Reflections and Impressions

Well, I have been downright awful about maintaining this blog over the past many months, but I promise to redeem myself in my last month in Rwanda . . . that’s right, I only have one more month living in Rwanda, but I know for certain I will be back.  I think I’ve made tremendous inroads in the research that will keep me VERY busy over the next several years, I’ve developed professional relationships and learned ever so much from my colleagues, and I’ve made some incredible friends . . . Over the next month, I’ll update some of my research and reflections on global surgery . . .

In the meantime, I want to draw attention to some of the blogs from colleagues that have visited Rwanda.  I’m always fascinated by the impression Kigali, Rwanda, and Africa in general can make on visitors–having lived and worked here for almost two years, I sometimes forget some of these first impressions . . .

The most recent blog is an active blog right now by two UVA anesthesiologists–it’s really exciting to have more people from UVA involved . . . http://UvaRwanda.wordpress.com/

Marcel and Kristi’s blog builds on two other anesthesiologist’s blog: Faye and Michael. http://marchrwanda.blogspot.com/

Not to be outdone, here are a couple blogs from surgery residents that have come to Rwanda over the past year: James from Colorado visited last March: http://blog.travelpod.com/travel-blog/jcromie/1/tpod.html.  My good friend Amber came to visit and participate in research in May, and I find her reflections particularly insightful: http://amberrwanda2011.blogspot.com/

Enjoy these reflections as I gather my own . . .

Murakoze cyane!

Make Surgery Sweet . . . Advocacy for Change

One of the things I had not planned on doing as much as I have is political advocacy and something I’ve termed “communication facilitation”–getting stakeholders to talk to each other. I certainly respect the importance of health advocacy, and I am thrilled that surgery in Rwanda is getting to that stage.  You can’t really improve surgical capacity, can you, without advocating for surgery to have a priority spot in healthcare planning?

One of the phrases that has stuck with me from our March Strengthening Rwanda Surgery meeting came from one of the Rwandan surgery residents.  ”You have to make surgery sweet,”  he said.  So true.  I wanted to make t-shirts.  That phrase sums up a lot of the issues surrounding surgical capacity.  Around the world, there is a severe dearth of surgical services to the poorest of the poor (more than 2 billion people without access to emergency and essential surgery!).  A large part of may be due to lack of proper surgical materials, but much of the burden is due to a scarcity of surgical providers.  You can buy materials and build facilities . . . and once surgery enters more properly into the global schema of healthcare and more funding is allotted to surgical development, this can be addressed.  Training a surgeon, though, takes a team.  Right now, there’s not much draw to become a surgeon in many places where surgeons are scarce (could be extrapolated to rural America, couldn’t it?).  So, what’s the incentive?  To improve surgical capacity, there have to be more trained surgical providers.  So, how do you make surgery sweet?

The March meeting was phenomenal in that it brought together a group of international stakeholders and Rwandan surgeons and health officials to discuss just that.  The hope was that it would get everyone on the same agenda–Rwanda’s.  It certainly was a good start, I think.  It really helped to form and strengthen relationships, which is key in moving forward for any real, sustainable change to happen.  Since then, a core group of international stakeholders and Rwandan surgeons have continued the conversation and planning via Skype teleconference.  When a large educational / human resources for health scale-up meeting was held in Kigali in May with 16 US universities, surgery was ahead of the game . . . this gave us another opportunity to brainstorm and plan together.  It also gave me a chance to meet President Kagame and mention the word “surgery” at least 3 times in his presence.

I don’t know if what I personally do will make a change but maybe by facilitating communication and helping the Rwandan surgeons and trainees to find their voice, there will be a way to make surgery sweet in Rwanda.

Until next time . . . the pictures below are from the March meeting and then the May meeting.

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Busy, busy bustle . . .

I’ve been driving in Rwanda for nearly three months now, and although I discovered that my fuel gauge is not 100% functional and that more than 3 people in the car leads to nasty grinding sounds, there are still a few things which continue to baffle me:

1. There is some sort of unspoken language for drivers, complete with complicated hand signals and varying degrees of honking . . . I still cannot discern the utility of flashing your brights at me, apart from blinding me.  I’m not very good at deciphering the other signals either.  I mean, when does a right turn signal NOT mean a right turn?  Sometimes the left turn signal means a right turn?

2. Is there a utility to repaving the same road every two weeks?  Really?  And it’s not just one road either!  Any road that gets repaved is bound to be torn up again in 2 weeks . . . and 2 weeks after that . . . and 2 weeks after that.  They are quite smooth and lovely to drive on the first time . . .

So, I will apologize for my blogging absence and hope that you enjoyed the guest blog from Rebecca.  It was quite a delight to have her here.  For me, the past several months have been very busy.  I spent the holidays in the US (between Kentucky, Virginia and Alabama) and returned to Rwanda mid-January.  Since then, I have been busy with finalizing the report on the surgical capacity survey for the Ministry of Health, showing visitors around (a radiology resident, my surgery program director, and more . . .), and planning an international surgery meeting.

So, Albert and I finished the survey of surgical capacity–having visited every government-supported hospital in Rwanda.  I presented the results at the first Strengthening Rwanda Surgery meeting held a few weeks ago here in Kigali.  I won’t go into too much detail on the results here (the suspense is killing you, right?) because I would much rather report on the changes and impact of the information . . . time will tell.

One of the things I will comment on is that with all of the visitors to Rwanda and the push to increase surgical capacity, it is very clear that human resources are the biggest need.  Not only are there not enough educators, but there aren’t enough students going into surgery.  What’s the enticement?  How do recruit students to pursue a career in surgery?

One of the ways is by providing mentorship and stability in the education process.  There are a lot of pushes to do this with academic partnerships, which I commend.  I also can’t speak highly enough of my Rwandan mentors–their job isn’t easy!  One of the very positive things the past several months was participating in an Essential Surgical Skills training session in January for the new interns (senior medical students) . . . There are a few pictures of that and other adventures below.

More adventures to come . . .

