Perspective
Lessons from Rwanda
What continues to bring one U.S. physician back to Africa.
By Robert Levin, M.D.
In 2006, Robert Levin, M.D., traveled to Rwanda with Partners in Health, the medical humanitarian group co-founded by Harvard infectious disease specialist and medical anthropologist Paul Farmer, M.D. This was Levin’s third trip to Africa. In 2002 and 2004, he worked in Sudan and Uganda, respectively, with Doctors without Borders. Levin, a graduate of the University of Minnesota Medical School, completed family medicine training in California, then returned to Minnesota, where he spent three years as a faculty member in the North Memorial Family Medicine program, which is affiliated with the university’s department of family medicine and community health.
I flew into Kigali, the capital of Rwanda, early in the morning on a late April day in 2006. By mid afternoon I was in a car heading for Rwinkwavu, a collection of villages set in the rural eastern part of Rwanda about two to three hours from Kigali. For whatever odd reason, the district hospital entrusted to the oversight of Partners in Health lies deep in a valley 25 minutes from the tarmac highway. One would expect a district hospital to be located just off of a main drag. Its location, however, may protect this hospital from being completely overrun by patients.
The descent to Rwinkwavu from the main road is long and constant, and the one-and-a-half-lane dirt track winds through fields of sorghum and banana trees. The landscape is notable for layer upon layer of rolling hills and snakelike valleys. Fittingly, Rwanda is known as the land of a thousand hills. In the rainy season, everything is very, very green. The area looks gorgeous in the early hours of the day and in the evening, when the light casts a spell over everything. At those times, clouds play in the blue sky, the sun is orange-red, the fields are a brilliant green, and the dusty dirt road becomes a rich, reddish color. But because of Rwanda’s proximity to the equator, dusk and dawn are far too transient.
During the dry season, driving down the dirt track is a different kind of experience. The ground is hard and unforgiving and pounds the suspension of the Land Cruiser. We repeatedly open and close the windows of the vehicle to avoid becoming engulfed in a toxic cloud of road powder as we pass oncoming cars or get caught behind wide, slow-moving trucks. The upside, of course, is that no one worries about drenching downpours, flooded roads, or tracking mud into the vehicle or through houses. From a medical perspective, the dry season has other positives: Although it heralds the onset of more pneumonia and meningitis cases, malaria takes a significant break.
I found the hospital at Rwinkwavu impressive. Work was going on everywhere, including on the grounds. The hospital, which sits at the top of a small hill, had been renovated, and the set of buildings that house adult, pediatric, and maternity wards were now a gleaming creamy white. A dormitory sits further up the hill, along with an office building that has a large conference/training room; the outpatient clinics are at the bottom of the hill. As in every clinic or hospital I have worked in overseas, people mill about, waiting to be seen in the emergency room or laboratory, taking a breather from caring for a relative within the wards, or just hanging out. A hospital can sometimes provide a welcome diversion from a typical slow day in the countryside.
As I got oriented, I was not surprised to learn that the major illnesses attacking this population were the big three: HIV/AIDS, TB, and malaria. I have seen and treated malaria and, to a lesser extent, TB, and was mentally prepared to care for people with HIV/AIDS. But I was surprised, after a short time in the countryside, to learn how food plays into the management of all of these diseases.
Food as Medicine
Despite the fact that this country appears so fertile, food is a huge focus here partly because Rwanda is the most densely populated African nation. Partners in Health strongly supports giving food packages to patients being treated for AIDS and TB. But this creates unexpected difficulties. Food is so critical that people regularly pose as being HIV positive in order to get supplemental nutrition.
This was brought home to me during my first venture into treating patients. I was working with a Rwandan doctor, Yves, who was helping to orient me, when I noticed how concerned patients seemed, even when their CD4 counts were high, if they were not started on treatment. At first I thought the patients believed the new anti-retrovirals were so powerful they could protect them from developing AIDS regardless of their CD4 counts.
