Visiting Solomon: AIDS in Ethiopia

Publication of this article introduces a new feature of AIDS. Periodically we will publish first hand accounts of handling HIV/AIDS in various countries in the world (see instructions to authors). The fax from my Ethiopia office informed me while on a trip to Rwanda that Solomon had Kaposi's sarcoma. I phoned Addis Ababa and was informed that Solomon's head was swollen to twice normal size. ‘‘We took blood, ’’ my nurse said quietly … ‘‘for the test. ’' Over the past 3 years, I have been inundated by AIDS cases. In this nation of 65 million, UNAIDS estimates that there are 3 million HIV-positive persons, 1 in 11 HIV-positive people in the world. Virtually every family has been affected. The infection here is caused primarily by the clade-C virus type, spread is largely heterosexual, and virtually all males (and 80% of females) are circumcised. The protective value of circumcision seems questionable. Traditional practices such as uvulectomy, scarification, bleeding, and tooth extraction are common, as is the practice of going to local ‘injectors’ for therapy with unknown substances. Popular local healers advertise in Amharic newspapers, claiming to cure AIDS with herbal preparations. HIV testing is widely available, but only one laboratory in Addis Ababa does CD4 cell counts. Measurements of viral loads are unavailable. AIDS medicine is not commercially available. A small ‘black-market’ supply exists, but physicians are untrained in HIV therapy. Last week a surgeon said to me ‘‘Dr. Rick, I have two patients to start on HAART. Do you have a paper on how to do this? ’’ I tried explaining that reading a paper does not make one an AIDS doctor. All of this scenario is quite a strain on a nation with a per-capita GNP of 100, male life expectancy below 42 years, and WHO Health System Attainment ranked 186 out of 191. Admission to government hospitals is very difficult, with 42% of hospital beds taken by AIDS patients. Solomon is a 27-year-old clinic registrar. A handsome and reserved Amhara, he worked for us every day, and took college classes at night. A year before, I treated him for herpes zoster, knowing well what that clinical symptom could indicate. I did not suggest HIV testing for reasons discussed below, but advised him about health, including adherence to safe sex guidelines. In my absence, he received chemotherapy for his Kaposi's sarcoma (imported adriamycin and vincristine), and improved. He did not return to work. Our clinic staff visited him at home every day, bringing gunfo and atmeet, the Ethiopian equivalent of chicken soup and a vitamin B-12 shot. He did well for a month, then developed a high fever. Empiric treatment with ampicillin and gentamycin at home worked well. On my return, a nurse and I went to see him. We drove west 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 headed for slaughter. We drove past the Black Lion Hospital, the decaying university hospital. The hospital got its first CT scan last year, but routine supplies are missing. When I dropped a woman needing a Cesarean section there, they phoned and said ‘‘Bring us sterile gloves, needles, and two bags of normal saline and we'll operate. ’' We drove up the hill towards the merkato, the sprawling city marketplace. At a stoplight, a middle-aged beggar with leprosy, missing most fingers and toes, shoved his palm into my car window asking for money. Next to him stood a mother wearing a ragged white dress with a naked baby sucking on her pancake-like breast. I gave them each 10 centimes, half the price of a roll of bread. On either side of the hill was a shantytown of tin-roofed hovels, where families of seven or eight people live in one or two rooms with a dirt floor, one dim light bulb, and no running water. My nurse told me Solomon lived in ‘‘a very nice room with a wooden floor and solid tin roof and electricity. His mother is in from the countryside to assist, and a brother in Yemen returned as well. ’' After some minutes, my nurse said ‘‘park here. ’’ Dozens of local kids surrounded us, observing the rare spectacle of a farenge (foreigner) in their village. We walked down the hill and entered a small compound with a main house and several rooms on the side. Several women sat on the grass braiding their hair and sifting teff, the local grain. We entered a room with dirty-blue walls, about 20 by 25 feet in size, and a bed against the left wall. Solomon's brother and mother were in chairs on the far side. There was a small sofa opposite the bed, and a radio-cassette player on a corner table next to a photo of Solomon on graduation day. Inside the door was a sign which read, ‘‘God is love. ’' 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. I asked him where Solomon was. He pointed to the bed, where