In 2013, The Center for Global Health (CGH) completed a contract with Tulane University and the Centers for Disease Control and Prevention working with the National University of Rwanda (NUR)to increase the number of practicing physicians in Rwanda 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.
Starting in January 2007, 25 faculty from the US 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, infectious disease, pulmonology, gastroenterology, cardiology, endocrinology and family medicine. Drs. Cal Wilson (Director of the Project), Louise King and Michael Miller, (physicians living and working in Rwanda), worked with the Dean of the Department of Family Medicine at NUR, and with 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.
While involved with the project, Michael Miller, DO, was an Assistant Professor in the Department of Family Medicine, School of Medicine at the University of Colorado. Throughout his time living and working in Rwanda, he provided quarterly updates on his progress and experiences. The following is a description of his experiences and work in Rwanda in his own words.
An American, a Rwandan, and a Dane walk into a hospital. It sounds like the beginning of a bad joke, but the multicultural nature of the work here helped recently as we encouraged the residents to contemplate their own culture of medicine.
The one-day session started with the Rwandan residents in small groups, each with a faculty member who happened to be from a different country: The US, the Netherlands, and Denmark. First exploring general characteristics of Rwandan culture, we moved to the medical culture, ending with ideas on how they, as Family Physicians, could change aspects of that culture to improve patient care. Just as a fish might need help in comprehending that it is wet, having outsiders to lead them in this cultural self-examination brought forth some realizations that might otherwise have gone unrecognized.
We began with some of the more obvious cultural aspects, like “time is elastic” and a value of a “strong sense of community”, but then were able to delve deeper into cultural attributes. One of the residents pointed out that there is an ambivalence between “the rational and the mystical”, between acceptance of both scientifically based medicine and traditional healing practices. Indeed, this duality can be seen everyday at the hospital. Recently, we saw a young man who had dislocated his shoulder while swinging a machete in the fields. He had spent last 3 months since the injury seeing traditional healers, believing that someone had put a spell on him. Unfortunately, these delays in treatment are very common, and the residents agreed that it is something about the medical culture that needs to be changed. But, as I pointed out, we from the rational West do not have all of the answers. A modicum of the mystical and a prioritizing of relationship over time may be elements that need to be added back into our own logical culture.
The strength of our Family and Community Medicine program is not the curriculum or the schedules, nor is it the didactics and teaching. The strength of our program lies in the personal mentoring that we have been able to give the residents over the past several years. The UCD in 2008 started to try to change the educational culture by spending much of the teaching within the Family Medicine program n one-on-one and small group bedside teaching, in contrast to the high didactic, low contact system at the time. It is making a difference. We see our graduates with a commitment to patient centered medicine, and have hopefully empowered them to change their medical culture, one patient encounter at a time.
One of my favorite diagrams to show medical students involves a simple set of boxes. From an article entitled “The Ecology of Medical Care” originally published in the NEJM in 1961 by K. White, the figure starts with a box of 1000 community members, and the inset boxes gradually get smaller as it describes the proportion of the population that falls ill and accesses the health system. The smallest box represents the 6 out of 1000 each month that need to be transferred to another physician at the tertiary hospital. This little box is where the Rwandan medical students spend almost all of their 6 years of training. All but 4 weeks.
The department of Family and Community Medicine was asked a year ago to develop and implement a 4-week training course in Community Health for 5th year medical students. For most of them, it is the first time that they had ever experienced the Rwandan healthcare system outside of the tertiary training hospitals in the bigger cities. They trade in their stethoscopes for notebooks, tasked with listening to patients, nurses, and doctors at the district hospitals and community health centers to learn about the health system at the grass-roots level. The students are introduced to ideas such as Community Oriented Primary Care, Health Systems, Preventive Medicine, Health Education, and, of course, an intro to the principles of Family Medicine. Instead of wards filled with patients languishing with end stage heart or renal failure from diabetes or hypertension, the students spend their days at the health centers, listening to patients’ stories. Recently, at one of our weekly debriefing sessions, the students recounted one of these narratives.
