Friday, April 29, 2016

The Tangled Pair: Implementation Science and Service Delivery in Chiapas, Mexico

Rose Molina, MD
Fellow in Global Women’s Health, The Connors Center for Women’s Health and Gender Biology, Brigham and Women's Hospital

Rose Molina (Global Women's Health Fellow) and
Carolina Menchu (Professional Midwife) in
Laguna del Cofre, Chiapas
As part of my Global Women’s Health Fellowship, I have collaborated with Partners In  Health/CompaƱeros En Salud (CES) in Chiapas, Mexico in implementing and evaluating the impact of a rural maternity center in providing peripartum care for women with low-risk pregnancies. I traveled to Chiapas for 2 weeks in March as part of this ongoing collaboration over the course of my two-year fellowship. As I reflect on this project, I have realized that there are several challenges in the relationship between service delivery and implementation science. However, overcoming these challenges is essential for both teams to achieve their ultimate goal in improving health outcomes and being able to demonstrate impact in our context in Chiapas.

Implementation science has been defined as “the study of methods…to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions” with the intent “to investigate and address major bottlenecks (e.g. social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.” Along with adaptive trial designs, implementation science has become a buzzword in global health research. It occupies a space on the continuum of monitoring and evaluation (M+E) for internal organizational needs and rigorous research for knowledge generation. Purpose, funders, and resources determine its location on this continuum.

OB ultrasound course in Jaltenango, Chiapas
Global health work encompasses many levels of direct patient care, program analysis, and policy change. One of the central goals in global health work is to demonstrate the impact of interventions and scale up the successful ones in a sustainable way. This is where implementation science is needed. Decision-makers and funders need high-quality data to decide what programs to fund for scale-up. Questions that need to be addressed are 1) What types of data are needed to influence health policy makers and funders to improve health systems? 2) How should meaningful impact be defined for a given intervention? The purpose of implementation science research is to measure the impact of how a program or intervention is designed and carried out. This requires close collaboration between the research team and the team designing and implementing the program, as each informs the other. Good implementation science is iterative, reflecting and evolving with program development. One example of how we applied a research lens to program development was the process of integrating respectful maternity care into existing best practices and developing systems to evaluate these new indicators in our rural maternity center.

Despite the need for implementation science research, little or no infrastructure exists for this purpose in many resource-limited settings. Limited mentorship from personnel experienced with this type of research is another challenge. Furthermore, where limited funding exists, resource allocation may place research priorities further toward monitoring and evaluation on the continuum, which may have implications for generalizability and potential for scale-up.

Maternity center in Revolucio'n, Chiapas
While I was in Chiapas for this recent trip, I had the opportunity to participate in both the service delivery and research teams. With regard to clinical teaching and supervision, an OB/GYN resident and I led a basic obstetric ultrasound course for the general physicians in CES. We performed approximately 35-40 ultrasounds on pregnant women in 4 communities, and we saw the physicians’ skills improve in a short period of time. With regard to research, I helped develop M+E indicators and research protocols that evolve with the changing scope of the project. As I continue to work on this project in Chiapas, my goal is to ground my research in ongoing clinical activities, which can then provide continuous iteration in how the research can best adapt to the clinical reality of the maternity center. This experience continues to shape how I understand implementation science research within an organization dedicated to providing excellence in primary care in a challenging, marginalized environment. Lessons learned from this experience have been invaluable in further developing my career in global health research.

