Back to the Field

Before I arrived, I had heard Rwanda referred to as "The Land of a Thousand Hills."  Now that I've been here a month and spent some time in the countryside, I can definitively say that "thousand" is a serious underestimate and "hills" a misnomer that misrepresents the steepness of the rises.  Because of this rugged landscape, there is hardly a straight, level road in the country (or at least, the western half).  If you have a fear of heights, get carsick, or have recurring dreams about driving off the edge of a muddy cliff and falling a few thousand feet to your death, Rwanda is not for you.

However, I currently have none of those problems, so when my office suggested that I spend a week doing site visits to health centers in the northwest corner of the country, I very happily agreed to do so.  After spending three weeks running around to "H1N1 Emergency Task Force" meetings and updating epi-curves, I was quite excited to get back to the field, meet real people, and get a true understanding of the challenges facing the Rwandan health system.  I spent most of my time in Cameroon doing sites visits (over two dozen of them), often walking (through calf-deep mud) to remote clinics and spending a few days observing the work being done there.  More than three years of graduate school, it was these visits that gave me an understanding of the difficulties of providing health care in extremely resource-poor settings and an appreciation of the dedication and perseverance of the providers who work under the most challenging of conditions. (For more on my experiences researching the Cameroonian health system, check out my posts from summer 2008.  Spoiler: A baby gets named after me.)


The purpose of our four-day excursion was to conduct an assessment at small health centers around the country.  There were a half-dozen three-person teams doing this exercise, each with representatives from the CDC, the Ministry of Health (MOH), and the NGO currently supporting/managing the health center.  Some teams were based in Kigali, but most were out in rural areas in the western half of the country, along Lake Kivu.  My team was based out of Gisenyi, a stunning, what-passes-for-touristy-in-Rwanda town right on the lake and a stone's throw from the city of Goma in the Democratic Republic of Congo (DRC). (See map at right.)  Gisenyi lies in the shadow of Nyiragongo, a still-active volcano which last erupted in 2002, killing 45 people in the DRC.  It's also 60km from the jumping-off point for gorilla tracking, which is what makes it semi-touristy.

We began our excursion on Tuesday morning.  Although Kigali itself is characterized by its many hills, windy streets, and greenery, the moment you leave town all that becomes much more dramatic.  The mountains are taller, the roads full of hairpin turns, and the land incredibly lush.  There were stunning panoramic views of hundreds of hills, with low-lying early morning fog nestled in deep valleys, and a brilliant pink sky, but what amazed me most was that seemingly every square inch of land was terraced and farmed.  Given that some of these hills appear nearly vertical, this is quite the feat of engineering.  But it also speaks to the scarcity of land here in Africa's most densely populated country, as well as the devotion of people to their land.

Along the four-hour drive there were the standard scenes characteristic of Africa: skinny elderly men in suits riding bicycles, women who look as old as time carrying huge loads of firewood on their heads, small children in faded, tattered cast-off American clothes swinging mini-machetes on the way to the field, babies strapped to their mothers' backs, peeking around for a glimpse at their siblings.  In some ways these scenes are reassuring, a reminder of previous time spent in Africa, and from the comfort of an A/C, moving car, its easy to romanticize the life of Rwanda's rural population.  But the moment you step from the car into the blazing, dusty heat of town or the bitter chill of a mountain-top village, or haul a bucket of water up a hill or cook in the dark over a smoky wood fire, you realize that life is extremely difficult for most people in the developing world, regardless of how "simple" it may seem.

But I digress.

Most of the main road between Kigali and Gisenyi is quite good, although given the large number of petroleum-carrying trucks that alternately bring traffic to a grinding halt (uphill) and fly past dangerously close at high speeds (downhill), perhaps it would be better if it wasn't just one lane.   However, the non-paved, dirt/mud tracks out to the health centers are typically crater-laden.  The resulting ride is so bumpy and jarring it makes you wonder if you can get shaken baby syndrome as an adult.

After visiting one health center halfway between Kigali and Gisenyi on Tuesday, we came back to Kigali for the night.  The next day, even earlier, we set off once more. Four hours later we meet up in Ruhengeri (see map) with some team members who had decided to stay out in the field the previous night. Ruhengeri is the last major town before the Ugandan border and, like Gisenyi, is a hub for UNHCR (United Nations High Commission for Refugees) food distribution.  It was around 9am when our two cars meet up on the main road in Ruhengeri.  Given that the people in the area are very used to the presence of wazungu (white people) in the form of UN workers, what garnered us considerable attention was that a bunch of wazungu poured out of two giant SUVs, ran in circles around them, and then piled back in within a couple minutes. Kind of strange behavior.

