Wednesday, March 30, 2016

Improving Access to and Safety of Anesthetic Care in Rwanda through Education Part 1

Elliott Woodward, MD
Resident in Anesthesia, BWH

I firmly believe that one of the most important factors in determining the efficacy of a medical trip abroad is how much one understands the history of the place being visited and the cultural context of the care that is already being delivered there.  With that that in mind, I spent what little free time I had in the weeks leading up to my trip to Rwanda learning everything that I could about the country.  I was lucky enough to be accompanied on this adventure by a BWH anesthesia attending named Stewart Chritton who had spent a year living and working as an anesthesiologist in the capital city of Kigali two years prior to our trip. 

Through discussions with Stewart, informational material from the Canadian Anesthesiologist’s Society International Education Foundation or CASIEF (the organization that I would be working under during my time in Rwanda), books such as “Land of 1000 Hills”, and published materials on the Rwandan anesthesia residency, I learned what I could before leaving.  Shortly after arriving in Rwanda, I supplemented this knowledge through an early visit to the Genocide War Memorial in Kigali and discussions with locals employed by CASIEF.  In this way, I began to build a more nuanced picture of Rwanda, its history, and the task that lay ahead of me as a visiting educator for their anesthesia residency.

Rwanda is a small country in the Great Lakes region of Africa with a population of ~11.8 million inhabitants.  It is difficult to understand much about this country, including the current state of anesthetic practice, without referencing its tumultuous past and the genocide that took place within its boarders in April of 1994.  The events leading up to the genocide are complex, with their origins tracing back to as early as the 1880s at which time the country was first colonized by Europeans.  Under German and then Belgian rule, the native population was divided into what would later be classified by many as ethnic groupings based largely upon socioeconomic status (how many cows someone owned) and physical characteristics such as height.  

Over the subsequent decades, tensions between two of the major groups that were created (the Tutsi and Hutu) increased as foreign influence favored one group over the other in an effort to maintain control over the country.  Ultimately, after the nation gained independence from Belgium, the Hutu violently revolted against the minority Tutsi population who had previously wielded much of the power in the country and had actively suppressed the Hutu.  This resulted in the expulsion of more than 100,000 Tutsi to the neighboring territories now known as the Congo, Uganda, Burundi and Tanzania.  

The majority of these displaced individuals remained refugees for years as conflict continued between the ruling Hutu in Rwanda and military forces primarily composed of the expelled Tutsi and their families.   Refugee forces and their supporters joined to create a group known as the Rwandan Patriotic Front or RPF which was ultimately led by a man named general Kagame.  This group fought ongoing discrimination and violence against the Tutsi that remained in Rwanda and for the opportunity for those that were displaced to return to their home country.  Conflict between these groups culminated in the genocide of 1994 when a government-led extremist group called for the death of all Tutsi and Tutsi-supporting Hutu that remained in the country.  Approximately 500,000 – 1,000,000 million men, women, and children were killed in a matter of 100 days before the massacre was finally put to an end in July 1994 by the advancing RPF.
  The country was torn apart by the genocide and it took some time before it could begin to rebuild and provide services such as medical care.  In fact, in the years immediately after the genocide, there was only one anesthesiologist for the entire country.  Out of necessity, individuals that are now known as anesthesia technicians stepped up to meet the anesthetic needs of the people.  While many early practitioners learned experientially, the field ultimately evolved to its current state, requiring three years of specialty training after high school in order to qualify to practice.  While this group has provided an indispensable service to Rwanda since its inception and still provides the majority of anesthetics in the country, the limitations associated with the brevity of their training remain clear.  In fact, after arriving, I was told of two completely avoidable intraoperative deaths that occurred shortly before we started because a technician didn’t fully understand the risks associated with provision of anesthesia for their patient.

       Rwanda recognized long ago the need to increase the number of practicing anesthesiologists in the country in order to keep patients safe during the perioperative period.  Efforts to boost numbers through sending physicians abroad for training were complicated by poor rates of repatriation.  With this in mind, the Rwandan government approached the Canadian government and ask for help creating a Rwandan-based training program, hoping that graduates from this program would be more likely to stay and practice in Rwanda than their foreign-trained counterparts.  The Canadian government agreed and, with the joint support of the American Board of Anesthesiology (ABA), CASIEF helped to establish a Rwandan anesthesia residency which opened its doors in 2006. 

It was with significant input from North American sources that a curriculum was developed for the anesthesia residency in Rwanda, a curriculum initially taught primarily by foreign physicians.  From the beginning, however, the ultimate goal of CASIEF has been to create a system that is capable of training residents in Rwanda without outside support. 

  To this end, CASIEF paired visiting physicians with local providers and, over the years, there has been a transition whereby visitors have moved away from the role of primary educator to one where they supervise/support teaching by local doctors.  This tactic has also been adopted by Rwandan Human Resources for Health (HRH), another organization that was established in order to “lay down the blueprint for guaranteeing long term equitable access to high-quality medical care and education” and has been helping CASIEF to educate the Rwandan residents over the past few years.  (As an aside, I am proud to say that the Anesthesia Department at Brigham and Women’s Hospital has played an important role in many of the successes that these organizations have achieved as multiple resident and attending volunteers have served as volunteers in Rwanda through HRH and CASIEF over the years.)

Currently, the residency is structured so that each Monday is an “academic day,” where residents are entirely free from clinical duties with their day instead filled with didactic lectures, case reports, and simulation-based training.  In terms of didactic education on Mondays, visitors working with HRH are responsible for what has ultimately been labeled “foundations,” a year-long introduction to anesthesia for first-year residents which covers the breadth of intraoperative anesthesia practice through what is largely a systems-based approach. CASIEF visitors such as myself on the other hand are responsible for facilitating a similar course for the senior residents called “core curriculum”.  With this structure, residents cover material multiple times over the course of their residency, with the intent that the depth and sophistication of their grasp of the material increases each time that a subject is revisited.

With the above in mind, I gathered my things to head to the hospital on the first Monday after my arrival.  As I walked through the crowded streets leading to work, I remained eager to determine the best way to contribute during my short time in Rwanda, and to see what things I too could learn about the practice of anesthesia from this group of people whose perspective on medical care was inevitably so much different than my own. 

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