During a recent visit to Jerusalem, I found this fax from my Addis Ababa office waiting on my desk one morning:
Dear Dr. Rick, I would like to inform you concerning Solomon Shume, the registrar in our clinic. He developed some skin lesions around the neck and face. We performed a biopsy which revealed pathology compatible with Kaposi's sarcoma. I am writing to let you know about the problem, and to ask if there is any recommendation on your side.
This was enough. Kaposi's in a young Ethiopian, especially one whom I know had herpes zoster in the past, has to be HIV. I spoke with some experts in Israel and learned of the debate about whether Kaposi's should be treated or not. I phoned my office in Addis Ababa, who informed me that Solomon's head was swollen to twice its normal size. We imported chemotherapy for him.
In a period of a few weeks I was inundated by AIDS cases. First there was the teacher, the brother of my long-time patient Paulos. Then Musah, my friend Mohammed's brother. Then the woman in the bar. And now Solomon. What a tragedy. Who is next?
ONE DOCTOR FOR 40,000 PEOPLE
I thought back to my introduction to Paulos' brother, the teacher. He was thin, but was comfortable and did not look ill. He complained of headaches and described his left side as getting progressively weaker. Upon examination I detected his reflexes were increased; when I jerked the ball of the foot upward, it set off a series of reverberatory movements that lasted 30 seconds. "Sustained clonus," I jotted down. His left big toe went up when I stroked the bottom of the foot with a key -- a sign of an "upper motor neuron" lesion, most likely a brain tumor.
Brain tumors are not easy to treat in America, but here in one of the poorest countries in the world, dealing with a brain tumor is almost an impossibility. I thought back to my training in Baltimore: I would order an MRI, have a senior neurologist confirm the diagnosis, get a neurosurgeon to consult and plan a biopsy. All within a day or so. We would consider surgery, radiation therapy, and perhaps chemotherapy as well.
In one of the poorest countries in the world, dealing with a brain tumor is almost impossible.
Back to reality. Here in Addis Ababa when I saw him there was no CAT scan and no neurosurgeon. Getting a chest x-ray is a task, and the 550-bed university hospital has chronic supply problems. Dedicated Ethiopian doctors spend hours on call working in suboptimum conditions, striving to help their people. There was no chance of getting further tests done here, and no money to send him abroad for more precise evaluation.
As a general internist in America, I was one of many, and it was easy to feel powerless and frustrated. In my one year in practice in an upper-middle class community, I sometimes got the feeling that I was passing time as a gatekeeper or doorman, sending patients here and there for opinions from consultants in the medical hierarchy. I used to ask myself: "Is it really necessary to send this patient to a lung specialist? I mean, will he really treat asthma differently from the way I do?"
Here in Ethiopia, with one doctor for about 40,000 people, I have few colleagues to rely on or consult, and have gotten used to working under limited circumstances. I refer to texts, look up Medline articles on therapies I am unfamiliar with, and occasionally call friends in the States with a question.
I treated the teacher for tuberculosis, which can also cause brain tumors. He did well for about a year. Later, I got a call from Paulos that his brother was not well. "What now?" I asked.
"He is coughing and has chest pain. I think it is birrd, cold," he said. Usually these things turn out to be insignificant; Ethiopians take to bed for a week or two for minor ailments, but one can never be sure.
Ethiopians often attribute their various aches and pains to blowing winds or to cold. When riding in a taxi or bus, windows are always completely closed, and Westerners feel as if they're suffocating. But Ethiopians are untroubled, content in knowing that dangerous winds will not touch them, at least for the duration of the trip. When a popular Ethiopian died sometime back, a doctor friend told me it was due to AIDS. In the media, it was reported that he died of birrd, cold.
DO I TELL THEM?
Paulos' brother was too sick to come to me, so I got in my car with Paulos and went to examine him. We drove a few miles down paved roads and turned off to a dirt road in a poor section of the city. After a few hundred meters and a couple of turns, the road became virtually impassable. "Okay, stop," Paulos said.
"Paulos, this is Addis Ababa," I said. "I need someone to watch the car."
"No problem," he said, and after 30 seconds one of his brothers showed up. "Samson," he said, "watch the car."
