While Rwanda is politically stable and economically growing, there are only about 520 clinically practicing physicians for the almost 9 million people living in Rwanda. The Center for Global Health (CGH) is in the midst of a contract with Tulane University and the Centers for Disease Control working with the National University of Rwanda (NUR) to change this situation through: 1) the sustainable development of current post-graduate (residency) education programs in anesthesia, internal medicine, obstetrics-gynecology, pediatrics and surgery; and 2) development and implementation of a sustainable post-graduate program in family medicine.
Since January 2007, 25 faculty from the US have provided bedside and classroom teaching of required post-graduate curriculum in molecular biology, immunology, general and subspecialty pediatrics, otolaryngology, emergency medicine, obstetrics and gynecology, maternal fetal medicine, urology, general surgery, infections disease, pulmonology, gastroenterology, cardiology, endocrinology and family medicine. Drs. Cal Wilson (Director of the Project) and Michael Miller, (physician living and working in Rwanda), are working with the NUR Dean, department of family medicine and the Ministry of Health to develop the policy and process for the implementation of a family medicine post-graduate program which began in August 2008.
Michael Miller, DO is an Assistant Professor in the Department of Family Medicine, School of Medicine at the University of Colorado. He is currently living in Rwanda as the Center for Global Health family medicine faculty working on our contract with NUR. During his time in Rwanda he has agreed to send quarterly updates of his progress and experiences. The following is a description of his experiences and work in Rwanda in his own words.
December 2011
Armed with protocols and guidelines, but very little training, Community Health Workers (CHW) make up the bottom rung of Rwanda’s Health Care System. There are so many of them, two per village in a country of 11 million, that the annual CHW rallies are held at the national soccer stadium. These Health Workers are overseen by Cell Leaders, which are overseen by a Community Health Centre, staffed by Nurses. This is the somewhat effective system for Primary Care in Rwanda. But we believe that we can make it better.
The past several months we have been focusing on the “CO” of FAMCO, Family and Community Medicine. With the help of a visiting Family Physician, Dr. Barry Bacon, who is here for four months from the state of Washington, the students have started visiting selected health centers weekly. There, they help to train the nurses, consult on patients, and participate in Community Needs Assessments. This is the next step in improving health care in Rwanda and Family Medicine is leading the way.
In her blog, Dr. Agnes Binagwaho, the Rwandan Minister of Health, wrote:
"We also need to equip the health facilities at sector level with health professionals at a grade that is higher than A1 that can attend to most of the problems that arise in the community without the need to transfer patients to the district hospital. While sometimes necessary, transfers are not always in the best interest of patients. They take them far from home, thus disrupting the flow of routine activities in their homes. Bringing specialists to their communities is the best as this will bring more comprehensive care to the surrounding population."
This is a great description of what we are doing: bringing the specialists to the people. The FAMCO residents, trying to navigate the ship of a new Primary Care discipline through a sea of specialty care, have had an identity crisis. Questioned by their specialist colleagues, they see that they will never learn enough paediatrics to be a paediatrician, enough obstetrics to be an obstetrician. But they have found their identity and uniqueness in the principles of Community Medicine, and it is exciting to see their enthusiasm and energy.
You can read Dr. Binagwaho’s blog at: http://dr-agnes.blogspot.com/
September 2011
“Who will round on your patients this weekend?” The question from the visiting professor as he completed the Friday rounds with one of the Family Medicine residents was a simple one, but one that was difficult to answer. “My patients?” The resident looked down at the woman in the bed in front of him, not grasping the significance. This was only the second day he had seen her, but he was the third to round on her, and he wouldn’t be the last. Rwandese don’t claim any one doctor, neither a primary care physician nor a specialist, as their own. Nor do the doctors have “their” patients for whom they are responsible. People seek care from the medical system and the responsibility for them stays collective, seemingly impersonal. The simple question addressed a crucial difference in the medical culture.
