Reflections on Living and Working in Rwanda

by Kelly Everhart MS, MIV, Geisel School of Medicine 

Rwandan Ministry of Health

We landed in Kigali around 10 pm, 30 hours after leaving Boston Logan. The first thing I noticed about Rwanda's capital city were the lights — on approach to the airport, instead of the haphazard array of neon and LED lights I associate with US or European cities, we flew over thousands of yellow sodium and low-wattage fluorescent street lights. Few, very few, lights fell outside of the linear arrangement lining (some of) Kigali's streets — I later learned that the homes which do have access to electricity conserve it tightly, since electricity is an expensive commodity here.

The second thing I noticed blew in through the aircraft's open doors once we were parked on the tarmac — smoke, the smell of a whole city's cooking fires. But, coupled with the many military and policemen carrying semi-automatics patrolling the airport and the history of the 1994 Genocide I had finished on the plane, the smoke elicited apprehensive thoughts in my mind, so incongruent with the friendly hospitality I now associate with the same smell.

I have been in Rwanda for 5 weeks. This is my first visit to Africa — I have lived in Rome, traveled extensively in Western Europe, taught geology in Iceland, and avidly listened to global health narratives that many of Geisel's faculty weave into their lectures. I am grateful to the many kind travelers who gave me very simple advice before this trip: come with an open mind (and don't ride the motos or eat buffets — risk management). Wise words — every day, I am challenged, over stimulated, impressed, made humble, made joyful, motivated and moved by the deep relationships that develop between people with a shared purpose.

I have spent all of my time at  CHUK and CHUB, two of the four referral hospitals in Rwanda. Although they serve all patients, they tend to be frequented by those who cannot afford care at the newer facilities. At these hospitals, nurses are in short supply, and so family members are tasked with the daily care of patients — bathing them, cooking for them, feeding them, obtaining their medications, and in many instances, administering the medications themselves. Two of the most touching scenes I have ever witnessed involved these relationships. In Butare, prisoners — identified by their bright orange or pink cotton clothing - are frequent patients due to the local prison. A patient prisoner is accompanied by a (relatively) healthy prisoner, who wears a cap with a red cross on it, and functions as the admitted prisoner's family member. Reflecting on the handful of occasions I've spent time with American prisoners, I was wholly unprepared for the gentle, thoughtful, and thorough affect and behavior of both prisoners. Similarly, in Kigali, I was on Rounds when I noticed a patient who we knew had no family or friends vomiting in the corner. Before anyone on our team could react, a family member from a nearby patient calmly "adopted" our patient - and cared for him (in addition to her own family member) for another 20 days.

One of the most challenging things I've experienced so far is sensory overload — smell (the only sensory modality that is not gated by the thalamus, meaning smells shoot right from the nerves at the top of your nose to your cortex, no signal modification or attenuation — the odors of illness can be rough), touch (people are always touching you, or you are in very tight quarters), sound (from continual "muzungo!" — white person! — to heavily accented French or English that you really, really want to understand but can't seem to, to competing radios playing football games, American pop, Rwandan politics), sight (so, so much to learn if you look around — and important to avoid oncoming traffic that does NOT yield to pedestrians), taste (leaded gasoline has a peculiar taste when you breath in fumes while walking along a road).

The challenge is no so much tolerating the uncomfortable as making sure that the uncomfortable does not block the wonderful — smell (Rwanda is covered in flowering trees that smell delicious, afternoon rainstorms, the cooking fires), touch (cool breezes run through the open hospital windows, Rwandans give very firm and friendly handshakes), sound (sung prayers coming from open windows, heavily accented French or English that you DO understand, Kinyarwanda phrases I know, "Yesssss, Good Morning!" shouted by school children when you ride past), sight (Rwanda is a country of steep, green hills and open skies with villages and mountainous lakes tucked in between, smiles, or the lifted eyebrows that took me 3 weeks to pick up on as a signal of approval), taste (grilled goat and fish, Rwandan coffee and tea).

All of which encompasses the daily work to be done. I came to Rwanda under the auspices of the Human Resources for Health program, which is mandated to establish a sustainable medical education system in Rwanda, delivered by Rwandan physicians, by the end of 2018. Although I have spent about half of my time in the clinical context, participating in the care of Rwandan patients and teaching physical exam skills to younger Rwandan medical students, the most meaningful work that I have done so far has been working with Rwandan medical residents on their research theses. By the end of their residencies, PGY4s (the top of the medical education heap) are required by the Ministry of Health to complete a scientific thesis of primary research pertaining to Rwandan health care. Written in English (English was made the official language of education, business, etc in 2009 — prior to that time, Rwandans learned French and Kinyrwanda), these theses are graded by officials at the Ministry of Health; a passing grade buys you a ticket to specialty training, a coveted and prestigious opportunity. Not only are the residents writing an entire thesis in a new language, they do so without the benefit of an education that taught the Scientific Method, statistics, the ins and outs of evidence-based science and literature, the ethics of intellectual property (think plagiarism), Word, Excel, SPSS. In tutoring these residents one-on-one, I couldn't help but recall Sir Thomas Moore's Utopia: you first make a thief, and then you punish him. It took some dedicated exploration of the context of each resident's background and current lives (they have an truly astounding amount of responsibility) for me to develop real compassion for blatantly cut and paste passages, improper data collection, etc - but it didn't take me any time to be profoundly impressed by the motivation and intellectual acuity of these physicians. Out of these relationships, I am working on a mini-curriculum to be delivered to the rising PGY4s early on in their theses, hopefully while I am still here in Rwanda.

A few other observations:

When a Rwandan says "No problem!," what they mean is: "I acknowledge the fact that you have spoken to me," which should not be mistaken for "yes," or "I agree," or "that sounds like a good plan." Alternatively, a prolonged sound in the back of the throat (ironically, the sound that Americans make when they want to acknowledge communication without indicating an opinion), is an affirmative.

Rwandan children are the most playful kiddos I've ever encountered. Running and riding bikes through villages (neighborhoods of concrete and brick residences both in cities and throughout the countryside), you collect an entourage of excited children who happily practice English, mimic you when you skip, gallop, or hop like bunny, or just run alongside of you for a while, giggling for no apparent reason other than the joy of company (which I share!). They also seems to really, really like watches.

The generosity in this country knocks my proverbial socks off. Our medical team has had the privilege of numerous invitations to visit Rwandans in their homes; even with very limited resources, their hospitality is overwhelming. And generosity in these scenarios is synonymous with a strong and vibrant community of family, friends, co-workers, neighbors - that I hope to take back to the US with me as an ideal structure for relationships in my own life.

I am so looking forward to the three weeks I have remaining here in Rwanda - three more weeks of serious learning (approaching paradigm shift), deepening relationships, making future plans, and the happiness and fun of shared purpose.