We headed down the road to his house, a small structure made of wood in a crowded area. There was a decaying fence around it, with a few sheep in the yard. As we entered the dented tin gate, I saw that the hut was poorly lit, poorly painted, with a wood floor, a kitchen table, photos of deceased relatives on the walls, and a huge football trophy on the table (a sign of Paulos' successful coaching).
The patient was on the sofa in a darkened corner. I leaned over and opened the shutter to add some light, revealing multiple, scattered, dark lesions. I watched silently as he slowly took off his shirt to identify the site of his chest pain, revealing similar lesions scattered over his trunk. Clearly he had Kaposi's sarcoma. The diagnosis now became clear: tuberculosis of the brain along with Kaposi's sarcoma. It could only be AIDS.
We paused for tea and discussed African football. "What do we do now?" I thought to myself. "Do I tell them anything? Do we sit down and speak with him privately, or hold a family conference?" I know the culture well; you do not openly give grave news. I got up to leave. But what about the diagnosis? The teacher did not ask, and I did not tell.
Paulos walked me back to my car. "What do you think?" he asked.
There was no use in warning him about anything else. I never mentioned the word AIDS.
"He is ill, very ill," I said. I wanted to let them know that he would not do well, but I was careful not to take away hope. "I will try treatment, but be aware that it may not work. And be a bit careful in touching him," I said. "Watch out for contact with his blood or stool or any other body fluids." There was no way that this fellow would be having intimate relations or be much of a danger to his community. There was no use in warning him about anything else. I never mentioned the word AIDS. I felt that they all knew about the possibility, but it was an unspoken assumption.
I left the country for a few months. When I returned, one of the first questions I asked my gardener, Belay, was: "How is Paulos' brother?"
"He's okay," he replied.
I was surprised. I would have expected a significant deterioration in two months. "Lucky guy," I thought to myself. That night as I was speaking with Endaleh, a handicapped boy who lives with me, he asked: "Did you know that Paulos' brother died?"
"What?" I said with astonishment. "Belay told me that he's okay!"
The following morning, Belay came up to me. "I need to tell you something," he said quietly, "Paulos' brother died. Since you had just arrived, I did not want to give you bad news."
Paulos and a younger brother came to see me recently. Over tea in my living room, I expressed my sorrow at the death of his brother.
"Paulos, what do you think was the cause of your brother's death?" I asked.
"Bronchitis," he replied, "or maybe birrd."
Solomon is a 27-year-old who worked for five years as the registrar in our clinic. Back in 1990 when we had 25,000 displaced people and were setting up medical files on all of them, he was enormously helpful in organizing this project, arranging the files, and managing to locate lost charts when others could not.
He was a handsome and reserved Amhara, quiet and hard working. In the evenings he took classes at local colleges; he received a 2-year diploma from the Commercial School, and had begun taking business classes at the university.
When the fax from Ethiopia arrived in Israel saying that he had Kaposi's sarcoma, I was shocked and saddened.
Our office staff, to their credit, visit him at home every day. They cook him gunfo and atmeet, the Ethiopian equivalent of chicken soup and a Vitamin B-12 shot, and Solomon did well for a couple of weeks. He then developed a high fever and people feared he was dying. Our Ethiopian doctor went to see him and started him on ampicillin and gentamycin. Strong drugs, seven injections daily.
I returned to Ethiopia in the middle of this, and wanted to see him. In the Talmud it is written: "It is the duty of every person to visit someone who has fallen sick." In Jewish tradition, each visitor is said to take one-sixtieth of the illness away from the ailing person.
I had no idea where he lived, and with whom. My nurse told me he was renting "a very nice room with a wooden floor and electricity and a solid roof." His mother came from Nazareth, a couple of hours away, to help him. His brother, who had been a refugee in Yemen returned as well. My nurse and I drove off to see him.
A beggar with leprosy, who had lost most of his fingers and toes, shoved his palm into my car, asking for money.
We drove west from my clinic for a few miles into the center of town along potholed roads, dodging donkeys carrying loads of firewood and herds of goats marked with a dot of red dye on their backs being taken to the slaughterhouse. We drove past Black Lion Hospital, the decaying university hospital, and drove up the hill toward the merkato, the sprawling marketplace of the city.