The World Health Organization describes the need for “patient-centered” healthcare, detailing an emphasis on “an enduring relationship of trust between people and their health-care providers”. While this idea may be intuitive in the West, after years of building such a system, it represents a paradigm shift that needs to happen in a place like Rwanda. Even a bigger paradigm shift then we thought. But glimmers of this shift are beginning to shine as we stress these ideas to these pioneers in Family Medicine. Patients and colleagues are beginning to recognize them as Family Doctors - generalists in the breadth and specialists in the depth of their medical knowledge – and they are called upon, even after hours, by their patients for assistance.
September marks the return of the rain to Rwanda. After three months without a drop, even the cows were beginning to give evaporated milk. But now that the nights are once again dark and stormy, the fields of volcanic soil are vibrant with farmers, hoeing and planting in community as they prepare for the promise of the rainy season. Here in Rwanda, almost everything is done in community. From farming to fishing, even roadwork and travelling to the market, the labour and its fruits are shared. Rwanda recently passed a law banning thatched roofs, requiring all houses to be covered with sheet metal or tile. The new requirement hit the poorest families especially hard, with some literally not being able to afford a roof over their heads. But communities have mobilized in response, sharing both money and manpower. Our area or “umudugudu”, made up of mostly ex-pats and wealthy Rwandans, has even been able to help out some of our roof-needy neighbors!
June 2011
It’s been an extremely busy time on the pediatrics ward. The rainy season in April and May brings the RSV season, and the dimly lit wards are filled with a cacophony of wails and coughs, the children often two to a bed. Their mothers, who stay with them in the same bed, develop a community as they swap food and stories from their homes, sometimes caring for each others’ children.
On any given day this month, if you were to walk into one of these wards and let your eyes adjust to the jaundiced light streaming through the painted windows, you would find Dr. Jean Bosco, one of our first year residents. Dr. Bosco, now 47, became a catholic priest while in medical school in Tunisia, and administers blessings as freely as paracetamol to the children he sees. As a young physician during the genocide of 1994, he was only one of two physicians who survived and stayed at the hospital, treating hundreds of patients every day, even well after the war was over. Although he has had 20 years of learning by experience, he now wants to become a Family Physician.
Though Dr. Bosco is only one year into his four years of training, we are now only one year from graduating the first Rwandan Family Physicians. A key step in making sure that this training program is sustainable is to ensure that there will be jobs waiting for them when they graduate, jobs doing what they have been trained to do. In Rwanda, the healthcare is largely run by the government and not the private sector, and their understanding of the role a Family and Community Doctor in the system is crucial to the future. They are the ones who will be assigning them to a workplace and giving them a paycheck, but if they do not fully appreciate the unique skills that Family Medicine offers, our doctors may get lost in the system. As a step toward refining this understanding, we are hosting a workshop in August with these officials to discuss the role, so that our graduates can be assured that they will be working in a job that reflects their training. We then can review the curriculum so that we are sure we are training them in a way that reflects their future role. This is an ongoing cycle that of course started before the training began, but as the reality of Family Medicine nears, these elements need to be revisited and clarified.
March 2011
As we held the x-ray up to the light that was meandering through the dirty window of the Surgical Outpatient Department, it was clear to us why the farmer couldn’t use his shoulder. A proper light box hung on the dingy wall behind us, long forgotten because of the unreliable electricity and the cost of new bulbs, but the resident and I had no trouble seeing the problem; a dislocation with accompanying fracture. What made this case remarkable was not the way in which he sustained this injury, by forcibly swinging his machete while clearing his field, but his answer to the question, “When did this happen?” “Two months ago.”
Many of the patients come to see the doctor at the rural hospitals here only after tolerating their problems for months. Illnesses and injuries that would send most of us on a frantic drive to the ER are endured, even for years, and the patients present with such stoicism and calmness that is in complete contrast to the severity of the problem. The reasons for this delay in seeking treatment are many and varied – a preference for traditional healers, lack of transportation or money, or a simple cultural acceptance of troubles – but there is undeniably a sense of strength and resolve among Rwandans that is uncommon in the Western world.