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Rebecca’s Radiology Visit

I’VE BEEN QUITE REMISS IN MAINTAINING MY BLOG, BUT I PROMISE MORE IS TO COME.  AS I PREPARE MY THOUGHTS, HERE’S A GUEST BLOG ENTRY FROM REBECCA, A VISITING UVA RADIOLOGY RESIDENT:

Rebecca teaches radiology to a group of junior medical students at CHUK

Now that three weeks have gone by in Rwanda, I cannot believe that I am headed back to the States. It seems that I did so much in that time, it warrants some recap.

I boldly proposed to travel to Rwanda for my dedicated research month during my residency program. I am delighted, as compared to prior classes, that my month was allocated in my 2^nd year and not my 4^th. Last June, I met with a mentor of mine Dr. Rheuban who mentioned that there was a team of surgeons doing work in Rwanda. From that, I contacted my colleague, and now friend, Robin Petroze to learn about what her plans were. Fast forward, many discussions and emails with her, paperwork to get permission, ACR travel grant, contact with RAD-AID, and Rwandan Hospital Ethics committee approval, I came to Rwanda to carry out my ambitious research project.

I say ambitious because, as I learned quickly, time in Africa is different than time in the States. I planned to go to 8 hospitals in less than 15 work days, not knowing anyone except for Robin initially and a few important email contacts of Rwandese physicians and medical professionals, not having a car and reliant upon drivers, and not speaking the prior formal language (French) or local language (Kinyarwandan). However, it all came together, and in fact I had completed my radiology needs assessment with not just 8 sites, but 9!

My goal was to complete said needs assessment of select hospitals prior to helping initiate a collaborative between CHUK (the main teaching hospital in Kigali) and UVA Hospital. Once done, I expected to and do have better idea of what resources are available and can cater our support appropriately, specifically with respect to the adjunct of radiology education during surgical teleconferences. Little did I know that my questionnaire may be very straight forward if I spoke to the right person, but often this person was gone, or did not speak English. Often I felt like it was a struggle to get every response. I completed as much of it as possible, with a focus on less financial-based questions and more radiology-oriented questions.

Oh but wait – let me explain how I chose my hospitals. I selected the main teaching/referral hospital in Kigali, the main teaching/referral hospital in Butare (where the medical school is), King Faisal Hospital (private hospital), and 6 district hospitals (referrals from health centers) – 2 in the greater Kigali area, and 4 in each geographic quadrant of the country. Themes that emerged included some of the following:

-         Radiologists: There are 8 radiologists for the country of 10 million. All of which are working in Kigali, none of which are in smaller cities/towns. Training was from nearby African countries as currently there is no radiology residency program and no mention, at this time, of creating one as needs are more on a non-specialist, primary care level.  The private hospital has 4 radiologists, district hospitals have none – reliant on radiographers and general practioners to make their own “impression”.  They, collectively and individually, could not have been more welcoming with respect to their reception of me. I felt like one of the group right away, enjoying reading by the light box/work station side-by-side, with diagnoses not commonly seen in the States: sequelae of chronic developmental hip dysplasia, seizures secondary to Neurocystercosis, advanced (gross morphology included) hydrocephalus as sequelae of meningitis, and innumerous fractures due to “road traffic accidents”. Trauma/emergency radiology is certainly not lacking.

-         Radiographers: There are about 100 radiographers now that have been trained in a 3 year program at the Kigali Health Institute. After graduation, technologists are placed in a district hospital without additional support. By this I mean, little if at all technical support, no quality assurance program, and variable degrees of radiation protection. There is a push for radiographers to have the opportunity to learn more about sonography, at the current time done by either radiologists, general practitioners, or OB/GYNs. I cannot begin to express my degree of respect and admiration for the lone radiographer, working often entirely by themselves, hand developing their own films, and relying on old equipment full of “personality”.

-         Equipment: A spectrum of functionality, not entirely to my surprise. As one Hospital Administrator said, “the only difference between us and a health center is technology [radiology]”. Most all equipment is donated. Unless there is a warranty associated with the equipment (such as at King Faisal Hospital), broken equipment may go months without being repaired, if at all. A few district hospitals had a machine I had never heard of: Shiumadzu, manufactured in the 1950s, now many of which broken as there are no longer spare parts made and no one knowledgeable about how to fix them. Conversely, CHUK had 10 impressively working ultrasound machines scattered around the hospital campus. Regarding cross-sectional imaging, for example at King Faisal, the MR machine has its own warranty/technicians that would help with repair (from Kenya). With projected/planned acquisition of more cross-sectional imaging equipment, I wonder just how feasible it will be to maintain these machines. I mean, it is challenging enough at home! For a juxtaposition, see my pictures!

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-         Insurance: What’s American’s excuse? All Rwandese, to include anyone who wants to buy in (foreigners alike that is), can get basic medical insurance for the equivalent of 2 dollars. Immunizations, basic medications, basic health care, radiology examinations… are provided for. Also to include preventative/screening care, if that is a priority of the individual patient. With the current system in place, there are three tiers of medical insurance, the cheapest of which was already mentioned and patient’s payment of 10% of the total cost, government’s payment of 90%. Comparison from the district hospital level, even the tertiary referral centers where some district hospitals were superior in terms of donated/new medical equipment, to the private King Faisal Hospital was profound. Taking into account the gross national income of just a few hundred dollars a year, difficulties with clean water, the vast majority who use walking as their primary transport outside of the capital city, and reliance on agriculture for all life activities, the basic services provided are undeniably a step in the right direction.