Mexico (Chiapas): Medical Experience

Kaysia Ludford
Resident in Internal Medicine
PGY2, Brigham and Women's Hospital

This spring, I traveled to Chiapas, Mexico to work in rural communities cared for by CompaƱeros en Salud (CES), an NGO of Partners in Health. CES has been in the state Chiapas for about 5 years, currently supporting 10 rural clinics in the Sierra Madre region of Chiapas, located in the southern most part of Mexico, abutting Guatemala.  The organization has partnered with the Ministry of Health in Mexico to select 11 “pasantes”: physicians who have just completed their last year of medical school to work as primary care physicians in these clinics during their mandatory year of service. All medical school graduates are required to do this year. The pasantes tell me that oftentimes, most graduates (especially those with higher grades who have more luxury of choosing) opt to stay closer to home in urban areas if they are from big cities or try to go to work in big cities . Graduates from more rural locations also try to go to bigger cities as well as this opens more opportunities for jobs and fellowships after the year of service is over. As a result, communities like those in the sierras of Chiapas which are rural and poor have typically struggled to recruit highly qualified and eager pasantes to work there. All that has changed however since CES implemented its program there.  Among the many things the organization does are its provision of logistical, material and education to the providers. The organization sponsors 10 clinics, three of which I was fortunate to work in during my month there.

Lugana del Cofre, from left to right
 pasante extraordinaire Sebastian
 Each clinic has one pasante who is responsible for providing medical care for the local community (about 1500-2000 people in each place) for one year. CES supports the clinic with medications for a range of illnesses ranging from depression to infection. This supplements but does not overlap with the supply stock provided by the Ministry of Health. Additionally, CES has formulated a training curriculum for the pasantes. Every month all 10 providers come together at the organization’s headquarters for 4 days and receive courses in global health/social medicine and general medical topics and ones unique to practicing medicine in resource-poor settings. As part of that training CES also has frequent volunteers from different residency programs in the US who travel to the communities and work with the pasantes for 2-4 weeks providing additional support and help with reasoning through and making medical decisions of patients attending clinic. It was in this context that I traveled to CES and to Mexico. I worked in 3 communities Reforma, Laguna del Cofre and Soledad, each very similar but at the same time very different from the other.

Throughout my time working in these communities with the pasantes, I was most struck by the genuine care and tenderness with which each of these young doctors treated their patients. Because they lived in the communities 24/7, leaving only for the course with CES each month, they knew their patients intimately in a way I have not seen while practicing medicine in the US. Patients would routinely invite me and the pasante into their homes to share dinner (on one occasion we had a delicious posole chicken soup), to hang out with their children or just to chat. The beauty of having that sort of relationship is that it fosters a sense of trust and understanding that is hard come by behind the confines of an office desk. As a result, patients felt extremely comfortable going to the pasantes with even the most complex social problems, or knocking at their door at odd hours of the morning if someone became acutely ill. They were always greeted with a welcoming smile and kind words; the disadvantage to this being that the pasante is always on call and without ever having much opportunity get a mental and emotional break from the role of “doctor”.  The other thing that struck me was the great lengths to which pasantes go to advocate for their patients. When I was in Laguna del Cofre for instance, a 40 year old woman was taken to us by her family, lethargic, anorexic and insomnic for more than a week. The paperwork that accompanied her showed that she had developed acute and persistent renal failure over the previous few months with the kidneys functioning less than 5% of normal.

We suspected that her renal failure was the reason why she had no appetite, was lethargic and had swelling in her legs and fluid in her lungs and that she urgently needed to be hospitalized to undergo further testing. Recognizing this, the pasante re-scheduled all our remaining patients in clinic that day so we could travel two and a half hours to the nearest hospital with this patient. Once we arrived we were met with resistance by the hospital team there as they did not have the necessary tools to take care of the patient and felt they would not be able to offer much:  no equipment to check her basic labs , EKG to check her heart function or dialysis to remove the toxins that had built up in her blood from her failed kidneys. The pasante cajoled, argued and negotiated with the staff opting to pay out of pocket for the necessary lab tests for his patient that night. Together we came up with a plan for her care there, the pasante wrote the admission note and thankfully because of his herculean efforts, she was admitted and fluid diuresed off her lungs significantly improving her breathing.

Overall I was inspired by my experience in Mexico to see ways in which dedicated physicians are making strides in improving individual lives and the health of whole communities with limited resources. I feel encouraged and excited about my own journey to strengthen and improve care in marginalized places in my home country of Jamaica. 

