Places we go: Rwanda & Burundi

Desperate conditions led to greater desire to help.

Background

Rwanda is unfortunately perhaps best known for the tragic genocide that occurred there in the summer of 1994, in which approximately 1,000,000 people lost their lives in three short months. Since then, this small beautiful country of perpetual green has worked to establish itself among the more progressive African nations, resulting in a renaissance of economic activity and improved overall conditions for its people. Despite this, essential health services remain inaccessible to most Rwandans, with only one physician for every 12,000 people.

As steep as the health care challenges are in Rwanda, they are much worse in its southern neighbor Burundi, which is always ranked among the poorest nations in Africa. Poverty, hunger, and insecurity are facts of daily life in Burundi, where the majority of the people struggle in subsistence agriculture, simply trying to produce enough food for their families.

ADVERTISEMENT

Experience

I was privileged to travel to these densely populated countries in early 2018 with a team from my local church. As those with similar experiences can attest, I returned with revised perspectives on the concepts of comfort, contentment, resourcefulness, need and renewed appreciation for the skills and experience I have been fortunate to cultivate in emergency medicine.

As the sole physician on our team, I was fortunate to serve with two highly experienced and compassionate nurses. We each traveled with two bags: one for personal belongings and one large duffel bag with medical supplies. All of the medications we dispensed were bought daily at whatever nearby pharmacy had enough stock for our needs. We ran out every day

Each day we were introduced to increasingly desperate conditions, always eliciting in us the same responses, in sequence: first astonishment, then eagerness to help, frustration at the interminable lack of resources, and finally, respect for those who persevere with so little. The next day would be the same; wash, rinse, repeat.

ADVERTISEMENT

Rwanda

The first days of our trip we served in a clinic in Mwogo, south of Kigali. The health center there was no different than any other building in the community, meaning that it had walls of cinder blocks, a roof and no running water or electricity. We were blessed to have excellent medical student interpreters (Rwanda produces about 90 new physicians per year for its population of over 10 million people), who were endlessly patient and accommodating.

We saw lots of gastritis, infected wounds, back pain (people carry everything on their backs, or their heads) and the worst ear infection I have ever seen. We debrided several wounds that here at home I would have sent to an OR without hesitation. Every patient was gracious, appreciative and offered a smile at the end of the encounter. Day One was the first of many after which I understood what it was to feel simultaneously exhausted and energized.

Burundi

ADVERTISEMENT

The next place we worked was a village in Cibitoke, in northern Burundi. No clinic was available here. We set up in a dirt courtyard, with triage under a shelter outside the gate, and a “pharmacy” in a small edifice nearby. It quickly became clear that I could never see all of the patients myself, so the two RNs with me were promoted to full independent practitioner status, and we went to work. We spent the day treating skin eruptions, infected wounds, stomach ailments, injuries and burns.

One particularly sick-looking gentleman was noted at triage to have a significant fever and profound hypotension. He likely had malaria and would probably have died had we not been in that particular village on that particular day. In Burundi, treatment is not assured unless it is paid for. We took up a collection among the group to pay the $40 that his complete inpatient course would cost, and a local pastor drove him to a hospital.

The next day we traveled to a village near Gihanga of about 300 Twa villagers. About 99% of the population of Rwanda and Burundi are either Hutu or Tutsi. Most are members of a pygmy people group known as the Twa.

One of the oldest people groups in Africa, the Twa are truly outcasts of society; they are not permitted to own land, and therefore tend toward a nomadic lifestyle. Property and possessions are essentially unknown to them, yet they appeared happier and more content than many of those I encounter on my shifts here at home. We treated primarily malnutrition and general aches and pains; remarkably, not one person asked for a narcotic.

ADVERTISEMENT

The final two days were the most arduous and invigorating of the trip. We traveled to Gatumba, just west of Bujumbura, to a refugee camp of about 3,000 people. The need for such camps is incessant. Because of the lack of infrastructure, water must often be obtained through manual labor from lakes, rivers, streams and swamps. To facilitate this, many people choose to live near these water sources that inevitably will flood, destroying homes and displacing families. The waters recede, the people rebuild and the cycle begins again.

With the aid of our Burundian translators, we saw over 500 patients in two days. We became experts in treatment of gastritis, skin ailments and wounds as well as crowd control, resource management and conflict resolution. The final patient count was increased by one due to a domestic disturbance when a rock in the hand of an angry wife impacted the scalp of an abusive husband resulting in a scalp wound. I observed a middle-aged woman vomit an intestinal worm over 12 inches long.