-         Education: Beyond training, nothing formal (as we think of CME). Radiologists complete 6 years of medical school (to include 1 year internship), 2 years practicing in hospitals, and then a 2 year radiology residency (in a non-Rwandan country; most commonly Tanzania, South Africa, and Kenya). Radiographers have three years training as mentioned before. General practitioners have no required, formal training in ultrasound. Which lends itself to many practical questions: How does one maintain skills? How does one learn how to use imaging modalities? How does one refine their knowledge base through feedback? Even without the medicolegal environmental mess that is the USA, how can one make the right diagnosis? There are many missionary, ex-pat groups doing work, some individuals and some teams – specifically, Israeli OB/GYN teaching radiographers by laptop to the very comprehensive Emergency Sonography manuscript and associated trainings at Parters-in-Health affiliated hospitals. To my great surprise, there were no overt radiologists/radiology groups teaching about imaging. Rather, it was the ED and OB/GYN physicians teaching relevant, basic ultrasound. Ultrasound – ostensibly the hardest imaging modality (as there is a great art in creating images in addition to interpreting the images), only second to Nuclear Medicine. In my opinion, I saw this as a missed opportunity for the global radiology community and promised myself to raise awareness of it upon my return. Especially given…

-         …Future endeavors: Impeding projects/developments include the formalization of the Rwandan Radiology Association, 64-slice CT for CHUK (currently 1/9 radiologists is in India completing a specific CT training), digitization of CHUK radiology department, activating the already laid down governmental cable to permit about 30 hospitals in Rwanda to be linked for teleconferencing purposes.

Don’t get me wrong, all the travel for my site visits was more than worth it, with the only real challenge being whether or not the car I relied on would 1. Be delivered and 2. Be functional enough if there was a mechanical problem. The rides through the countryside were breathtakingly pretty. Rwanda, known as the “Land of 1,000 Hills”, was more like the “Land of 1,000,000 mountains”. I thought this was stiff competition as compared to Charlottesville. Particularly gorgeous was the north, Ruhengheri hospital, as we approached Volcano National Park (where the mountain gorillas are) and the west, Kibuye hospital, adjacent to Lake Kivu (competition for any of the nicest resorts in the world). I actively/?obsessively took short videoclips to help convey my experiences better once home. Children running up, furiously waving with huge grins asking for pens and water bottles, passing genocide memorial after genocide memorial, and observing what the life of most Rwandese is like – peasants, working their own land with very crude/non-machinery tools, with no dearth of opportunity to socialize and participate in the overt commotion of very busy village life.

When not obtaining my data, other non-medical highlights included many work meetings with other ex-pats at various restaurants around the city, all cuisine available except surprisingly for Mexican food, with “claim” of chapatti as African (not Indian?!); exploring the city market which undeniably outdid the organic produce of Whole Foods! (if you wanted ANY kind of ingredient, you could get it, at your own barter); visiting the mountain gorillas thankfully (and safely) within a few feet so we could really see their expressions, identified not by finger print, but by nose print and the associated arduous journey through potato farm land, bamboo forest, and stinging nettle brush ending with a heavy rain (with delivery of twin gorillas for the 5^th time ever in history within a week of my being there);

The artists at Ivuka (www.ivukaarts.com) teach kids at a local orphanage how to paint and help them sell their paintings too.

Ivuka Arts gallery, a co-op of Rwandese self-taught artists whose delightful work is only compounded by their art outreach programs at local orphanages; salsa dancing with our friend Jimi, as some call the “Congolese Patrick Swayze”; going to the National Genocide Museum, to include walls of photos of child victims and mass graves, as well as to Ntarama memorial church with the chilling evidence of victim’s bones organized by type, neatly displayed clothing and items, and even blood-stained walls of children victims; meeting Rwandese friends and bumping into ex-pats in such a way that it seemed everyone was related to one another, no matter how remote the environment; new experiences to include going to the American Embassy for social hour, eating beef brochette, traffic jams with road signs/signals as a mere suggestion at best; and so on… More than anything, I was profoundly moved by how warmly I was received by all the people I met, in general, soft-spoken, with kind smiles and engaging eyes, committed to helping me navigate this new world that is Rwanda.

I should not delay writing any further the extent of my gratitude to Robin. Not only was she my hostess and colleague, but she became a dear friend, quickly assuming the status of “sounding board” for everything that happened and that I was thinking during this experience. She conducted herself with grace, as she organized meetings with groups of, at times, seemingly competing/competitive agendas, demonstrated unyielding dedication to conscientiously corresponding in all forms no matter what time of day/night, and modeling the patience that is absolutely required for an American to be operating in at times, a Kafka-esque African environment. I am also thankful for my mentors, who know who they are, UVA, and RAD-AID’s assistance for their respective contributions to this successful experience.

As I stare out the window at the Atlantic Ocean near Reykavik, regretfully headed home after a full-bodied, exceeded expectations experience, I promise myself a few things to make sure my trip was not in vain. First and foremost, I plan to, as best I can, convey the current state and need of the Rwandan imaging world, through my reports, photos, videos, and impending teleconferencing involvements. Second, I vow to make myself available for continued correspondence with the various health professionals and new friends I have met while there. And thirdly, I want to go back, further along in my training, to work in some capacity as a diagnostic radiologist and educator. For now, I end on the note: Rwanda was just the “dawa” (medicine) the doctor ordered, to fuel my continued dedication to international radiology through investigation of the progress and promise of the Rwandese medical frontier.

Across the border . . .

Rwanda is a rather small country—just the size of Maryland—so it is natural that I explore the region a bit.  My district hospital tour took me very near to each border: Uganda, the Democratic Republic of the Congo, Burundi and Tanzania.  Yet, I hadn’t ventured across the border until this past week, and a regional surgery conference seemed the perfect enticement to do so.

The residents from Rwanda . . . and a horse.

My friend Gita (also a surgery resident and Fogarty fellow doing surgical research in Rwanda) and I attended the College of Surgeons of East, Central and Southern Africa conference in Kampala, Uganda this past week, each presenting a paper from Rwanda and having an excellent opportunity to spend time with a few Rwandan surgeons and residents.  The conference was quite well run, and we were able to meet and gain insight from several leaders in surgery in the region.  I think it is extremely important to remember, particularly for those of us “do-gooders” from outside of Africa, that we are guests when we come to work here.  What I mean is that we must recognize and respect the agendas, talents and insight of the local academic communities.  I remember when I traveled to southern Mississippi after Hurricane Katrina to help with clean-up.  Some medical school classmates and I worked with a local church doing construction work.  Speaking about all of the “experts” coming in after the storm, trying to develop new ways to build houses and such, the organizer said, “We know how to build houses.   We don’t need someone coming in to do things their way.  We just want people to work with us in OUR community.”