Mexico (Chiapas): The Social Experience

Our host family's home in Reforma

Kaysia Ludford 
Resident in Internal Medicine, 
PGY 2  Brigham and Women's Hospital

One thing that struck me in the communities I stayed in was the simplicity of everyday life and how people seemed to be able to make themselves content without many of the normal conveniences or distractions we have come to depend on in our busy life here. Being there reminded me of my childhood days growing up in Jamaica where life was simple but refreshingly good because the ingredients to being happy were simply being around family and being able to meet basic needs.

The first home I stayed in was shared by a multi-generational family. In one house, the grandparents and their unmarried children occupied two rooms. A shared living room connected them to a second house. In that home, lived their married son, his children and grandchildren. All members of both households shared a yardspace connecting the two homes and an open outdoor kitchen, ensuring that they were constantly visible to and interacting with each other. Mealtimes were always abuzz with merry chatter, peppered by clanging utensils as both sets of families laughed and shared fond memories and jokes over tortillas and beans. Looking on it was clear that a strong bond of love cemented the family and that despite their limited resources they seemed happy. I began to wonder whether it only appeared that way to me because I was an outsider who was only seeing one side of the story but not the struggles and frustrations that certainly were also present. I thought back to the US and to my life there and that of my friends in academia and our never-ending quest for more: more training, more knowledge, more experiences, more ways to contribute to improving the world. For many, achievement of these things equaled success and by extension happiness. In Reforma, it seemed to me that having a family and being able to feed them was what gave satisfaction and meaning to life. In my mind I saw it as two different ways of seeing the world, neither better than the other, just different. I was curious to dig deeper though. I asked my24 year old host brother, Pablo* about it. What was it that made him excited in life. What were his hopes and dreams.
Pasante (Reforma) Gerardo

In some ways I was surprised by his answer. He shared with me that what gave him greatest joy was being with his wife and watching his children, 2 and 8 months grow up. However, his ultimate dream was to somehow find a way to cross the boarder to go to the United Stated to live for a few years so he could earn money to give his children more opportunity than he had. When he finished junior high, the high school had not yet been built so he completed his education at 9th grade. 

He wanted his children to go to high school. But not just that, he wanted them to go to college. He wanted to learn how to use the internet because he believed doing so would give him access to more knowledge and more leverage to help set up a coffee cooperative in the village where he would be able to sell organic coffee directly to foreign buyers, individuals, without using a middle man to sell to the catchment stores in the nearest town as they now did. That way, he explained, it would maximize profit paving the way for the town to further invest in infrastructure and machinery to process its own coffee ultimately ensuring more of the profit stays in the community. He loved farming, he shared with me, and would want to stay in his village growing coffee all his life; but he had children and he wanted a different life for them. 

He was not unhappy with his life, just wanted more. It struck me how similar he now seemed to everyone else around me in the academic world. Of course there were important differences but ultimately he wanted the same things as most of us do: to improve his community and to provide for his loved ones. His life was simple; he was happy; but he had a vision and a hunger for more. This realization was important for me personally because it reminded me of and re-enforced in me of what I perceive as my purpose in life. To pave the way to open doors and opportunities to make the dreams of people like Pablo, people like myself from places of limited resources possible. I am still navigating just how to do that in the world of global health. But I am inspired to keep working at it to help open up the possibilities for other.

Thursday, April 28, 2016

Perspectives from an Urban Slum in Beirut, Lebanon Entry 2

Lara Jirmanus, MD, MPH
Second-year Global Women’s Health Fellow, Brigham and Women’s Hospital