Soon, I learned they had a different motive. One woman was visibly upset when we told her that her numbers were too high for meds. I tried to explain that there was no advantage to early initiation of anti-retrovirals. With Yves’ help, I quickly learned just why she was so distressed. Because we only begin disseminating food when therapy is started, she would be denied the food package of beans and sosoma (soy, sorghum, maize, flour), sugar, and oil. And this, for her, was completely devastating.
In places where people are displaced because of war or conflict, getting sufficient calories is a day-to-day struggle. Yet here in Rwanda, where life is basically stable and secure, the soil is good, and, most years, rain is abundant, food still is absolutely central. It is so central that a middle-aged woman with HIV was devastated to learn that her health was good, that her HIV had not yet progressed to a threatening point, and that she need not take twice-daily medications with possible unpleasant side effects. All this concern and despair because a precious, reliable food source would not be made available to her and her family.
I had expected the devastation, suffering, and sadness that have been caused by HIV/AIDS, but I was not prepared for the fact that AIDS patients might worry more about getting food than treatment. I was also not expecting to treat so many cases of TB in both patients with and without HIV/AIDS. One who stands out in my mind is Alice.
Alice’s Story
She was only 5 years old when I met her in the pediatric ward as I made rounds in Kirehe, a village about an hour and a half from Rwinkwavu, where Partners in Health was attempting to turn a small outpatient facility into inpatient wards, a malnutrition unit, and a clinic for HIV and TB patients. The patients were housed in small rooms that had been designed for other purposes, and often were squeezed into beds with other patients.
I walked into the pediatric “ward,” to find Alice in the first bed to the right against the wall. Her large, almond-shaped eyes were impossible to miss. Other than her eyes, the most noticeable things about her were her thin body, close-cropped hair, and the well-healed, vertical scars on her forehead. Having worked in Africa before, I knew the scars were the result of traditional healing methods that involved either burning or the use of a razor.
Rwanda's Legacy
The tiny African country of Rwanda is now a serene place. Despite this, its legacy will be genocide. It is impossible, and maybe irresponsible, to discuss Rwanda without mention of this horrible event. The 1994 Rwandan genocide, the most efficient killing of human beings in history, left at least 800,000 Tutsis murdered at the hands of their Hutu countrymen in only 100 days. Although hand grenades and guns were used, by far the majority of Tutsis were put to death at the end of a machete. This is truly the material of nightmares and horror films.
The killing was intimate and full of anger. Often it was fueled by drugs and alcohol, especially among the young militiamen stationed at roadblocks all over the country. The majority of the Hutu population—neighbors, teachers, doctors, and storeowners—poured out into the streets to do their duty. Although thousands of Tutsis were mutilated, the Tutsi women bore the brunt of crazed Hutu anger. They were gang-raped, disfigured, and left to die slow deaths.
Contrary to what many in the West believed, this was not a spontaneous explosion of ethnic hatred. It was the result of months of planning, training, list making, international shipments of weapons, and malignant propaganda. The West made no attempts to stop the carnage. The U.N.’s peacekeeping force was small and ineffective. It did not have a mandate to take action. Had it not been for the Tutsi rebel army, the Hutu Power Movement would have succeeded with its goal, full extermination.
Rwanda now is at peace. It is one of the more stable countries in Africa. It is a place where things are mostly functioning and the roads are safe to travel at night. The distance this society has come since 1994 is inspiring. Somehow the people are moving past the pain and destruction of the past to make a better place. When asked how and why, most Rwandans, whether perpetrators or victims, will simply reply, “For our children.”—R.L. |
Despite her increased respiratory rate and frail condition, she mustered a shy smile as I began speaking with her mother. Using the nurse as a translator, I learned from Alice’s mother that she had been sick with a cough and fever and had been losing weight for well over a month. Her mother, who had a kind manner and was very attentive to her daughter, was forthcoming. I bent over to examine Alice and put my stethoscope to her fragile chest. Her lung sounds were worse than I had imagined, with horrible wet-sounding crackles bilaterally. Her chest X-ray reflected major involvement of the right upper lobe. She had been on ceftriaxone, a third-generation cephalosporin, yet was showing no improvement. At this point everything indicated probable tuberculosis: her history, her clinical state, and the lack of any progress on good antibiotics. Three-drug TB therapy was initiated, and Alice and her mother were tested for HIV. We were relieved to find that both were repeatedly negative.