This conference helped to remind me that improving surgical capacity and access to surgery in Africa means listening to and enabling local surgeons.  I am a guest here, and it is a privilege to be allowed to pursue my research.  I think that both Gita and I were impressed with the COSECSA leadership and have hopefully made some successful contacts for collaboration.

For better or worse, we had decided to take the bus from Kigali to Kampala.  The trip there was really not that bad if 9 hours on a bus can qualify as such.  The landscape in southwestern Uganda is similar to that of the neighboring Rwandan districts.  As you approach Kampala, however, the beautiful thousand hills of Rwanda flatten a bit, and whereas every bit of land in Rwanda is parceled out for crops, creating a unique geometric landscape, the brush of the soft Ugandan hills allows for a bit of empty space.  Kampala is certainly a large city, and the traffic is simply horrendous.  Colonial vestiges seem a bit more prominent in Uganda—or perhaps that’s just because there is more English, and I can understand it.

Following the conference, we decided to travel to the adventure capital of Uganda—Jinja.  As it was a weekend, we felt

Nile River

justified in a few days away from work.  That’s right—no computers and a vow to not talk about work . . .

Near Jinja is where the Nile River escapes from Lake Victoria to begin the long journey to Egypt.  Actually, there is some debate as to the true source of the Nile, with some claiming that it is in Rwanda, but I will leave that debate for others to pursue.  What brought us to Jinja was the prospect of one of the best one-day whitewater rafting trips in the world!  Unlike the whitewater rafting trips that I have done in West Virginia, dangerous undercut rocks are not a safety concern on the Nile.  The river is wide and deep, so the rapids are vigorously powerful swirls of massive amounts of water.  The volume of water is awe-inspiring (particularly after having spent a considerable portion of the day being pulled into its throws).

I regret, however, to have to relate some news that soured the experience a bit.  I have no proof of this claim and can only offer my absolute revulsion at what I heard.  Actually, the company denied such a policy, but I can still be outraged at the thought . . . The company we rafted with, Adrift, was the first to pioneer rafting on the Nile.  Their adventure center boasts guides from around the world, a bungee tower, and a commendable safety record.  However, as we began our journey down the river, we learned of policies that appeared blatantly racist.   Is it truly company policy that two muzungu (foreign, which usually means white) guides must be on every trip—that the specification is due to race?  This means that local guides—some who have spent more than 10 years rafting and kayaking the river—are given less opportunity, paid less, and discriminated against for foreign raft guides who come for maybe 6 months to work.  Someone told us it is because of the language barrier and not knowing English.  That’s bloody ridiculous!  Uganda was a British colony so all of the schools and businesses are in English.  Someone else said it was because the muzungu guides had wilderness and swift water rescue certifications.  Okay.  Fine.  All of the Ugandan rafters and kayakers I met were pretty darn smart.  If you can learn to kayak a Class VI rapid, you are probably motivated enough to take a rescue class if the opportunity presented itself.  I have nothing against raft guides from the US, Australia, New Zealand, Canada, etc.  In fact, in discussion while in Jinja, some of them said they would love the chance to help train local guides but were not allowed to.

Appalling.  Absolutely appalling.  Again, heresay, but still–What happened to social responsibility?  I had a fantastic rafting trip, but if that is the company policy, I feel incredibly guilty for giving them my money.  Who better knows the river than the people who grew up on its banks?  Of course, safety is an issue, and I am certainly interested that a company employs trained and certified raft guides, but safety doesn’t have a color or nationality.

Gita and I did take a hike along the riverbank the following day with a local kayaker/rafter.  Seeing the rapids from the shore just impressed upon us further the immense power of the water.  The landscape of the Nile is stunning, and it banks are vivacious with village life.  Much of that will change in the coming years as a new dam is being built.  Many of the first rapids will disappear, and thousands of people will be displaced . . .

And just in case you are wondering, I did NOT go bungee jumping in Jinja.  Crazy only goes so far for me.

Somewhat mentally refreshed (we did surprisingly well on our pact to not talk about work) and physically sore from the weekend sojourn, Gita and I returned to Kampala and then boarded the coach to Kigali.  Climbing over suitcases in the aisle since the storage area was packed with goods for market was suboptimal, but standing outside with my freezing toes and chattering teeth for an hour at 5 am at the border so that every single bag could be checked for plastic grocery bags (they’re not permitted in Rwanda) was a bit ridiculous.  Perhaps I could be convinced to fly next time, but then I would have fewer stories to tell . . .

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44 hospitals in 25 days . . . Reflections

You may have wondered at my blogging absence these past few weeks.  No, I have not been devoured by wild animals or gone to join a hippie colony or even been sitting blissfully drinking coffee and reading Jane Austen novels all day every day . . . In fact, I have been rather busy visiting every district hospital (except the psychiatric hospital) and referral hospital in Rwanda.  A total of 44 hospitals in 25 days . . . My days have been full of long car trips–quite often on bumpy dirt roads that leave me in desperate need of a massage–and 2-3 hospital visits a day.

All in all, it has been extremely enlightening, and more importantly will hopefully prove useful to surgical development and patient advocacy in Rwanda.  Surgery IS happening at the level of the district hospital, and while the basic infrastructure is usually in place, there is a severe shortage of materials and training.  There is no question that safe, appropriate and adequate surgical care is a growing health necessity in Rwanda.  I’ll write some more specifics, but I’ll use this particular blog post to describe some generalizations of the study . . . and also, of course, to relate a few adventures

Dr. Albert was prevented from joining our travels after that first trip to Byumba due to clinical responsibilities at CHUK.  So, he had the unglamorous job of making phone calls to hospital directors in advance of our visits to explain the study.  This was usually only moderately successful, for despite numerous phone calls and emails containing the survey, quite often we would show up and no one would be aware of our arrival or purpose . . . but, we were persistent and carried out interviews at every hospital.