a tuft of black hair protruded from a mound of dirty white blankets. He leaned over, touched Solomon's back, and with exquisite gentleness whispered in Amharic ‘‘Solomon, wake up. Your doctor is here. ’' It took several minutes for Solomon to turn from his stomach to his back and uncover himself. I was shocked by the difference 2 months had made. He had lost weight, his eyes were sunken, and his Kaposi's was clearly visible. ‘‘He looks good, ’’ my nurse said quietly. She told me our staff has been giving him a liter or two of intravenous saline every morning, along with a small vial of 40% glucose. Solomon lay back on a pillow. He covered himself carefully with a blanket – Ethiopians often attribute aches and pains to blowing winds or cold, two things to be carefully avoided. When riding in a taxi or bus, windows are always completely closed and westerners feel as if they're suffocating. Ethiopians however are untroubled, content in knowing that dangerous winds will not touch them, at least for the duration of the trip. When a famous Ethiopian TV personality died, a colleague told me he had AIDS. The media reported that he died of birrd, cold. I sat facing Solomon with my foot against the wall. He reached over and held onto my calf. I rested my hand on his leg. We chatted about my trip abroad and how our clinic was disorganized without him. After 10 minutes, there was a change in his mood, he became more animated and smiled a bit, his energy level picked up and his eyes looked less glazed. 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 ear drops and vials of antibiotics. There was a steady stream of visitors, close friends and casual acquaintances, in and out, shaking hands, sitting for a few minutes, and then departing quietly. Ethiopians show great support in times of need like this. I examined him. His chest was clear and respirations normal. His mouth was filled with candida. His abdomen was normal. He was not dehydrated, and his heart rate was OK. I looked in his ears, and thought I saw some signs of candida as well. I changed his ear drops. My nurse told us she was painting his mouth with gentian violet daily to keep down the candida growth. After 40 minutes, I shook hands with his mother and brother, and then sat down on Solomon's bed for a moment and placed my hand on his chest. ‘‘Solomon, ’’ I said, looking into his eyes, ‘‘May God bless you and heal you. ’’ ‘‘Thank you, Dr. Rick, ’’ he replied, quickly followed by ‘‘but what should I do about my ear pain? ’’ I told him I thought the new medicine would take care of it. As I walked out, I looked up at a poster of a kitten with a key in its mouth. It was captioned: ‘‘When God closes one door, he opens another. ’’ Solomon looked at me and asked: ‘‘Doctor, the poster, it's true, isn't it? ’’ ‘‘True, ’’ I replied emphatically, ‘‘100%. ’’ I winked at him as I walked out. His brother stepped outside. We looked into each other's eyes. I held his right hand with both of my hands as we spoke. ‘‘If you have any questions or would like to discuss anything, ’’ I said, ‘‘Now or later, feel free. ’’ ‘‘Thanks, ’’ he replied. I was certain that he had been informed of Solomon's diagnosis. I was equally certain that Solomon had not been. In America a doctor would sit down with a patient, tell him the diagnosis, perhaps not the whole story but he would not lie, and then encourage the patient to live, to fight, to be strong. Here in Ethiopia, ‘‘Don't ask, don't tell, ’’ seems to be the credo. I asked my nurse if we should inform Solomon of his disease. ‘‘No way, ’’ she replied, ‘‘He could commit suicide. ’’ In fact, the Ethiopian Medical Code of Ethics states: ‘‘Information about serious diagnoses and/or prognosis may be withheld unless the patient demands it. ’’ Most of my patients do not ask, much less demand. I always feel impotent in such situations. I would like to do something grand and save his life, or extend it significantly. Instead I ended up playing with ear drops and analyzing what we had spoken and not spoken about. I somehow 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 coping with a fatal condition. In America technical issues abound – drug doses, cell counts; viral loads take on great importance. There are discussions of whether to put a dying patient on a ventilator, or whether to resuscitate. The patient, the human being with hands and a heart, the human experience, can easily be 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. My visit had clearly boosted Solomon's spirits, and that is perhaps the most important thing I could do. As a physician who feels more comfortable defeating death 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 always feel aching and hollow, calm and a bit more appreciative of life, at least for a moment.