Insights like this accentuate to me the difficulties of an American trying to establish Family Medicine in a different culture. Our residents, though, are all amazingly adept at translating what we teach them into terms that their culture needs. Only a little over halfway through their training, they are already respected and consulted in the District Hospitals. We feel that we are just beginning to build the program, but the first class is off to a great start.
Thankfully, the number of full-time Faculty in the Department of Family and Community Medicine here has now doubled! Dr. Cal Wilson, former director of the Center for Global Health, moved here with his wife Mimi in December. We are looking for a third full-time faculty, hopefully to be added later this year, to allow for a full time presence at each training site. With the addition of up to 10 new residents in July, this looks to be a significant year for the establishment of Family Medicine in Rwanda.
As the first permanent faculty, my family and I have now been here over a year and feel quite established in life in a different hemisphere. When we were planning to move here, I had visions of my boys happily playing with the neighborhood Rwandan kids and quickly learning the language. Part of this vision has been realized – my boys play every day with Rwandan kids, as well as some from Kenya, Uganda, Tanzania – but all of these kids speak English. The only thing my three boys know how to say in the local language, Kinyarwanda, is “Ndashaka kugukubita” (I want to beat you up). They say it to each other all the time!
December 2010
As we stood over the hospital bed of a diabetic patient, Dr. Theoneste and I debated about how much insulin to give. I clicked on that part of my brain where I keep formulas for things like this - plug in: AM blood sugar, last night’s dose of insulin, carbohydrate count, etc. Then I realized that I would have to use a totally different part of my brain. As we talked with the patient, we realized that he probably would not be eating much today because he has no family here to bring him food. Medicine in a developing country has challenges that you don’t expect.
Over the past three months, the faculty for the Family Medicine residency has more than doubled. We are now working with Partners in Health at one of the training sites, and they have secured funding for a full-time Dutch Family Physician to help teach the four students assigned to the Rinkwavu Hospital in the East of Rwanda. Earlier this month, Dr. Cal Wilson, director of the Rwanda project and Former Director of the Center for Global Health, moved to Kigali. He will be teaching part time as well as overseeing other aspects of the project, including helping to develop a national Continuing Medical Education (CME) program and bringing Family Medicine into the medical school.
Later this month, the application season for all of the post-graduate programmes will begin unceremoniously with an ad in the national newspaper and an announcement on the radio. The application deadline is then one month later, an improvement on the two weeks applicants had in previous years. We will try to increase interest in the Family and Community Medicine programme by taking several recruiting trips to District Hospitals, encouraging the doctors to apply.
Christmas in a tropical climate is certainly different than in Denver. The Christmas parties have featured watermelon fresh from the garden, and the best presents for other expats are carefully hoarded American food items! The Season, though, takes on a whole new meaning when there is no barrage of TV ads and newspaper inserts, in a place where the outlandishness of Santa seems a little more absurd and the earthiness of the Nativity seems a little more real. Noheli Nziza!
September 2010
Even though this is Rwanda, practicing medicine here can be done in many languages. In addition to the many opportunities to speak French, English, and Kinyarwandan, I am using my broken Spanish from time to time as I communicate with many of the 30 Cuban doctors that are here helping with the healthcare in Rwanda. The other day, I spoke Russian with a mother who’s child fell and we were trying to decide if he needed stitches. Good thing I took Russian in college, but I never thought I’d be using it here!
Because of the recent addition of 6 new residents, the Family Medicine program has expanded to a third training hospital, Rinkwavu, in the eastern part of Rwanda. A joint venture between Partners in Health and the Rwandan government, the hospital is excited about the training, and we will be helped by a Dutch Family Physician and an Italian Internist. Already they have been hosting a Community Health module in which they travel into the communities and learn about health education.
No two days here are ever the same. Often I travel to one of the training sites to round with or lecture to the students or lead them in a case discussion. At other times they are taught by visiting professors or are rotating in other departments, giving me time to work on administrative tasks. In an effort to foster the spirit of flexibility, the Rwandan government sometimes declares national holidays at random times, shutting down the country. Last month they gave us the luxury of a 4 day warning - the time before that they announced it on the radio that same morning!