Another challenge that presented by not having Albert with us was that of language.  In my initial visit to Kigali last year, I had no trouble using only English in our meetings, and all of my correspondence throughout the past year has been in English.  Yet, in going out to many of the district hospitals, it was not uncommon to find a hospital where no one spoke English.   Or my other languages–being basic conversational Spanish and a fair knowledge of Pig Latin.  Fortunately, we had translated the assessment tool into French in advance so that each hospital had a copy in French and English.  Still, the majority of our interviews were in French—and I was impressed that despite never learning any French, I was able to understand a fair amount of the conversations without translation.  Jimmy found his job description expanded from driver to translator as well.  He says his English has improved considerably but isn’t quite sure when he will have the chance to use all of these surgical terms in daily conversation.

Fiberoptic lines are being laid to every district hospital (even in the rainforest!).

Driving along a Rwandan road.

 

Children at the water pump.

Driving along African roads is a rich experience.  Rwanda is so densely populated that it is rare to drive anywhere except the national parks and not see people traveling along the road (which, I must say, makes it difficult if you are female and need to use the bathroom . . .).  For a Westerner, the constant procession of colors, smells and sounds is a unique and sumptuous display.  Women in bright fabrics carrying bundles of firewood or baskets of food on their head.  Bicycles loaded down with produce, wood and the occasional goat.  Children carrying yellow plastic containers of water.

This might not be the safest mode of transportation . . .

The main roads in Rwanda are well-paved, and many of the district roads are . . . well . . . not.  As it turns out, traveling some of these roads in the rainy season is a set-up for adventure.  Spiraling dirt roads along hillsides with breathtaking views can be rather treacherous during a torrential downpour that turns the road to a river.  Fortunately, that only happened once . . . or twice.  The road was impassable only once . . . and I nearly had to trek the rest of the way up the mountain to the hospital.  Being as a crowd had collected around our vehicle, this likely would have resulted in a train of children following me up, calling attention to the muzungu all the way to the hospital.  Rwanda is also known as the “Land of a Thousand Hills”.  While that sounds quite wonderful, it is also false.  There have to be well over a million!  That can make traveling quite dangerous.  We saw an average of 1-2 accidents per day.

As I said previously, we did our best to contact hospital directors and provide them with the survey in advance.  Yet, our visits elicited a variety of responses, including marriage proposals.  I have to admit that at first it was a bit disconcerting—I had completed my interviews with the staff at one of the first hospitals I visited on my own when the doctor I was interviewing proceeded to ask if I was married . . . Later, it was just humorous.  The second instance came in the form of a text message: “Can someone like you love someone like me?”

Very few hospitals had completed the survey in advance, but we were usually able to complete it together.  My initial review of the results shows that, in general, the infrastructure for surgery is there.  Yes, there are a few hospitals without reliable

Destroyed by an earthquake, UNICEF tents serve as the hospital until the new hospital is constructed.

running water or electricity as well as one hospital that is still a UNICEF tent camp from an earthquake several years ago. The biggest needs are training (whether that be trained surgeons as residency-trained and certified surgeons are concentrated in Kigali and rare in the district) and materials.  One of the biggest unmet surgical needs is fracture care/orthopedic trauma with very minimal capacity at the district level.  Most general practitioners at the district hospitals say they are doing surgery and can do many procedures, but for many of them, this means just c-sections.

The most important lessons I learned from talking to hospital directors, practicing doctors and operating room staff.  Here’s a brief summary of some of the highlights of those interviews:

At one district hospital I discovered an ex-pat surgeon with remarkable insight.  Despite the fact that his hospital had no inhalational anesthesia, a 56 year-old xray machine that often is non-functional, and no reliable water source during the dry season, he was determined to treat as many patients as he could at that hospital.  As we were talking, a woman brought an elderly gentleman towards us.  I say elderly because his face was gaunt and pale, his eyes tired and weak, but it is possible that he was as young as 50.  His abdomen was quite distended, and as he walked (with help) towards us, he nearly collapsed.  One of the first things you learn as a clinician is to differentiate “sick” versus “not sick”, and this man was clearly quite ill.  The doctor quickly had someone come to help him into a stretcher and instructed them to begin IV fluid rehydration.  He turned to me then.  “You see.  The buck stops here.”  Patients are too poor to take a referral to Kigali, he explained, where family has to find accommodation and food.  So, if he doesn’t operate on them right here, they die.  He does his best, but many cases are complicated—advanced cancer presentations, complications due to malnutrition.  I found this response in many of the physicians I spoke with throughout my tour, particularly the general practitioners with more experience—You do the best you can with what materials and training you have—and try to live your own life at the same time.  Of course, they want more training and would like a reliable supply of materials, but in the meantime . . . you do what you can.

What this means is that surgery IS happening at the district hospitals and there is a huge need for further training and capacity building.  Safety becomes a huge concern, but as several doctors pointed out—sometimes, what is the alternative?  At another hospital, when I asked a group of young doctors whether or not they performed hysterectomies, they paused.  On further prodding, they said that yes, they do, but they aren’t supposed to, so what should they officially answer?  They seemed a bit cavalier about it, but as young doctors, they have limited guidance and mentorship.

Perseverance in such an environment can be challenging, and I am left in awed respect of so many people that I met.  Other responses are not at all surprising.  I found one hospital director incredibly cynical and left the interview rather depressed!  I walked into his office, and he pulled out a stack of business cards from ex-pat researchers like myself—people from CDC, WHO, Harvard, various international NGOs.  He explained that they all come to ask about how to help, but what happens?  Where does the research go?  He certainly has a point!  I recognized some of the cards, knowing that some of our research is being duplicated, but to what practical effect.  It was certainly a sobering reminder to me to re-dedicate my efforts to practical implementation.  Yet, as the director continued, that also is a problem.  He has noticed the rapid turnover of physicians, particularly the young Rwandan physicians.  The problem, he said, was the salary associated with the job.  “This job is a very sad job,” he said.  Generalists are not interested in learning more skills, so they just don’t do certain things and patients don’t get the care.  “The profession is lacking the interest to learn.”