April 6, 2016
Carrying trays of pastries and bottles of juice, my research assistant Micheline and I walk into the offices of the non-governmental organization (NGO) for a community meeting to discuss the trash.  A pile of waste sits at the top of the street near the clinic. Garbage was a primary health concern of residents in this slum, but we eventually discovered that the issue was fraught with local politics and conflict.
When we asked women in focus groups in March 2015 about causes of childhood illness, we expected to hear about asthma and diarrhea. But the first response was always the garbage.  The discussion would then take a negative tone, with people describing the problem as hopeless and blaming it on their neighbors. The Lebanese women would blame the Dom families, who lived in the worst conditions in the alleys below the clinic. The Syrian refugees reported being harassed and cursed at about the trash, and even having their children intimidated into taking out their neighbors’ garbage. Most of all participants would say that the trash problem cannot be solved without cooperation of all in the neighborhood. “’Eid wahad ma bi za’if,” or “A single hand cannot clap,” was a frequent phrase heard in the focus groups.
Underlying this lack of collaboration was another story, which only surfaced after I spent months building trust and conducting individual interviews with residents. In 2014, a landlord in the neighborhood removed the government dumpsters, to build two buildings, which he now rents to shop owners. The dumpster served the immediate neighborhood around the clinic.  Every morning, the government trash company, Sukleen, collected the trash from the dumpster, providing the only government service in the slum. While the neighborhood residents have no dumpster nearby, the landlord now collects rent from the land, which previously hosted the community dumpsters. The Sukleen truck still comes every morning to collect the trash from the informal pile on the street, which remains strewn with bits of waste, as residents have even stopped using garbage bags.
Over a year ago the Tahaddi NGO attempted to tackle the trash issue, recruiting support of the local government. The municipality was willing to place garbage cans around the neighborhood, but the residents were unable to agree upon where the cans would be placed. No one wanted a trash can to be near their home for obvious reasons, such as the smell and the mess. But resentment also plays a role. Allowing a trash can near one’s home would be tantamount to consenting to the initial injustice of having the dumpsters removed. While the current reality urgently begs a solution, with summer coming and a child in the neighborhood who was recently bitten by a rat, the resentment that an individual is profiting from rental properties, which instigated the local trash problem, remains a formidable obstacle.
It has been interesting to reflect upon the local trash crisis in this single slum, in the shadow of the national garbage crisis, which emerged over a year later. Lebanon’s garbage crisis has made international headlines since August 2015, when residents of the village of Naameh, where the national dump has been long overfilled, refused to allow any more trash to be deposited.  After national protests over the failure of the state to collect the trash, the Lebanese government eventually began depositing the waste in a makeshift dumps in Beirut suburbs. Residents of these areas keep their windows closed to shield themselves from the foul smell of rubbish. In March 2016, the Lebanese government negotiated an agreement to reopen the Naameh landfill for 2 months. Now as trucks now transport waste across the city, the sweet smell of rotting waste intermittently wafts through downtown Beirut, carried by the spring breeze.
The local problems in Hay el Gharbeh echo the national situation. In both cases the political leaders fail to make the needs of the population their top priority, privileging the interests of friends and allies.  Thus a spirit of non-collaboration trickles down to even the most mundane of issues, with real public health consequences. With these obstacles before us, one can see why it may be difficult to resolve a seemingly simple problem, such as the dumping of waste on the street.
Although in the beginning of the study in March 2015, conversations in the trash felt hopeless, by June, participants seemed more ready for action. I visited the members of the community board, in order to gain a sense of whether they would support a local trash initiative in June 2015, and people became enthusiastic about the idea of having someone come door to door to collect the trash. I then had to leave to return to my clinical position in Boston, but one of the men in the neighborhood approached the NGO after my departure with the intention of starting a local trash collection initiative. The NGO afterward noticed that the immediate area around the clinic was cleaner than it had been in months, in spite of the national trash crisis.
Upon my return, however, I learned that no trash collection initiative had begun, but rather two women, Rim and Nisrine, whom I mentioned in my previous post, had been sweeping the neighborhood. In addition one of the neighbors of the clinic receives daily payment from the Tahaddi clinic for sweeping the area. During my previous trip in January, Tahaddi contacted an international NGO, which agreed to help organize a local cleanup of the neighborhood. The purpose of our community meeting would be to create a plan for keeping the neighborhood clean, after the neighborhood cleanup scheduled for April 21.  
The meeting was attended by some 12 people in total, including Issam, one of the local Lebanese landlords, and women from each of the three social groups, Lebanese, Dom and Syrian refugees, as well as the Medical Director and Health Program Director of the Tahaddi NGO.  While in previous meetings side conversations had emerged with conflicts between Syrian and Lebanese participants, this conversation was perfectly civil and completely focused on the trash.  Furthermore, the Dom participants spoke in this meeting, although in previous meetings they sat silently. One of the secondary objectives of my study in the neighborhood was to foster collaboration among the various social groups, which is complicated in a neighborhood where they often find themselves in competition over limited resources.
After an hour or so of debate, the participants agreed that Issam, the landlord, would hire a man to collect the trash. He would go door to door and would take 5000LL or about $3 per month from each household to collect the trash twice a day. The NGO would furnish the initial cart, and all participants in the program would receive trash bags when they initially sign up and then they could go to Tahaddi NGO would supply them with used plastic bags to throw out their trash.
I then presented the plastic bag dispensers, which were sewn by women in the neighborhood. I demonstrated their use and announce that everyone who collaborates with the program would receive plastic garbage bags as well as a bag dispenser to store plastic bags which they can bring to Tahaddi to refill (See Image2c_Jirmanus). The eyes of the participants lit up.  Rima, a Syrian woman, whispered to the woman beside her, “I made that one.” Someone pointed and said, “I want the one with the Tahaddi badge.” There were three colors, blue plaid, red plaid and a pink one with flowers on it.
After the meeting adjourned, Issam excused himself and returned with two men, who agreed to help with the trash initiative. One would help to collect names and the other would collect the trash. As people left the atmosphere was hopeful. Everyone left carrying a bag of trashbags and a plastic bag dispenser.