Mama Oscar is a 34-year-old mother of five whose youngest is in the hospital for diarrhea. She brought him in with signs of severe dehydration, but this was corrected easily with IV fluids, and he was diagnosed with amoebic dysentery. But because they couldn’t afford the national health insurance, they could only afford the lab test and not the medicine. Even though it was determined by the umudugudu, the community leader, that the family qualified for the 3,000 franc per year insurance premium (about $5), it is mandatory to enroll the entire family at once. Weakened by days of diarrhea but not able to pay for the cure, the boy was left with the support of IV fluids until his family could borrow the money.
Such are the realities in the community, stories that expand the minds of the medical students beyond the walls of the university teaching hospitals to think about the Rwandan healthcare system as a whole, to think outside the box.
Dr. Vincent, one of our imminent Family Medicine residency graduates suddenly got an excited look on his face and confidently raised his hand to stop me. He had a better way to explain it. We were gathered with a group of nervous medical students around a Power Point presentation, though no one seemed bothered that the power flicked on and off with the passing storm. This morning I was introducing the concept of Community Oriented Primary care, struggling to explain an idea that requires a paradigm shift to Rwandan students who had spent all of their time learning about diseases at the tertiary hospitals.
Vincent turned to the students and explained in English, throwing in a French word or two when his third language escaped him, “It is like when they handed out the mosquito nets in the community and many in the fishing villages used them as nets. They didn’t understand the importance of what we were trying to do.” The group laughed and nodded, replacing their stiff postures and furrowed brows with smiles and sighs. This is when I knew that our new graduates would be ready for their journey towards becoming faculty. And they will be better at it than me.
This year will mark the beginnings of transition for the imported Family Medicine professors as we begin to take a step back and ease the teaching responsibilities to our new graduates. I, myself, began immediately teaching at a residency, and I vividly remember the fears that came with the idea of that position. These fears are universal. But these new Family Physicians have something that I’ll never have here: a comfort with the language and culture of their students that allows them to be even more effective teachers. We have tried to instill in them the medical knowledge they need, but this connection is what will propel the program to the next level.
After living in Rwanda with my family for 3 years it is encouraging to see the program advancing. Life here is sometimes demanding, sometimes exciting, but always interesting. A great example is some recent visitors we had at our gate, two well-dressed Rwandan ladies representing the national census. These “enumerators”, with name badges declaring, “If you don’t count, you don’t count,” were 2 of the 10,000 schoolteachers across the country assigned by the government during their one-month vacation to count every person in the country, including us, the abazungu. It was very entertaining to watch as she carefully recorded the answers to the typical “how many TVs do you have in the house” questions, as well as “how many wives do you have” and “what is your rank as a wife”!
It may seem strange, but recently a Rwandan doctor told me that not too long ago some people wished they were HIV positive. Can you imagine someone wishing for that? Skeptical, I questioned the doctor further, unconvinced that someone could sincerely desire for such a terrible thing. As I listened further, I came to accept the reality of this strange truth, born from an unfortunate mixture of the desperation of poverty and myopic “vertical” programs.
Often in global health, a government, NGO, or even individuals readily give money to help fight a specific disease. HIV, tuberculosis, “tropical” diseases such as malaria – each can have it’s own source of funding and infrastructure, leading to multiple departments and even separate laboratories within one hospital. And there is no doubt that these programs are making a difference.
Currently in Rwanda, where the HIV rate is 3%, over 75% of HIV-infected adults are on antiretroviral medication. Malaria is becoming rare in most areas of the country with an incidence rate under 5%. This has been possible because of these generous programs. But they often have unintended consequences. Many times, though well funded, these resources can only be used for patients with the targeted disease. Known as a “vertical” program, they sometimes lose sight of, either by lack of vision or lack of flexibility, the rest of the needs of the people.