I do hope that he is wrong in his cynicism.  The issue of salary incentive is certainly a poignant one, but I have met many

Makeshift traction for an extremity fracture.

doctors, particularly young ones, who are eager to learn.  I also met several hospital directors who were extraordinarily receptive and motivated to be advocates for their hospitals.  Surgery was unanimously a major need.  Retaining staff at some of the most remote sites is an incredible challenge—this includes trained doctors, surgeons, nurses, and anesthetists.  Procurement and waiting on materials is also a major concern as is the availability of pathology services.  Materials are often antiquated and sometimes non-functional.  It is not infrequent for xray machines to sit unopened in a hallway for up to a year waiting to be installed or new anesthesia machines to be donated to hospitals with no anesthetist.

It is clear that improving surgical care is not an easy task but a very important one.  It requires coordination, communication and increased effort.  An experienced district hospital general practitioner commented:

“I think we need training because we NEED to do more, more than we do now.”

Stay tuned for more to come . . .

Birthplaces and Barracks

Friday marked the first official day of my travels to the hospitals outside of Kigali.  The chances of the day proceeding as planned were slim, but . . . well . . . TIA.

Jimmy and I were supposed to pick up the car we’ve rented on Thursday.  Jimmy is a good friend that I’ve hired to drive us around Rwanda–he’s a wonderfully talented artist, musician and also teaches salsa dancing, so he will definitely be good company on the trip!  Well, the owner had taken the car in for an oil change on Thursday, but it ended up needing some work done, so no car . . . Fortunately, the owner is also a good guy so he arranged for someone to drive us in the morning and then for another car to borrow later in the day.

Okay.  Not as planned, but we still have transportation, so no problem.  We went to CHUK to pick up my co-investigator, Dr. Albert, but he was in consultations with some visiting plastic surgeons.  Suboptimal in terms of our schedule for the day, but overall very good for patients (particularly as there is no dermatome at CHUK to do skin grafts) as burns and post-burn contractures are a HUGE issue here.

New ORs at Kanombe . . . in progress . . .

Our first hospital for the day was Kanombe Military Hospital.  Kanombe serves as a district hospital for a very large area as well as the military hospital for the country.  As you walk in past armed guards, you do have the sense that you are entering military barracks.  Our visit here was delightful, though–particularly as we saw several people that we (okay, mostly Albert) knew.  Appropriately, Kanombe serves as a referral center for orthopedic trauma . . . or is planned to serve as more of a referral center.  Currently, their entire operating block was under construction–they are upgrading from 3 to 5 operating rooms (not including maternity).  Within the next 2 years, they plan to build an intensive care unit and have better training for trauma care and intensive care.  The site definitely has potential as a trauma center–which is appropriate for a military hospital!

I want to share one comment from the hospital medical director that I found particularly interesting.  As we were introducing the survey and he was perusing the questions, he asked if we were surveying internet capacity at the district hospitals as well.  I replied that no, we hadn’t been, and he urged us to include this in the survey, as he thinks it is vital information for training.  Interesting, I thought.  Technology and the internet has certainly revolutionized healthcare and training.  It’s fascinating.  However, the director also laughed when we asked whether they planned for a CT scanner, saying that the maintenance is not sustainable and it would likely be broken within a year.  Interesting.

Next, we had our first adventure outside of Kigali, traveling north to Byumba, to the hospital where Albert was born.  The main roads in Rwanda are quite nice for the most part—well-paved and smooth, so rather than the bumpy jostle we’ll expect for some of the district hospitals, we could relax.  The trip began weaving along the valley beside rice fields, boggy wetlands from the rainy season.  As we made our way closer to Byumba and the Ugandan border, the landscape took a sharp upward bent, climbing along a winding road through hills and mountains.  The borrowed car actually had an altimeter that reached about 2600 m.

The approach to Byumba Hospital climbed even higher, providing a gorgeous view of the surrounding hills.  Rwanda is called the “Land of a Thousand Hills” and I sometimes wonder if that is an underestimate.  Albert pointed out his primary school and the house his father used to own (we met his father after the hospital visit), the houses of the Congolese refugee camp scattered along the hillsides, the church with its spire radiant in the distance.

Byumba Hospital is a small district hospital with no surgeon and limited surgical procedures.  As we came to visit the operating room, we saw a list of statistics on the board outside the door.  Interestingly, the number of surgeries in a month increased by about 3-4x the month during which Army Week took place.  Army Week occurs each year and sends residents and surgeons to the district hospitals to operate for one week.  They also had a list of all of the operations performed over the past month posted (complete with patient name, age, diagnosis).  From early September to mid-October, they performed 61 major surgeries.  These are all performed by general practitioners and range from curettage of osteomyelitis to hernia and hydrocele repairs to lipomectomies.  Because of limited staff and facilities, operations are often cancelled to allow for caesarian sections.

Byumba OR

Being his hometown, Albert is very interested in going to Byumba to do more surgeries, and his introductions there were crucial.

The sun was setting as we left Byumba, and the air had grown chilly, being one of the coldest areas in Rwanda.  As we started our descent, raindrops began falling.  We had just left the town when a thick fog engulfed the road and our vehicle, ensconcing even the front bumper of the 4×4.  Now, let me remind my readers that we were on a mountain with a thousand foot drop just beside the road and no guardrails on this road.  So, we crept along slowly, slowly, and ever-so slowly until the fog lifted and we were able to descend in safety.

We arrived late in Kigali, but despite the many delays in the day it was quite productive.  I considered it training for the next month . . . around 45 district hospitals . . . Ready . . . Set . . . Go . . . More reflections to follow!

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Let the adventure begin!

Let the adventure begin . . .

So, as I wrote last time, research progress is slow–marred by communication (or lack thereof), lack of response, etc.  So, our team decided to just go ahead and begin.  We would take the survey tool (a survey that looks at demographics, personnel resources, material resources and an interview of procedures performed) to all of the hospitals in Rwanda.