At a stoplight, a middle-aged beggar with leprosy who had lost most of his fingers and toes, shoved his palm into the window of my car, asking for money. Next to him stood a mother wearing a ragged white dress with a naked baby. I reached into my pocket and gave them each 10 cents, half the price of a roll of bread.
We parked and 30 or 40 local kids surrounded us, looking at the rare spectacle of a farenge (foreigner) coming into their village. As we got out of the car, they started the familiar chant I hear daily throughout the city: "Farenge, give money, Farenge, give money."
INVOKE THE MAGIC
We entered the house, and Solomon's brother introduced himself. He was in his early 30s, tall and thin, with a full head of short black hair. He graciously bowed slightly as he shook our hands and smiled, revealing two gold teeth. He pointed to the bed, where I saw a tuft of black hair protruding from under the white blankets.
It took several minutes for Solomon to turn from his stomach to his back and uncover himself a bit so I could see him. When he did, I was shocked by the difference two months made in his appearance. He had lost weight, his eyes were sunken back, and his Kaposi's spots were clearly visible.
We chatted about my trip to Israel and the weather in Ethiopia, about how the clinic was not doing well without him, and about local politics. After 10 minutes, we saw a visible change in his mood. He became more animated and smiled a bit, his energy level picked up, and his eyes looked less glazed.
The Talmud states: "The essential duty of visiting the sick is to pay attention to the needs of the invalid, to see what is necessary to be done for his benefit, and to give him the pleasure of one's company."
I asked Solomon about his symptoms. He complained of lack of appetite, about pain in his mouth, and especially in his ears when he swallowed. He showed me his eardrops and vials of antibiotics.
I did not think there was much I could do medically for Solomon, but I thought I should examine him, if only to invoke the magic of "laying on of hands." I looked inside his mouth. It was filled with candida yeast. My nurse told us she was painting his mouth with gentian violet daily to keep down the candida growth.
After 40 minutes, I got up to leave. I shook hands with his brother, and then sat down on Solomon's bed for a moment and placed my hand on his chest. I recalled the statement of our sages: "If one visits the sick, but fails to pray for mercy, he does not fulfill his religious duty."
"Solomon," I said, looking into his eyes, "may God bless you and heal you."
"Thank you, Dr. Rick," he replied.
NOTHING MORE TO DO
I always feel impotent in such situations. I would have liked to have done something grand and save his life, or extend it significantly. Or should I have discussed deeper and more delicate topics with Solomon, perhaps told him he is gravely ill with AIDS.
The Talmud says: "One who visits the sick should speak with judgment and tact. Speak in such a manner so as neither to encourage him with false hopes, nor to depress him with words of despair."
I felt we should be talking about what it means to have AIDS, about families and love, about ultimate issues.
I felt we should be talking about what it means to have AIDS, about what is important in this world, about families and love and kindness, about missed opportunities and ultimate issues. But here in Ethiopia many things are left unsaid. Neither Solomon nor the teacher ever asked their diagnosis.
In America, AIDS treatment involves technical issues such as AZT doses, schedules of aerosolized pentamidine, T-cell counts and viral loads take on great importance. There are discussions of whether to put a dying patient on a ventilator, or run a "code" on him if he arrests in hospital. The patient, the human being with a heart and soul, may be easily swept aside by issues of technology.
In Ethiopia, such issues are simply not pertinent. Instead people stay together, visiting, supporting, and awaiting the inevitable end. Quietly.
I was happy that I came to Solomon's home. It had clearly boosted his spirits, and that is perhaps the most important thing I could have done. As a doctor who feels much more comfortable defeating death (yes, sometimes we are successful) than making life's demise more calm and pleasant, I welcome situations like this with a bit of trepidation as a way of opening myself up to life's uncertainties, to develop an attitude of kindness and compassion.
In the end, I always feel like I should do more, even though I realize that there is nothing more to do. When death comes, I feel aching and hollow.
And a bit more appreciative of life.
At least for a moment.
Contributions can be sent directly to Dr. Hodes at:
Dr. Rick Hodes
PO Box 7600,
Addis Ababa, Ethiopia
Contributions can also be sent to:
711 3rd Ave, 10th floor,
New York, NY 10017