I consulted with an ophthalmologist friend of mine (officially, the longest distance consult ever recorded, at 8,295 miles) about a child of 18 months, blind since birth, whose preferred method of self-calming was to stimulate his retina by inserting his thumb into his orbit just below the supraorbital ridge, which according to his mother was the only thing that would cause his persistent crying to cease.

It also caused a rather disconcerting proptosis. (And I used to get irritated with my kids for sucking their thumbs.) I debrided and dressed a severely infected leg wound, the result of a burn, and almost certain to require amputation; on that particular day transportation to a hospital was not available so we implored the patient to return the next day, by which time we would make arrangements. He didn’t show up.

Lessons Learned

I returned from Africa with several takeaways, the most significant being: Go. All emergency medicine physicians need to do this at least once in the prime of their career. It just might be the key to preventing burnout, soothing frayed nerves and lightening the load we all carry. It really is true: one of the best ways to improve one’s own outlook is to commit oneself wholeheartedly to the service of others.

Just because we don’t hear about a humanitarian crisis in the news doesn’t mean that there isn’t one, right now. Physicians are virtually nonexistent in Burundi, with about one for every 25,000 people (half as many as in Rwanda).  It is a difficult place to which to travel, and its small size and lack of natural resources limit its appeal to global contemplation. Yet millions are without basic medical care and other necessities. The lack of resources and training in Burundi and other places constitutes a perpetual crisis that begs for attention.

All over Rwanda are reminders of the cruelty that humans are capable of exacting on one another. Bones of those killed during the genocide are still being recovered in crop fields today. At the incomprehensible Genocide Memorial in Kigali, over 250,000 Rwandan Tutsis are buried in mass graves.

Several who passed through our clinics during our brief visit are living with HIV or suffering sequelae of AIDS, largely the result of rape expressly perpetrated during the genocide to pass on the infection. And yet, in few other places have I seen such a desire to listen to instruction, to assist in mundane tasks like setting up a clinic, to show respect for others and their belongings, and to serve in any way possible.

One of the greatest physical needs of people the world over isn’t medicine, or clothing or shelter, but clean water. In East Africa, people (usually women) typically spend three or four hours per day obtaining, carrying, cleaning and storing water. We saw firsthand the life-changing ramifications of the presence of a well within a community, and also the negative consequences to health and quality of life that the absence of one creates.

Driving back to Bujumbura after our day in Cibitoke, I watched a young boy run alongside the bus, expertly rolling an old bike tire alongside him with a stick. I watched children play soccer with just a wad of clothes and rags tied up in a ball. Spending time among those who possess next to nothing yet appear remarkably content reinforces the idea that possessions are not the source of contentment. I wonder to what extent this truth can expand, and if it’s also true that more possessions actually contribute to discontentedness. I think many times they do.

I love to travel and take vacations, but it always seems that when I return, I need more time off to recover. Maybe it’s the places I go (ski trips are tiring), or maybe it’s something else. What I know for certain is that after returning from Africa, I was invigorated and energized, even with the jetlag. I felt what I did mattered, even if the overall impact was small, and I left the continent fulfilled. Without question, Africa gave to me above and beyond whatever service I provided there.

This was the practice of medicine, pure and unadulterated. Documentation was limited to a patient’s name, age, and (occasionally) their diagnosis and prescribed course of treatment. The idea of follow-up was, for the most part, laughable. Following is a list of issues about which concern was simply nonexistent: metrics, meticulous documentation, exposure to litigation, post-visit surveys, narcotic overuse and dependence, difficult consultations, worry over patient complaints, hitting core measures, whether the EMR will crash again, and a thousand other issues.

Here’s the list of issues that did warrant our concern: The patient in front of us. And the hundreds in a line behind her. This was undeniably liberating, and confirmed for me that I made the right choice of career and specialty; the challenge now is to hang on to that perception with all I have. Until, at least, I get to go back.

Acknowledgements

• Staci Lofton, RN, Stephen Harms, RN, and the rest of the medical team from New Beginnings in Longview, Texas.
• Aimable Izere, Pastor Ezechias, George, and all of the Rwandan and Burundian students and translators who were invaluable to us.
• The Roots Network (therootsnetwork.org), a terrific organization working in Rwanda and Burundi to serve and transform the lives of the amazing people in Africa.