I’m still not sure if we know exactly how many hospitals are in Rwanda.  I had difficulty obtaining a list of the names of the hospitals from my MOH contact, but between my co-investigator Dr. Albert and colleagues at CHUK and the MOH, we’ve put together a list of about 45.  We’ve rented a car and driver and have until November 26 to visit them all . . . could be rather exciting.  Since people are not responding to the email from the MOH asking them to fill out the survey, we are calling the director . . . or anyone at the hospital, really.  We’ve been asking all of the residents who they know at various district hospitals and calling them to set up meetings.  It’s very much on the fly, and I’m sure my patience will be extremely well-tested at the end of November, but TIA–you have to do what works.

It is interesting to note, though, the support from the surgeons at CHUK.  For the most part, many of the consultants and residents really don’t know what is available at the district hospital level.  What they see is everything that gets referred to Kigali and not taken care of at the district hospital level.  Yet, there is pressure for the surgeons in Kigali to go for week-long missions to the district hospitals.  Seems to me . . . and them . . . that a survey of resources would be extremely useful.

Another reason to really push to do this survey, and to do it in the next month, is to highlight the importance of emergency and essential surgical skills at the district hospital level.  The survey tool itself is mostly qualitative and subjective, but it does provide a baseline.  The tool I am using is adapted from the World Health Organization Situational Analysis Tool for Emergency and Essential Surgical Care. Alarmingly, I have heard that the WHO is soon to cut funding to their Emergency and Essential Surgical Care program.  Not that this will stop the people working to improve surgical care, but that just seems ridiculous to me!

Anyway, we are set for an adventure the next month.  Prior to beginning our galavant around the country, however, we visited a few of the hospitals in Kigali.

The first hospital I visited was Muhima, a district hospital located within Kigali.  Muhima is a reference center for maternity-obstetrics and gynecology, so while they perform some procedures (a LOT of c-sections!), they perform no procedures in general surgery or orthopedics.  In fact, they just recently acquired 2 specialists in OB/gyn who come 3 times per week, so they will be able to start doing obstetric fistula repairs and more hysterectomies, for example.  The doctor I interviewed stated that the biggest barrier to providing surgical care apart from OB/gyn is surgical supplies and having no surgeon.  Many of the general doctors, she says, have been trained in surgical procedures in seminars, but without the supplies and with no more personnel, they refer everything from cricothyroidotomy to shoulder dislocation to appendectomy.  Plus, she says, with nearly 10,000 births per year a few years ago and only 2 ORs which are in constant use for OB, there is no place, no people, and no supplies to perform general surgery or emergency procedures.

The next Kigali hospital was Kibagabaga Hospital, a fairly new district hospital just on the outskirts of the city (and very near the wealthier areas of the city).  As you pull up on the cobblestoned drive to neatly manicured lawns, the hospital has an air of cleanliness.  The one-story brick buildings are arranged geometrically around ample green space.   It is a very aesthetically pleasing hospital . . . especially considering many preconceived notions of district hospitals.

Dr. Albert smiles with the Kibagabaga OR staff after our interview.

We realized as we walked in that something was going on—the first day of a fistula camp with surgeons from the USA (IOWD).  Interestingly, there had just been a fistula camp with a surgeon from Ethiopia at CHUK for 2 weeks maybe only 2 weeks ago (again, coordination–neither group knew about the other).

Kibagabaga definitely has more surgical capacity than many other hospitals—that much is clear early in the interview.  We met with the head OR nurse, the surgical tech and another nurse for information.  I was impressed to know they take care of many basic surgical emergencies, including fracture care, abscesses, and chest tubes (my initial impression from CHUK is that very, very few district hospitals take care of fractures or chest tubes . . . time will tell).  They have 12 surgical nurse technicians that do basic procedures like fracture care, abscesses, lipomas, biopsies, wound care—no intraabdominal procedures, no hernias, etc.  Actually, I was surprised to hear that most of their general surgery care is provided by a surgeon who comes after work at CHUK to Kibagabaga—he just completed general surgery training and is trying to get more training in urology.  So, the proximity to Kigali is good here.  They have no permanent surgeon (and only 1 Ob/gyn, who is the hospital director).  There’s kind of an undertone that this is a model district hospital, and they also have support from many international missions providing surgical care throughout the year.

More adventures coming soon . . .

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Two steps back . . . Walking with a Purpose

I noticed the other day, as I walked through town, that I walk like an American . . . fast in comparison, with a purpose, you know–headed for a destination.  I weaved briskly in and out of the crowd, passing people quickly.  It was out of place.  Legitimately, I was running late to pick things up from the store for my housemate’s going away party, but it struck me as an interesting representation of my research and surgical experiences so far in Rwanda, particularly over the past week.  It also served as a reminder I think many of us in America sometimes need, particularly driven academicians and surgeons and medical students . . . Slow down.  Take in your surroundings and the people around you and appreciate the moment for what it is and who is in it.  Very few things are the emergencies we make them out to be, and, unfortunately, we sometimes miss some of the important, simple things in life . . .

Some sense of divine justice prevailed in this instance, however, and I was forced to wait 30 minutes for an empty bus home.

Yet, to return to the comparison to my experiences with research and surgery in Rwanda.  Sometimes it is important to slow down.  Sometimes it is just so frustrating!!  Take, for example, the first part of my research project.  I am surveying all of the hospitals in Rwanda using an adapted version of a World Health Organization situational analysis tool–essentially a very basic survey looking at hospital infrastructure, basic resources (like running water, electricity, oxygen) and basic surgical equipment, personnel, and procedures performed.  Being as I thought I had communicated my research plans well before arriving, and I also set up meetings early with the Ministry of Health (The plan was to send the survey out from the MOH since this would increase compliance, give authority to the study, and provide infrastructure and quality feedback to the MOH), we should have been able to send the survey out electronically over a month ago.  Well, that, of course, was delayed.  I am a firm believer in trying to build relationships and work within a local context–definitely more sustainable and useful to the population you’re actually trying to help–so I rolled with it.  I met with my MOH contact and privately railed at the communication problems, wondering if it was a language barrier or a difference in educational methodology, but I was patient and we slowly progressed.  I translated the tool into French with Albert’s help.  We decided to pilot the electronic tool (since I was told this was the best way to send it to people) just at 4 Kigali hospitals.  So, we sent it electronically to the hospital directors, copied to the Minister of Health, etc.  I sent a very polite follow-up email.

