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 2nd year and not my 4th. 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!
- 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 5th 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.