A few days after my return to the US, I received an update from the Tahaddi Health Program director about our meeting.  Unfortunately, neighborhood residents who weren’t at the meeting were unwilling to pay for door-to-door trash collection, and the program never got off the ground.  Furthermore, the international NGO, which had offered to help with a neighborhood clean-up withdrew because of “security concerns.”

The area we work is not a war zone. The residents of Hay el Gharbeh live the daily violence of poverty. The violence of waking up in the morning and not knowing whether you will be able to feed your children. Of sending your sick child out to work or to beg because it’s the only way to make ends meet. Of not being able to fix the hole in the wall that the rats crawl in. Of not knowing whether your child will be caught up in an armed scuffle on the way home to a neighborhood where the police rarely set foot. Not as striking as bombs and guns, social and economic marginalization is insidious. Paul Farmer calls our work “the long defeat,” a never-ending struggle to promote the health of those that live at the edges of our societies.  But this phrasing fails to capture the joy of this work, the proud smiles of the women at the community meeting to see their sewing put to good use, the appreciation of focus group participants at the chance to reflect on their own needs and priorities, and the inspiration of working with dedicated colleagues, like the Tahaddi Health Program Director who regardless of setbacks, still wrote in her last communication: “Sorry for the bad news but we will keep on trying and trying. I haven't given up!”   

Perspectives from an Urban Slum in Beirut, Lebanon, Entry 1

Lara Jirmanus, MD, MPH
Second-year, Global Women’s Health Fellow, Brigham and Women’s Hospital

March 28, 2016
I walk down the familiar street in Hayy el Gharbeh, a few steps from the clinic of the NGO partner for my Community Based Participatory Research Project.  For the last two years, I’ve been traveling back and forth to this site, working with the Tahaddi NGO, which runs a clinic and an education center in the urban slum, less than a mile from Beirut’s international airport.
In 2014, I worked as a chief resident in the family medicine program at the American University of Beirut. I worked in the Tahaddi clinic and began brainstorming ideas about community health programs we might do with the NGO and a professor at the American University of Beirut.  We initially hoped to design a community health worker program and in March 2015 we performed an assessment of health beliefs and practices with women in the neighborhood in the hopes of designing a program tailored to their needs. 

The Tahaddi NGO was initially developed to serve all in the area, with a special focus on the Dom, the Middle Eastern Roma, who have a 77% illiteracy rate in Lebanon, as compared to the 10% illiteracy rate in the Lebanese population.   The Dom in the neighborhood live on less than a dollar a day, well below the Lebanese minimum wage of $450/month. Now the neighborhood is also inhabited by poor Lebanese families and increasingly by Syrian refugees. 

