Susan Boiko, MD, Blogs from Rwanda: Visit to Marginalized People’s Settlement in Musanze and Partners in Health Hospital in Butaro

Monday, September 26
My first meeting with Nyamata Hospital Director Albert and COPHAD Project Officer Josephine to plan educational activities took place around 8AM.  The drive was pleasant with very little traffic on a well paved, two-lane road. The drive takes 30 minutes passing over bridges rising above swampy lowlands, then gently rising hills.

I had been at Nyamata Hospital last year with the CME program from Group Health Seattle, that time as part of a tour of Rwandan government health facilities.
The physician staff met with me in the conference room.  There is a 2 week course in dermatology at the medical school level. There are 2 European Trained dermatologists in Rwanda, Dr Francoise at King Faisal Hospital and another doctor at CHUK (pronounced Saishka) trained in Germany. It may be difficult to get an appointment. They asked for a basic introduction to Dermatology and for ongoing lectures on skin problems relevant to their practices. They wanted the first lecture to be at 7:20 a.m. the next day.
I saw 2 patients with Dr. Stephen, who has excellent English skills. Like the other doctors on staff, he works long hours and covers an amazing spectrum of medical practice. From outpatient consultations to inpatient medical, OB and surgical wards, some days he may do 5 c-sections then check on the patients postop. There is a Neonatal Care Unit with incubators and peripheral IV access. There is empiric antibiotic treatment for sick newborns and adults as any kind of infectious culture except for TB is not available.
I returned to HDI and worked on my lecture for 3 hours, then returned to Dr. Joseph’s house on foot and by bus, which took 2 ½ hours. (Taxi would have been 20 minutes). 4 additional hours and the lecture, “First Steps in Dermatology”, was finished!

Wednesday, September 21

Since Karl, Patricia and Anna were leaving the next day, this day was devoted to film editing by Patricia and sound editing by Anna at home. Karl and I proceeded to the HDI office.
The study tour to Musanze and Partners in Health was reviewed. The remarkable success in engaging the villagers by Mirabella’s testimonial led to discussions of how to improve networking between marginalized people in rural areas. HDI, COPHAD, Dian Fossey Foundation, COPORWA, Ford Foundation, CARE  International,  the Greater Virunga Trans Boundary Secretariat, United Nations, Dr. Kellerman Foundation heading 10 NGOs in Uganda and UOBDU (United Organization for Batwa Development in Uganda) and Partners in Health were mentioned as possible participants in a networking conference  which might focus on the topic of HIV/AIDs since Mr. Kalimba mentioned there were children with AIDS in the Eastern area who were untreated.  No one in our group was aware of any HIV testing in these communities.  Claude and Josephine will work with Ndera sector community health workers to bring HIV testing to Bwiza.
Second, Cassien, our HDI Project Manager, wants to develop a weekly, monthly and yearly plan for COPHAD with photo and narrative documentation of each activity. Cassien can give Claude the format for reports.  “A report is proof of activity.”
Finally, I will start my personal mission of teaching dermatology on the hospital and health center level. All training will be conducted in English and I will leave the Power Point presentations with a responsible individual for further study. I emphasized that my mission is NOT to see patients alone in a hospital or clinic. I am not licensed to practice in Rwanda. That process involves credentialing.  I am happy to give advice about cases. I will not write prescriptions, make chart notes, order tests or perform procedures. My vision is to make my teaching sustainable by providing resources for further self-study after my lectures  as well as a facilitate a link to Telederm Africa for difficult cases.

Tuesday, September 20

The morning began at  with  a hurried breakfast  so that we could get down to the paved road near our house and board one of the 2 COPORWA trucks, each with seating for 5.  An hour later, the truck arrived and we headed to HDi to pick up the rest of the team including Mirabella, a leader of the Bwiza community. Once a beggar, she resolved to find work and is now so successful as a construction worker that she has a cellphone so that people can reach her for jobs. She was first in the community to open a bank savings account.  A petite rotund woman immaculately coiffed and clad in an elegant patterned ensemble, she understood almost no English so Claude and Josephine acted as our interpreters.
The trip to Musanze district took over 3 hours to travel about 40 miles. Well-paved two-lane roads, then increasingly rutted ine-lane tortuous dirt roads led us to  Partners in Health spokesman Leonce, a Masters in Psychology graduate who oversees the PIH initiative involving three villages of marginalized people. After a brief introduction at the PIH living quarters adjacent to the hospital, we clambered into a truck with bench seating for 12 and drove up the mountainside (40 minute walk, 25 minute drive) to a village at 7,000 foot elevation of marginalized people where PIH had just constructed new brick and tin roofed homes, each with wooden shuttered windows and locking wood doors.  Leonce provided an optimistic statistic- before the houses were built people were literally sleeping under trees or in shallow holes they had dug. Childhood mortality was 80 percent from pneumonia, as the children were poorly nourished and stressed, with the evening temperatures approaching 40 degrees Fahrenheit. Since the houses were built, pneumonia deaths have dropped to zero.
As we trudged up the steep incline to the houses perched above the dirt road, there was a sharp contrast to the Bwiza village. In Bwiza 2 weeks ago, the children ran to greet us as a group, wearing clean school uniforms and shoes. The older villagers gathered at a flat place to sing, singing a song from their performing troupe repertoire and dancing a welcome. While listening to speeches, men and women occupied themselves with carving brochette (kebab) sticks from twigs.

