Death and dying in Ethiopia

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.

Eder

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.

The public health of death, dying, and grief has been neglected, but now is the time

Richard Smith

The dying spend less than 5% of their time with doctors and nurses, and 95% doing something else, perhaps alone, with family and friends, walking the dog, making love, reading poetry, or watching the television. “Dying is not hard,” said Alan Kellehear, 50th Anniversary Professor, End of Life Care, University of Bradford in London this week; it’s what happens on the journey to death, which may last years, that can be hard: anxiety, depression, fear, loneliness, social isolation, stigma, looking into the abyss, and suicide. Yet palliative care concerns itself primarily with the 5% not the 95%.

Continue reading “The public health of death, dying, and grief has been neglected, but now is the time”

Traditional death in Tahiti

I had been in Piri about two weeks when, one evening, Teri’i Tui Vahine said that Távana Vahine was very ill. I went down to Távana’s house at the seaward end of the village to see what was happening. Távana Vahine was lying on a mattress on the floor of a large shed. … It was crowded with twelve adults and sixteen children and young adolescents. The adults were Távana Vahine’s sisters and brothers, her and Távana’s grown children and some of these people’s spouses. The children were her grandchildren.

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Traditional death in Samoa

Among the Samoans the aged were buried alive at their own request. It was even considered a disgrace to the family of an aged chief if he were not so honored. “When an old man felt sick and infirm and thought he was dying, he deliberately told his children and friends to get all ready and bury him. They yielded to his wishes, dug a round deep pit, wound a number of fine mats. around his body, and lowered down the poor old man into his grave in a sitting posture. … His grave was filled up, and his dying groans drowned amid the weeping and wailing of the living.”…

Taken from The Craft of Dying by Lyn Lofland (1978), who in turn took it from The Role of the Aged in Primitive Society by Leo W Simmons (1945)

Taken from The Craft of Dying by Lyn Lofland (1978) , who in turn took it from The Role of the Aged in Primitive Society by Leo W Simmons (1945)

The remarkable death of an Ayurvedic practitioner

Rakesh Biswas, a physician in India, contributed this story.

I was reminded of a story from my childhood around the death of my grandmother’s father who was an Ayurvedic practitioner at a time when Indians held Ayurveda to be a superior form of medicine that could allow better patient outcomes, although the British dominant modern medicine was fast catching up at that time as well. 

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Examples of interventions used in compassionate communities

Examples of interventions used in compassionate communities

  • Poster campaigns
  • Trivial Pursuit/World café nights
  • Positive grieving art exhibition
  • Annual emergencies services round table
  • Public forum on death and loss
  • Review of local policy and planning
  • Annual short story competition
  • Annual Peacetime Remembrance day
  • Compassionate Watch programme
  • School and workplace plans for death & loss
  • Compassionate book club
  • Building/architecture prize for caring designs
  • Academic prizes for relevant dissertations
  • Animal companion remembrance day (involve vets)
  • Book marks, beer mats, etc

Compassionate Cities Charter

Compassionate Cities Charter

  • Our schools, trade unions, and workplaces will have policies in end of life care
  • Our churches and temples will provide appropriate supports for end of life care
  • Our hospices and nursing homes will engage in community development
  • Our Cultural Centres will raise awareness of end of life care issues
  • There will be a peacetime memorial parade/festival
  • There will be an incentives scheme for compassionate leaders – both individuals and organisations
  • The Town council will showcase its achievements and ambitions in this area
  • There will be annual local short-story or art competitions within the city to raise awareness of end of life care
  • We will incorporate diversity in all we do
  • We will address end of life care issues in the margins of our city – with the homeless, prisons, refugees, travelers, etc
  • We will expand our influence annually into another social sector –emergency services, universities, creches, etc

Transformation of dying over two generations in South India

Transformation of dying over two generations in South India

M R Rajagopal

When I saw a doctor-colleague bravely trying to face the impending death of his son-in-law from cancer recently, the transformation that happened in our society over two generations became obvious to me. The most striking memory from that encounter is the expression of the dying man’s 15-year-old son who was walking about in the background choosing books and other things and cramming them into a couple of bags. He certainly was not part of the conversation. On the other hand, when he came close enough the conversation flagged, he was being given an unspoken message, ‘This is grown-up talk; kids are not part of it”. He responded rather obviously by pretending not to listen and trying to put on an inscrutable face. He was being sent away to live with an uncle so that his father’s illness and death would not disturb his studies, as he was about to face an important high school examination.

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Death in Malawi: the community role

We don’t discuss death with the dying

Luckson Dullie

The community hospital was about 55km from the district hospital but the road trip between the two facilities took up to 90 minutes on the bumpy unpaved road. The sick man was eventually referred to a regional hospital, another 100km away. After almost a month in the hospital, he was discharged home. The doctors did not explain much except that he should take his medicine and come back if there was a problem.

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Emerging ideas on the role of communities in death and dying

Communities cluster: Lancet Commission on the Value of Death

Libby Sallnow, Nahla Gafer, Katrina Wyatt, Robin Durie, M R Rajagopal

– Outline of report and discussion points –

July 2019

 (1) Introduction

Death and dying are profoundly personal and intimate events, rooted in social experiences, relationships and culture. Like birth, they are fundamental events that define individuals, families and communities. Changes in healthcare over the past century have led to many significant improvements in health and wellbeing, but this increased professional involvement in healthcare has come at the expense of individual or collective ownership. Whilst this can be seen across many dimensions of health and wellbeing, it is particularly evident when looking at death and dying. A substantial body of evidence exists to suggest that contemporary experiences of the dying around the world are poor. This is seen both across and within nations. The advent of palliative care in the 1960s went some way to acknowledge the importance of the process of dying and to root its care in a holistic philosophy, but recent reflections highlight how this too remains a professional response to a phenomenon which is, at its core, a social event.

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