Zachary Mostel

Sackler School of Medicine, Tel Aviv University, Tel Aviv

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“There are three things telling me this is Polio: one, his crutch; two, his braced and withered legs; and, three, the broad kyphosis in his back. Surgery will improve his breathing capacity, but it may disrupt his center of gravity and impair his ability to walk.” A long queue of patients with mangled postures is waiting outside a damp basement clinic in the heart of Addis Ababa. These eager patients have traveled hundreds of kilometers to see Dr. Rick Hodes, whose clinic seems a world away from the trauma hospital directly upstairs.

His reputation spans several continents, having spent nearly 30 years practicing in Ethiopia. Dr. Hodes, who originally hails from Syosset, NY, is an internist specializing in spinal and cardiac disease. He has treated thousands of spine patients and personally determines their eligibility for surgery, which typically costs around $20,000.

Watching Dr. Hodes is like attending a master class in diagnosing spinal disease. His spine cases have included tuberculosis, polio, neurofibromatosis type 1, muscular dystrophies (Duchenne, Spinal Muscular Atrophy), rheumatologic disorders (Rheumatoid Arthritis, Ankylosing Spondylitis), severe scoliosis, and idiopathic causes. He also sees cardiac patients, many of whom have rheumatic and congenital heart disease. Patients will come in with hunched-over backs that are on the verge of fully compressing the lungs. Though it seems like a cosmetic deformity to the untrained eye, this condition can eventually cause death by obstructing breathing mechanics. Some of Dr. Hodes’ cardiac patients present with episodes of syncope and murmurs that can be identified even by first year medical students.

Abnormal vascular channels, both inside and outside the heart, allow blood to bypass the lungs. These shunts deprive the lungs of blood supply. Thus, the rest of the body is deprived of its oxygen source, causing episodes of fainting. Many of these heart and spine conditions can be addressed at early stages of the disease process. In the United States and Western world, there are routine health checks that identify these issues before they become problematic or dangerous. But, in Ethiopia, most patients will either delay treatment for years or never seek treatment as most locals have limited access to healthcare. This is the sad reality of medicine in many rural communities, such as this one.

Another patient enters the clinic with a serpentine spine. Dr. Hodes rests a device resembling a protractor on his back to measure the angle of curvature (termed the “Cobb angle”). Spine surgery is indicated starting with a 50-degree rotation. His key confirmatory criterion is pulmonary function. As Dr. Hodes says, “Normally, a person standing upright cannot touch their kneecaps. Try it! When a patient’s hand can touch their patella while standing upright, they have lost half their Forced Vital Capacity (FVC).” FVC is the volume of air one can exhale with force following the deepest breath possible. This measurement is Dr. Hodes’s gauge of the severity of lung diseases, and thus a benchmark of the patient’s risk of respiratory failure. In this way, his surgical recommendations are both life-changing, and also life-saving.

Having lived in Ethiopia for three decades, Dr. Hodes is well versed in traditional Ethiopian medical practices. Community healers perform small procedures that are not performed in Western medicine, in order to prevent and treat many medical conditions. Some of these include: uvulectomy (to prevent suffocation during pharyngitis), extraction of lower incisors (as diarrhea prevention), and the incision of eyelids (for conjunctivitis). As a practitioner of Western Medicine, Dr. Hodes does not perform any Ethiopian healing procedures. Instead, he accounts for such diverse health beliefs while he is collecting a history, performing a physical exam, and discussing treatment. As Dr. Hodes writes, “Physicians not versed in Ethiopian culture may not understand why a mother fears that her child with pharyngitis will die. They may miss the importance of scars over the eyelids, a small scab over the brachial vein of an anemic woman, or why the incisors of a baby are missing.”¹  For this reason and others, cultural awareness and sensitivity is crucial when treating an Ethiopian patient in any healthcare setting, including Israel’s Ethiopian community.

On a daily basis, I saw patients coming to Dr. Hodes for the very first time. Many of these new patients, who are visibly uncomfortable, have never spoken with a white person before. To bond with these patients, he always encourages them to ask three questions they may have. This technique is both comforting and trust-building. With every patient, he takes a series of photos in multiple positions (upright, bent, front, back, chest) for documentation in their file. Dr. Hodes often includes smiling selfies with his patient among these photos.

Dr. Hodes enjoys his role as a community figure in Addis Ababa. He goes far beyond simply dispensing medical care, and he opens his home to provide meals and a roof for those in need. Hence, his house has become a way-station for former and present patients who need a temporary residence. He is an Orthodox Jew, and his Shabbat table on Friday night is a celebration of life and bright futures for the patients who are living in his home. I asked his motivations to provide so much more than what is expected of a physician. He responded by quoting Talmudic tradition: “Whoever saves one life, saves an entire world.”

I had the privilege of meeting one of Dr. Hodes’ most unique and personally dear patients. He stood out in that he was both a cardiac and spine patient. His name was Ahkwahk (meaning “gift of God” in Oromo, one of several Ethiopian languages) and he was at the clinic for follow-up after several surgeries. At their first meeting, Ahkwahk told Dr. Hodes “I have a bad back.” There were three noticeable findings: the patient had four fingers on his left hand, a thoracotomy scar, and a lumbar kyphosis (instead of the usual lordosis). He was found to have the rare developmental disorder known as a VACTERL. Ahkmahk had the ‘VCL’ findings (Vertebral, Cardiac and Limb anomalies), and a cardiac operation seven years prior was performed to close his Patent Ductus Arteriosus (PDA). However, this prior surgery was botched. The pulmonary artery was inadvertently ligated, rather than his PDA. Ahkmahk still had a 13 mm PDA and was essentially living on his right lung alone. Dr. Hodes sent him from Addis Ababa to Colorado for the proper PDA ligation and a new pulmonary artery was produced from pericardial tissue. A second operation was also performed which removed his first three lumbar vertebrae to mitigate his spinal deformity. Dr. Hodes has since taken Ahkwahk under his wing and even secured an academic scholarship for the bright student. Ahkmahk will return to the United States and study at the University of Colorado at Boulder in the fall of 2017 where he plans to study biochemistry. Dr. Hodes is preparing him for campus life and unfamiliar cultural quirks in the United States.

Back in Addis Ababa, the lights are dimmed and the room is illuminated by a radiologic scan. Everyone present gathers around the peculiar image of a crooked spine. Dr. Hodes enlightens his colleagues: “This is classic spinal tuberculosis. There is a sharp, outward kyphosis. You can see fusion of the vertebrae from the inflammation and calcification. Isn’t that just a beautiful image? That should be in the New England Journal of Medicine!” The joke elicits a laugh from the crowd. Dr. Hodes is a seasoned expert in his field and can call them as he sees them. But his clinical assessments, like his patient encounters, often include a necessary touch of humor.

Reference

Hodes RM: Cross-cultural medicine and diverse health beliefs-Ethiopians abroad. West J Med 1997; 166:29-36