Here in Musanze was a downcast group- few with shoes, many in ragged, patched clothing; all the children were dirty and the few in school uniforms had dirty clothes.
Leonce explained the scene. The adults have some work where they can earn 1000 RF (about $1.80) a day. Instead of saving for food or soap, the entire village is drunk on alcohol in the evenings. PIH stopped giving handouts. PIH taught them to wash and how to clean their clothes but is trying to be sustainable and not give handouts. One school uniform is provided for each child and one pair of shoes, but when they wear out the parents are responsible for a new one. Often children do not go to school, as in Bwiza, because they might miss out on a meal. The land is steeply sloped on which the houses are built; some crops can grow to feed families but there is not enough arable land to sustain the community. I did see some goats.

The community is a 40 minute walk to the community health center and PIH hospital. An agronomist and social worker are in daily contact with all 3 villages and visit each settlement at least twice a week.

We gathered with the villagers in a dirt courtyard in front of the closest house to the road. First, Leonce introduced our team. Next, with Patricia on camera and Anna on sound, I took photographs as the villagers heard speeches from Claude and Josephine in Kinyarwanda about why we had come and about opening levels of communication with other communities of potters and marginalized peoples to share best practices. The defining moment came when Mirabella spoke. Fluently, forthright, with emphatic gestures and speech, she made it clear that, although three years ago she had been dirty and begging like them, she was able to be successful despite still living in a grass hut. Murmuring stopped, eyes widened, and all attention was focused on her as her cellphone unexpectedly rang. Awe ran through the crowd- a cellphone and nice clothes! Women and men began to cheer and clap, but a few disgruntled individuals were heard to mutter, “I bet she can’t dance!” This was proven wrong, as the villagers rallied to sing a song of how pleased they were with their new homes, and Mirabella proudly danced with the group.

Karl challenged the villagers to come up with a list of problems and methods of solving them.  Assets included home and the ability and desire to work. Challenges included lack of food and lack of arable land. Claude summarized when he told the villagers in Kinyarwanda and our group in English, that Mirabella had “touched their hearts.”

On the ride back to PIH, Patricia asked Leonce if there were any alcohol education programs or outreach to marginalized people. He remarked that he was not aware of any alcohol education programs for any social strata in Africa, but felt they were much needed.
PIH generously provided us and our drivers with a delicious lunch of locally grown beans, cabbage, African spinach and Irish (white) potatoes. The food for hospitalized patients, workers and guests is provided by an outdoor kitchen. The food is so good that sometimes patients don’t want to leave!

The hospital is simply magnificent. A series of white angular structures seamlessly blends in and enhance the hillside site. White simple walls with large windows provide natural light.  Signs everywhere point to areas:  men’s ward. obstetrics, meeting rooms, toilets, specialty clinics. Outside the pediatric ward there is a small playground with a child-sized rotating metal play-ride. Inside, a pediatrician proudly pointed out the oxygen and electrical outlets at every bedside, a first for Africa. A giant fan circulates air and high ceilings with ultraviolet light air purifiers line the ceiling/ wall interface, so that no bed nets are needed and nurses can monitor the children more easily. The hospital uses and electronic medical record system and the large size of the computer laboratory shows the investment OIH has made in EMR training.

Up the hill from the main compounds lie the morgue, an emergency backup power generator and 2 large water tanks. Water is pumped up from a river below. All the roofs are guttered to collect rain water.

The hospital was built on a holy site of a Rwandan religion that involved visiting the site to commune with spirits of ancestors. To respect this tradition, architects changed their plans so that a triad of trees with orange flowers where people felt close to ancestors, were preserved. Because of Claude’s experience having seen his parents killed in the Genocide as a teenager, he made sure to stand under the trees and have his photo taken, even though he is not part of that religion.

We got a late start back. There were some earlier rains and many minor landslides on the dirt roads. We passed tea plantations and steep hillsides covered with terraced plants for crops and for erosion control. There were some areas of younger trees. Little towns with handfuls of buildings broke up our journey. We got to the paved roads at 6PM, just as darkness fell. There was a lot of road construction so the maximum the drivers could go was about 45 MPH and many times we slowed to a crawl. We arrived back home at 8PM, ate a quick dinner and fell into bed, exhausted. Clearly the most hopeful, and yet the most challenging, experience so far.

Susan Boiko, MD

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