This is one of the three districts where Partners in Health are heavily invested with the Ministry of Health to improve the quality of health services since 2005.  Building intensive monitoring and evaluation, topping off salaries of MOH health workers to incentivize them to stay in the public sector, training community health workers, nurses, physicians to elevate the overall quality of health care provided. 

 

These last couple weeks I have rounded with the Rwandan docs on the Internal medicine wards, scrubbed into a couple emergent Cesarian sections and lectured/led discussions in the morning on various clinical topics to the Rwandan staff.  I am trying to implement small QI projects to improve overall delivery of care.

 

It is memorial week for the genocide. The hospital is busy, even though it is running at lower capacity than usual.

 

It is not yet a viable system.  Biopsy stains are read at the Brigham. Pathology slides are ad hoc transported on the next person leaving to Boston.  CT scans obtained in Kigali are file shared with a kind radiologist in Nevada huddled in some dark room across many oceans.  

 

But it is a subtle shift, that the MOH and PIH have been able to start: for the Rwandan health care staff, for the patients in this district, for their families who are either poor, or very poor.  A slow spread of human dignity passing over the country. 

Of course it sometimes feels like a zero sum game. There are so many chronic diseases that need complicated care.  We have 4000 dollars in our right to health fund every month. For things like radiation in Nairobi, or chemo for a kid, or a CT scan at a private hospital in Kigali for a patient who we don’t know what is going on. 

 

Psychological breaks, PTSD, reliving collective grief this time of year.  It is hard to fathom what this country went through.  One of the Congolese docs working  here said at breakfast yesterday -- “After what happened in 1994, death is nothing for Rwandans.  It is not a shock. For family of patients death is to be expected and endured.”  

 

It seems to me in my short time here, that is slowly starting to shift.  The long night’s journey into day has already began.  The atmosphere in this hospital, the commitment of the Rwandan staff, the fairly well organized MOH, and Partners in Health are all raising expectations of health care for the poorest of the poor in this district, and with time, hopefully throughout the whole country.  Rwandans are pretty far away from passable health care in a sense of the word most of us would conceive of. 

 

But slowly by slowly into the future, death from really dumb treatable diseases might happen not so often in Rwanda.  And from slightly less dumb diseases that require a degree of infrastructure and sophistication, a little less often than now.  Putting back on the table health care that never ever existed and offering it up for especially the most vulnerable Rwandans.  It is hopeful to watch.     

 

At least in this district(there are many where PIH has not expanded to yet) the “inviolable territorial borders” that were not penetrated 17 years ago to help stop the genocide, are being penetrated by a cohort of international health professionals in solidarity with the Rwandans.  Dedicated in the long term, integrated into the public health system of Rwanda, working alongside a functional ministry of health.   It is hopeful to be among them.