I chose to go to Ethiopia on my elective because of a novel, a coffee shop on a summer’s day and a traveller’s tale. Years ago I read ‘Cutting for Stone’ by Abraham Verghese – a richly descriptive story set around a hospital in Addis Ababa in the 1950s – and the evocation of the city, its food and music captured me. A few years’ later, as a 4th year medical student, I sat at ‘Kaffa Coffee’ in Dalston with a strong espresso and a plate of injera covered with richly coloured pickles and vegetable stews, listening to Ethiopian piano jazz rolling out like a wave across Gillard Square. Then a conversation with a friend who said: “The Addis Sheraton is like that bar scene in Stars Wars. It’s the greatest people-watching place in the world. Plus their calendar is 6 years behind and their clock runs six hours ahead.”
After trying and failing to arrange an elective through the Tikur Anbessa (Black Lion) teaching hospital, a friendly professor who had seen a documentary about him suggested that I contact Dr Rick Hodes. Rick Hodes is Brooklyn in Addis. He first went to Ethiopia in the 1980s to teach medical students. He returned in the early 1990s with the Jewish Joint Distribution Committee (the JDC) to be a public health doctor in the refugee camps for Ethiopians who were waiting to be airlifted to Israel. He stayed in Addis, later working at the Mother Teresa Mission centre. It was here that he met a child with terrible – but theoretically treatable – spinal deformities. Just like any of us would do, he adopted him so that he could add the child to his American health insurance policy. The child duly flew to the States for life-transforming surgery. Rick went on to adopt a further four children in this manner, who also duly flew to the States for surgery – and this is his family today. Rick developed a reputation for being able to treat these cases and decided to develop a more robust programme.
Nowadays Rick runs the JDC’s Ethiopia Hearts and Spines programme, officially, and unofficially runs a boarding house for some of the children he is treating or has treated.
The Hearts and Spines programme is a gateway clinic, run by Rick and a small team, for the management of heart and spine disease which is life-threatening but treatable by surgery. Patients come through word of mouth, after being spotted on the street in Addis Ababa, or via referral from medical professionals. He sees about 400 new spine patients in a year about 100 new heart patients, in addition to follow ups and people who don’t fit into the programme. Only about 10% of those attending with documented spinal disease can currently be funded for surgery. Rick triages patients according severity, likelihood of sudden deterioration and the likely success of treatment. He arranges surgery, usually conducted at the FOCOS Hospital in Ghana by Dr Oheneba Boachie-Adjei, but occasionally in Texas (at the Texas Back Institute by Dr Ted Belanger) and sometimes in Addis Ababa by visiting teams.
‘Surgery’ in Ghana, where the most serious cases go, is a process lasting eight months in which the patients – usually children between the ages of 7-18 – undergo six months of 23-hour per day traction, prior to the actual surgery which usually involves remodelling or removing vertebrae, and then inserting titanium rods to support the spine in its new shape. Back in Ethiopia, Rick follows the patients up his clinic and manages complications. None of the patients can afford the cost of surgery which runs close to $20,000 per patient including ongoing care and the programme at the moment receives little Ethiopian government funding, so relies on charitable funding from abroad.
There are cardiac centres in Addis Ababa and in Jimma, but these generally operate only on simpler single valve defects. As of 2016, there are no paediatric cardiac surgeons in Ethiopia. Rick generally sends his patients with these more complicated problems to the Amrita Hospital in Cochin, India and occasionally to Israel.
During my elective I sat as an observer in the clinic which happens 3 days per week, helped with administration and interviewed patients and their relatives. The clinics were fascinating, both for the people and the pathology. Patients were mostly children or young adults, usually attending with family members, from all over Ethiopia. The waiting room was a melting pot of people from different regions, religions and ethnic groups. While most patients had deforming spinal disease or unseen but equally devastating cardiac disease, there were a significant number with neither but who nonetheless had heard of Rick as a great doctor. Cases include scoliosis, kyphosis, lordosis as well as more bizarre Z-shaped deformities and combinations of the above. I saw several spinal curvatures greater than 180˚. In addition to the common congenital, rheumatological, traumatic, infectious causes of spinal deformity, I saw Rick diagnose a six year old girl with one of the rarest described conditions in the world, fibrodysplasia ossificans progressiva, in which a person’s muscles transform into a bony cage around the body. Rick could offer her nothing – indeed there is no known treatment – except to add her to an international registry of such people.
Life outside the clinic was fascinating. Addis is a fun city with bars, live music, great food – a mix of Ethiopian, Italian and Arabic – and interesting museums and cultural attractions. I explored these with people I met at my guesthouse, other visitors to Rick’s clinic and one of the kids living at Rick’s house. I visited Lalibela, whose 900 year old rock temples are among the wonders of the world. The most unusual experience I had was Shabbat dinner on Friday nights at Rick’s house. Every week, the resident kids and a smattering of local and out of towners gather in his hard-used living room. The other guests are doctors, students, anthropologists, musicologists, engineers, funders, politicians. Rick hands out novelty hats to everyone and we gather in a big circle, hold hands, and sing the protest song ‘If I had a hammer’ by Pete Seeger, followed by Shalom Aleichem, and then he makes Kiddush. Rick reappears a bit later with his aluminium camping mug, out of which he eats most of his meals – this is a signal that food is ready in the kitchen. Injera, Shiro Wat, pickles vegetables, pasta fill my plate.
My elective in Ethiopia was great. I got to eat the food, live in the city and listen to the music just as I’d hoped. I got to explore a culture which is like a parallel reality to our own –“What if the Ark of the Covenant was secretly ferreted out of Solomon’s Temple?”. I saw fascinating medical cases and helped in a small way. The trip broadened my horizons of what one can do with a medical degree and indeed how a person can choose to live. And I did make it to the Sheraton Addis Ababa – if only because Rick likes to use the toilets there after a long hard day in clinic.
Thanks to the JMA for its financial help. Do get in touch if you are thinking about an elective in Addis or want to get in touch with Rick.
Gabriel Doctor
Barts and the London