Over the next four or five days, Alice improved but then worsened. In consultation with the Partners in Health country director, Michael Rich, M.D., who also happens to be a TB expert, I placed her on a course of steroids. She rapidly improved and was later discharged.
Unfortunately, she returned to our facility about a month later looking worse. Her mother carried her as they walked up the dirt driveway to the hospital. Even from a distance, I could see by the way Alice was draped around her mother that she was doing poorly. She looked no better and, perhaps, worse than when I had discharged her from the hospital. She had gained no weight despite the medicines and food package given to all TB patients. She was in respiratory distress and looked up at me imploringly without a smile.
I transferred her to our other facility, the Rwinkwavu District hospital. There, she could get an immediate X-ray and, most importantly, be put on oxygen. During the next several weeks, everybody on the Partners in Health team examined her. She was given just about every IV antibiotic we had but did not improve. She continued to require supplemental oxygen, and the light in her almond-shaped eyes began to fade. Her mother, usually talkative and friendly, became quieter and more withdrawn.
Because she needed a higher level of care, we arranged to transfer her to the private hospital in Kigali. There, a CT scan showed severe bilateral cavitary disease. As a second line therapy for TB, she was eventually started on streptomycin. She remained at the private hospital for more than a month before she died. Her disease was already extensive by the time we first saw her in Kirehe. From Rwinkwavu District Hospital we had sent sputum to the United States for culture and drug sensitivity testing. After her death, the results finally made their way back across the Atlantic. Her culture came back resistant to both Isoniazide and Rifampicin. Alice died of multi-drug-resistant TB.
A Struggling System
Alice’s story is no different from that of thousands, maybe millions, of others around the globe. For me, though, it is obviously more immediate and personal. And I think it illustrates many of the challenges of providing health care in Rwanda and in the developing world in general.The health care system in Rwanda functions on a level comparable with that in many settings with limited resources. Notably, though, the central government through the Ministry of Health has tried to develop a public health insurance program to which all but the most destitute contribute. It is administered, district by district and is a commendable experiment. But it suffers, not surprisingly, from inadequate funding. This translates into vast numbers of people left untreated for diseases easily cured, such as malaria, an infection that kills more than a million children a year across the globe.
Rwanda, like many poor countries, faces a striking shortage of health care professionals because it lacks training facilities and because many health care professionals leave to work in Western countries. For many reasons, doctors and nurses throughout the developing world run to find opportunities in the West causing a “brain drain” in countries such as Rwanda. Even if the best programs for TB control and maternal and child health, for instance, are put into place, they won’t survive without an adequate supply of physicians and nurses to implement them. The problem of having too few health care professionals will intensify if it is not addressed both by the poor nations themselves and by the Western countries that benefit most from this migration of the medical workforce.
In the time I have spent living and working in areas of poverty, disease, and conflict, I have seen things that make me feel both hopeful and cynical. But I continue to do this type of work because the rewards and challenges are immense. The patients that we save bring a short-lived feeling of having done something substantial and important, while children like Alice, who die deaths that would be prevented in the United States, serve not only as a source of anger but also as a catalyst for continued work and dedication.
Although direct clinical involvement is often the most interesting part of the job, unequivocally it is the training of local health professionals to carry out medical work in a skilled and compassionate manner that is most crucial. It is extremely gratifying to work with enthusiastic, promising local doctors, nurses, and community health workers. Whether we like it or not, those of us working overseas are teachers and role models. I can only hope that what I teach and how I carry myself is worthy of emulation and will somehow make a small difference down the line. MM
Robert Levin now lives in London.