In a poor village, as the Rwandan doctor explained to me, a person with HIV could receive assistance not only with medication and medical bills, but food and even a new roof, while neighbors with other debilitating illness were left to their own. “They had the wrong disease.” Fortunately, awareness of this problem is growing. While maintaining some of the focus on specific diseases and keeping the momentum gained in addressing these problems, some programs are also allowing the flexibility to consider other issues. There is a shift in the global burden of disease from infectious diseases to chronic, “non-communicable” diseases such as hypertension and diabetes, and there is a need for a primary care, horizontally-focused workforce to address these needs as well as the psychosocial and spiritual needs of the patient.
This is the strength of Family Medicine, and increasingly our residents are showing that they are embracing the concept and the fact that this is what makes them unique among Rwandan doctors. The post graduate year (PGY) IV residents are diligently working on their required research projects in order to submit them by the end of the month, before their final exams.
Although they had a great amount of latitude in choosing their topics, most of them chose qualitative, community health based themes, such as exploring local attitudes toward vasectomy or youth acceptance of STD training. For them, this is not just a requirement for graduation, but a great chance to promote the FAMCO program in Rwanda, with many of them planning to present their research at the World Organization of Family Doctors (WONCA) Africa conference this November or even try for publication. Although the first class of residents will not graduate until October, they will sit for their final exams next month. Administered by our faculty as well as an external examiner from a Family Medicine program in South Africa, the exams will consist of three days of written questions, Objective Structured Clinical Examinations (OSCE) stations, and a clinical exam in which a selected patient consultation is observed.
Successfully passing these exams and acceptance of the research by the University Research Committee would mean not only earning a Master’s in Medicine degree, but becoming one of the first Family Physicians in Rwanda.
“What is your differential diagnosis?” A year ago the question would have been met with a puzzled look from the doctor. It had already been concluded that the young Rwandese lady on the Internal Medicine ward had a complicated urinary tract infection. She had been seen at the Community Health Center and sent to the hospital, specifically to the medicine ward, for more definitive treatment after failing a course of oral antibiotics.
But there were no bewildered looks today. My 2nd year Family Medicine resident was used to the drill. He has learned that on rounds you need to not only revisit the diagnosis, but expand it to include all possibilities. The patient, as we found, actually had a gynaecological infection, which served to illustrate my point.
Rwandan hospitals are organized strictly by four departments: surgery, maternity, paediatrics, and internal medicine. Once a patient gets assigned to one of these areas, often by a triage or health centre nurse, it is hard to keep the health care staff from falling into one of these silos of thought.
This, of course, is the strength of Family Medicine; the house on which the parapets of specialty are built. Though it does not fit very well yet into the vertical medical system, our residents are learning to keep the differential diagnosis open.
With the first graduates of our 4-year programme scheduled to finish in October, we are expanding our teaching. At the request of the Ministry of Health, we are in the process of creating a 2-year Family and Community Medicine diploma which will allow for more trainees and a quicker increase in the number of available Family Physicians. This new direction of the program will allow us to more quickly meet the Ministry’s goal of two Family Physicians in each of the 44 District Hospitals. Some of these diploma graduates can then go onto receive their Master’s Degree with two more years of study.
In order not to sacrifice the quality of teaching to the Family and Community Medicine residents, we will of course need to increase the size of the faculty. We are working to do this in two ways. Within the next the next year, we will be able to hire two more U.S. Family Practitioner’s with help from a large new grant from the U.S. government directly to the government of Rwanda. In addition, and more importantly, a few of the new Rwandese graduates will become junior faculty members, so that some day we can turn the entire program over to them (which is the whole reason we are here)!
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 paediatricsto 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/
“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!
It’s been an extremely busy time on the pediatrics ward. The rainy season in April and May brings the RSV (respiratory syncytial virus disease) 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 Familyand 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 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.
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 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!
As we stood over the hospital bed of a diabetic patient, Dr. Theonesteand 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!
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!
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 powertool 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.
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 ofthe 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.