the morning to advise members in the community of the Eder to be aware of the death of so and so and to be present early to put up the tent and bring chairs, plates etc to the deceased person’s residence to kick start the burial process and the grand send off the dead. The announcer also adds a penalty fee will apply to those who ignore his message and don’t present themselves.
Typically, no food can be eaten until the dead person is buried and laid beneath the ground. Following this, all attendees at the burial will return to the deceased house for a meal prepared by the Eder members.
The immediate family then takes a central sit, usually on a mattress and accepts incoming guests for three days. At the three-day mark, an early morning ‘crying session’ will be held, to remember the memories of the deceased. Another feast – a memorabilia- takes place on day forty following which things start to resume to normal. A widow grieving her husband’s loss, would typically sleep on a mattress on the ground for 40 days out of respect for her husband. Thereafter an annual remembrance event will be held, with a feast being prepared if families have capabilities to arrange it.