Not a single response.

Doesn’t seem to have surprised many Rwandans I am working with (I wasn’t expecting 100% compliance, but I had been told people would respond to emails from the MOH, and Rwanda is an incredibly tech-savvy country), but it leaves me wondering why it took this long to figure out . . . So, back to the beginning we went.  Looks like Plan B is going to be going to every hospital and knocking on doors to get the information.  While it is certainly frustrating, I look forward to visiting all of the hospitals–or a large majority of them anyway.  I definitely think the data will be better than what would have been submitted electronically . . . so, more adventures to come

Since I have a few new people following the blog, I wanted to reference back to one of my earlier posts explaining what on earth I am doing here in Rwanda.  So, check out the background on my project here.

So, research is not as “productive” and driven as an American pace may be, and I’m learning that with patience comes perseverance.  Changing the system is not easy, but there have to be efforts at every level–from working with the Ministry of Health and the surgery residents to having the opportunity to visit the district hospitals, certainly the place where more surgical care needs to be delivered and where there is more potential impact on patient lives in the long run.

So, more to come . . . and I will learn to slow down when I am walking (As it turns out, the blisters I have on my feet from playing sand volleyball are forcing me to slow down . . .).

The Consequences of Delaying Care

This next post is, I’ll warn you, extremely depressing, but I wanted to provide a few poignant stories (I read recently that people are more likely to donate money or time if they are given a story than if they are given statistics.  I like this.).  I include these stories to highlight the incredible gap in care and the severity of surgical need in the developing world . . . and why the answer isn’t so simple.  I’ve met some amazing people and incredibly intelligent, self-motivated doctors in Rwanda.  The truth of the matter is that by most standards, medical care is bad.  It’s not that these are bad doctors providing care.  Quite the contrary.  Yet, the system is marred by delays, an overwhelming burden, and inefficiencies in resources and supplies.  Here are a few cases to illustrate:

1) A 44 yo male presented to the emergency department with a 5 day history of abdominal pain and signs of obstruction (distended abdomen, not passing stool, vomiting).  This was on a Thursday night.  It’s unclear when he presented to a health center (the majority of patients must first go to a health center, then district hospital, and then are referred to the capital).  Per the report of the resident on night duty then, the history was otherwise unremarkable.  He says the patient denied prior bowel problems. After an evaluation (physical exam and xray), he was given a diagnosis of sigmoid volvulus; gastric decompression and IV fluid was prescribed, and an operation was recommended.  This was planned for OR on Friday.  I actually saw the patient about 2 or 3 pm lying on the OR table–a very thin, cachectic appearing man.  The OR staff had to wait for instruments for an emergency laparotomy to be sterilized as there were no instruments available.  At 8 pm, they began the operation.  The resident on duty found a completely obstructing rectosigmoid tumor (very low colon cancer), which he resected (with the help of a senior) and performed a colostomy (way to divert the bowel).  When the case was reported, someone asked why they performed a colostomy and did not re-connect the patient (colostomies are particularly difficult to care for in resource-limited settings where having supplies for the patient is expensive and not always guaranteed), the resident said there was not enough left–meaning it was a low tumor which would have been felt on digital rectal exam.  The resident on call when the patient presented had not performed a rectal exam because he could not examine the patient in private.  The patient was seen in a large room full of patients in the open with no privacy–basically in a main hallway.  Furthermore, he pointed out that since everyone was listening when he questioned the patient, even if he was having rectal bleeding, he may not have admitted it.  The program director chastised the residents some, particularly on the importance of taking a good history–extremely important in this setting as diagnostic methods are often limited.  Another resident murmured in my ear something along the lines of “we don’t have time to take a detailed history–it’s too difficult.”  The patient did not recover fully from the operation and died the following day.

2) A female patient is in the ER Internal Medicine resuscitation room (like a medicine trauma bay) . . . clearly septic and extremely ill-appearing, on dopamine for blood pressure support.  Apparently, she presented with severe abdominal pain.  According to what history I could obtain from the staff, she had actually come to the hospital one month ago with abdominal pain and was sent home.  Just prior to this admission, the pain had worsened, and she had visited a traditional healer–she had evidence of fresh cuttings (knife cuttings, about 6) on her abdomen.  I saw the patient with the resident and a senior surgeon.  The surgeon told me that just seeing those markings from the traditional healer is proof of peritonitis–that the pain had to be severe and generalized to have the traditional cuttings.  He told the resident she needed an operation, and the plan was to go in the afternoon (get a few repeat blood tests, actually get into the OR).  I asked the senior surgeon if he woud participate–he said no, the resident would, so I offered to be available to help.  I waited all day for a call, which never came, so I went back to the hospital in the afternoon.  That’s when I discovered that the first patient was first in line for an operation, but there were no instruments available for a laparotomy.  By the time the resident went back to check on this patient after the rectal cancer patient, she was dead.

3) A 17 day neonate is transferred to from a district hospital.  He began having abdominal distention at 5 days of life.  The intern said the history was “normal” but that didn’t satisfy me in terms of birth history,etc.  Anyway, the anesthetist was reluctant to operate because he thought the baby would need a ventilator post-op (as it turns out, there are apparently 2 neonatal ventilators somewhere in pediatrics, but no one in surgery knows for sure where they are).  They finally convinced them later that day to take the baby to the operating theatre, and the resident found all of the small bowel and mesentery to be necrotic.  The baby died that afternoon.

I can’t help but wonder–if any of these patients would have presented even 12 hours earlier, would their course have been different?  Or, if the hospital–the main university teaching and referral hospital in the the country–had the equipment . . . Or if they had supplies and personnel at the district hospitals to take care of fractures, for example (I’d say 75% of the patients the on call resident deals with are lower extremity fractures transferred from district hospitals . . . most of which would be effectively treated with an external fixator . . . oh wait, they rarely have those available . . . so they get transferred from all over the country to the main referral, university hospital to go to the OR for debridement and casting, essentially) . . .

Again, it’s a complex problem that will need complex solutions . . . Hopefully these stories help to convince you how important the problem is, however.