June 2010
When I peeked into the Operating Theater to check on one of the Family Medicine residents, I noticed the Black and Decker drill case. Seeing this common household power tool in the hands of someone I am in charge of teaching made me realize just how different family Physicians in Rwanda will be. Dr. Mugali, a second year resident, was using it to plate a femur fracture, one example of the vast range of skills needed to treat patients at a rural Rwandan hospital, often with very limited resources. Specialists like Orthopedic Surgeons are rare, and patients often cannot be transferred.
If a patient is referred to the hospital in the capital, they must pay for transportation and find some one to bring them their meals, do their laundry, even help them to the bathroom while they are there. In addition, the waiting list to see a specialist is sometimes long. Because of this, many simply do not go, so their sometimes complicated problems must be handled at the rural level.
We only accepted 3 new Family Medicine Residents in this year’s Intake (Rwanda’s rough equivalent to the Match) while we were hoping for 10. Fortunately, though, we received special permission from the Ministry of Health to extend the application period and are hoping for several more.
One of the difficulties is that Family Medicine, as in most places where the discipline is new, is poorly understood. The concept that a doctor can specialize in the common rather than in a specific field is difficult to comprehend. But once people understand the concept, many realize that it fits well with the needs of Africa, and there is growing support and excitement among the medical community, especially some of the other specialties. Rural areas seem to be one of the sources of the greatest enthusiasm. Here, the doctors have a realization of how inadequate they are to handle some of the patients at the rural hospitals, and from this frustration is born an appreciation of Family Medicine.
March 2010
As my morning commute was slowed by a silent crowd of onlookers, I knew that something tragic had happened. These types of crowds rarely gather to look at good things. Even the traffic seemed hushed as we squeezed into a single file, taking our glimpse past the throng down the steep Rwandan hill. The white roof and green body were still recognizable as one of the large inter-city busses that hurtle along the country hillsides, seemingly invincible. When I realized how close we were to the training hospital I got sick to my stomach.
As soon as I arrived at the hospital, I sought out one of the FM residents in the dark, one-room emergency department. Instead of using expensive electricity, the room was dimly lit by the daylight pushing through the windows which were painted for privacy. My eyes took a minute to adjust to the dimness, but I immediately could see the wide eyes of the frightened victims as they looked up to see the mzungu doctor. Over the next several hours we circulated among them, attending to everything from a sore back to a tension pneumothorax. Several patients had to be transported to the referral hospital because we only had one oxygen tank. What would have normally sparked a barrage of expensive CT scans and lab work at a fully equipped hospital was done with a rudimentary Xray machine and physical exam. Only one patient died at the hospital, but the police left most of the presumed dead at the scene.
Training excellent Family Medicine doctors in and for these conditions has it’s challenges, but the residents are progressing and should be ready in a few months to move into the third year. They are split between two training hospitals and are already looked to as leaders and experts by many of the other staff. As the concept of Family Medicine is more clearly understood within the medical community, support for the training is increasing as well.
Working at the hospitals is both multicultural and multilingual. Cuba, a country with a well organized medical system, is well known for exporting their doctors all over the world for short term aid. About 40 Cuban medical staff as well as doctors from India, Germany, Belgium, the Netherlands, and the U.S. join with Rwandans in working at the government hospitals, though most of patients speak only Kinyarwanda and some French, although some speak Swahili or Kiswahili, other Bantu languages of east Africa.
Over the next several months The Center for Global Health will be sponsoring several visiting professors who will help to teach the Family Medicine residents as well as residents from the other programs at the National University of Rwanda. Visiting for two to four weeks or more, these doctors in Surgery, Ob/Gyn, Dermatology, Pharmacology and Family Medicine will help to strengthen the training. In addition, we hope to be joined by 2-3 more full time family medicine faculty within the next year.