Broken Hearts Physically, it is falling apart. It is dirty, has leaking ceilings, broken windows, and smells like hell. The walls are covered with water stains, the paint is peeling, and the floor tiles are often missing. The piped-in oxygen died years ago. Some faucets have not worked for years, others run permanently. At times the entire building has no water. In fact, during the cholera epidemic that hit Addis Ababa in the mid- 1980s, there were times when the only water in the neighborhood was in the fountains in front of the hospital, built by the North Koreans for the 10th anniversary of dictator Mengistu Haile Mariam's Revolutions. I spotted a nurse friend and asked her if there were any interesting cases to see. "Oh yes," she replied. "You're a cardiologist, you'll be interested in Bewoket. He tells us he walked to Addis Ababa from Gojjam Province, about 300 kilometers away." She led us into a room with nine beds, each occupied by a child. I looked over at Bewoket, a boy who looked about 12, wearing a torn hospital gown and an Orthodox cross. He was sitting straight up, attached to a tall oxygen cylinder, breathing rapidly. There are no face masks for oxygen delivery, so a piece of used IV tubing was taped to the oxygen valve on one end, and then taped into one nostril. He was in obvious distress and appeared to be chronically ill.

"He has rheumatic heart disease," the nurse explained. "I don't know which valves are involved, but he has very bad valves . . . and a very bad x-ray." She reached over and took the x-ray from his rusting metal bedside stand. I held it up to the light and saw that his heart took up at least 75 percent of his chest, far more than the upper limit of normal, which is about half. He was clearly in severe heart failure. As a medical student in New York, I had a lot of training in American cardiology-ischemic heart disease (heart attacks and angina) and hypertension. I learned about rheumatic fever as one of the many possible diseases of the heart and had seen all of two cases. As a resident in internal medicine in Baltimore, I never saw a case. When I arrived to Addis Ababa in the mid-1980s to teach at the medical faculty, I was assigned the job of running the cardiac clinic, lecturing the students about heart disease, and consulting on cardiac cases on the wards. I was challenged with a new spectrum of disease with which I had little experience. I went back to the textbooks every night to read about what I saw on the wards, and within a couple of months I could successfully diagnose most patients using only my hands and my stethoscope. In Ethiopia, echo machines are very rare, and one practices middle-of-the-century medicine, relying only on the stethoscope and what lies in between its ear pieces. A good doctor here will listen, percuss, and palpate. He will have the patient sit forward and listen to the heart at several points on the chest, and then lie on his left side and listen again. He will feel for the vibratory "thrill" of a heart murmur, the collapsing pulse and "pistol shots" over the arteries in aortic regurgitation and the transmitted vibrations of aortic stenosis radiating into the carotid arteries of the neck.