For the next few days we drove from one health center to another, with my team covering seven.  I know that doesn't seem like a lot of four days of work, but when it takes 3 hours to drive there and two hours to conduct the assessment (with most of that time spent combing through hard copies of various work plans and performance indicators), it was a fairly productive week. And quite frankly, I'm not sure I could have taken much more, given that I saw my life flash before my eyes numerous times during the week, as our car perched perilously over the edge of cliffs and we stared down into the valley a few thousand feet below.  One slip of the wheel on the mud road, one moment of distraction from our 19-year old driver John, one rickety plank in a makeshift bridge and I wouldn't be here right now.  I spent most of these hours alternately calculating the time it would take for a car to plunge 4,000 vertical feet and trying to calm myself down, arguing that if my three other teammates (who had 8 young kids between them) weren't fearing for their lives, neither should I.  Can't say I succeeded in either venture--neither physics nor self-hypnosis have been strong points of mine.  However, to my great surprise, we reached our sites safely and I was on occasion able to appreciate the stunning vistas, daring to look down from the ridge line at the lush, undulating green blanket that is Rwanda.

Overall our visits went well.  Given that most of it was conducted in Kinyarwanda, my job was mainly to check off certain boxes on the assessment when told to, and to smile and seem less like a scary USG official and more likely a helpful ally in the fight for quality health care.  I think I was more successful at the first task. Even though most of the conversations with the health providers was lost on me (15 minute discussions in Kinyarwanda were translated into "He says yes" or "She says no" summaries), I was able to learn a tremendous amount about the logistical, financial, clinical, and management challenges facing the facilities.  Its always amazing (and inspiring) to me how people who may have had very little education, whose pay is 6 months delayed, who are caring for hundreds of patients a day, who are still keeping their records on paper, are able to provide efficient and affordable health care to so many people.  No, it may not be of the quality we expect in American hospitals, but if these providers were unwilling to fight through these conditions, there would be no health care at all in most of the developing world.  Sometimes I wonder if they can award the Nobel Prize in Medicine to "All the Overworked, Underpaid, Working-with-Insufficient-Equipment-and-Training Health Care Providers in the Developing World."  Schmaltzy I know, but no more ridiculous than Obama getting the Peace Prize after less than 9 months in office (and I voted for him!).

But I digress.

There's no need for me to get into the details here, but here's a quick summary of what I took away from these site visits.  One, many of the problems providers face are created by donors (USG, Global Fund, etc) and their endless reporting requirements.  Yes, we have an obligation to make sure tax dollars are going to good use, but when clinics have to maintain their accounts by hand, quarterly reports become a giant time-suck. Two, the "long-run" isn't something most providers think about.  They don't have time to consider strategic plans or sustainability measures-- they are too busy contending with challenges in the short-term.  There are babies to be born, malaria to be treated, HIV to be diagnosed; developing five year performance targets doesn't rate high on their to-do list, and rightly so.  Three, people here desperately want to gain skills and become more efficient, since they know that one day soon (thanks to the requirements of PEPFAR II), they'll have to do everything on their own.  One clinic asked us to write down all the things we thought they could do better.  Most of our suggestions had to do with management and documentation, since those are areas where providers lack skills.  Being a good clinician isn't enough anymore, in any part of the world; you must also know how to run a facility, but I don't know of a medical program anywhere that teaches that.

So that's the work side of things.  I can't say I did too much fun, personal stuff on this little trip.  By the time we got back in the evenings and my heart rate came down to normal, it was time for dinner and bed.  But on my last night in Gisenyi one of my teammates, who was working for the NGO partner, invited us to his house for the evening.  My wazungu colleagues and I went over to his house around 7pm, when pitch blackness has settled over Rwanda.  (This is the problem with being on the equator- very clearly demarcated hours of sunlight: 6am to 6pm.)  After standing outside near a light and getting attacked by moth-dragonfly hybrid creatures, we went inside, only to be surrounded by hundreds more.  They didn't seem to be bothering the 15 local people there, but we started killing all of them insight with our bare feet-- probably not the most appropriate thing to do, but one of my colleagues had a phobia of bugs.  Following greetings, drinks, and speeches, it was "time for the babies."  I knew my teammate's wife had recently had their second baby.  I didn't realize that "recently" meant one week ago.  The poor infant (who had a surprising amount of hair) was plucked from his crib and passed around, followed by his 14-month old sister.  Although being attacked by bugs, feeling disoriented from having been discourteously woken up, and being forced to pose for pictures with wazungu, the little girl was incredibly adorable and sweet, if just a little grumpy.  Who could blame her.


(My teammate was embarrassed by the closeness in age of his children, since so much of the reproductive health messaging here, with he is a part of, focuses on birth spacing.  Its a complicated campaign, but the logic, in short, is if children are spaced further apart, they are healthier and more likely to survive past age 5.  When I told him that my brother and I are only 16 months apart, he seemed to feel much better about things.)

When we finally completed our last site visit on Friday and started heading home, I was sad to go.  There is so much about public health that is impossible to learn sitting behind a desk (not that I've sat behind mine for more than 5 minutes since I got here).  Being able to put a face to the name and a context to the services is invaluable. Readjusting expectations to coincide with local realities is a part of public health that I think often gets overlooked by policymakers.  I know I now have a much better frame for understanding the Rwandan health system and a deeper appreciation for how far it has come from its devastation 15 years ago.    

You can check out all pictures from my trip to Gisenyi at http://www.facebook.com/album.php?aid=2144120&id=1012910&l=5e4d1d2b9c.  There are more landscapes, more health centers, more people, and even me pretending to change a flat tire.