The living conditions are squalid at best. In winter rainwater turns the dirt roads into mud, which mixes with open sewage.  In summer the heat rots the garbage, and brings the rats. The Lebanese government doesn’t service this neighborhood, which is classified as illegally occupied government land, and so residents dig wells, which bring in salty water, and build their own sewage pipes or septic tanks beneath their homes.
In focus group discussions we asked about the children’s health and were told what we might have guessed. Mothers identify their living conditions as the greatest obstacles to children’s health: open sewage, trash-strewn dirt roads, drafty homes with zinc roofs, and a state of chronic insecurity, both physical and economic.
After we reported back our results to the neighborhood, some of the local women became inspired and began to clean up.  I returned to ask them about their intervention, which they did without my prompting.  I found Rim and Nisrine (names changed for the purpose of confidentiality) sitting on the wall across from Rim’s one-room shack. They explain to me that they started sweeping the road in front of their homes and the clinic for a month after our last community board meeting.  Inspired by the collective voices of the Lebanese, Syrian and Dom women stating that the environment was the greatest cause of childhood illness, they took it upon themselves to clean the neighborhood.  The NGO staff saw such a difference they thought the neighborhood had organized a door to door trash collection service.
Nisrine looks discouraged as she explains. “Sure, we were sweeping and cleaning up. But you know how it is around here. No one helps.  It was just the two of us, and after a month we gave up.”  Indeed, there doesn’t seem to be any noticeable difference. The ground is strewn with empty potato chip bags and candy wrappers, pieces of a cracker mixed with dirt and pebbles. A women whom I don’t know approaches to listen in, followed by her three-year-old daughter.  The woman watches disinterestedly as her daughter leans down to pick a dusty piece of cracker off the ground. 
“Don’t eat that,” says Nisrine to the child, “it’s dirty.” She nonchalantly rises to grab a broom and sweeps the crumbs and dirt to the side of the alleyway. Neither Nisrine, nor the child’s mother stops her from eating the first piece.  I think back to one of our first community board meetings. We had food at all the meetings and focus groups, and I recall the first time a child picked a pastry off the floor.  I opened my mouth to say, “Throw it away, it’s dirty,” but held my tongue as she stood between her mother’s legs, eating it happily, her mother smiling down at her.  Some of the children wouldn’t have had breakfast, if it weren’t for our meeting.

I reflect on the women’s responses to our focus group questions about how people keep their children healthy. Participants would mention hand washing and hygiene.  But what about when the social conditions prevent you from doing what you know to be correct? What about when you don’t have water to wash your children’s dirt-caked hands? At times we, as public health practitioners and physicians find ourselves teaching people to “keep themselves healthy” by making recommendations that they are unable to follow. These interactions may bring shame, or just a feeling of being completely misunderstood by a well-meaning doctor who knows nothing of their reality. In either case the physical environment looms insurmountable, perhaps to the point that it feels pointless to remove a dusty piece of cracker from a child’s fingers. 

Tuesday, April 5, 2016

Emergency Medicine Bedside Ultrasound Training CHUK hospital in Kigali, Rwanda Part II

Kristin Dwyer, MD, MPH
Fellow in Emergency Ultrasound, BWH

For the second half of my rotation in Rwanda, I have continued working with the emergency medicine residents in the ED with a focus on ultrasound education.  I have Rwandan EM residents scanning with me 8 hours a day, though we are frequently interrupted to help out with coding patients.  There are many people who die at CHUK hospital each day due to lack of resources that we have ready access to in the United States.

Outside of the ED at CHUK
Chronic dialysis is not an option, and we regularly watch patients die from hyperkalemia or fluid overload in the setting of renal failure.  Many patients come in with spinal cord injuries from trauma or motor vehicle accidents, and we often do not have enough cervical collars to use for these patients. There is only one suction machine to share around the ED, so many patients die from blocked endotracheal tubes. 

Despite these daunting problems, I have noticed significant progress in the 1.5 years since I was last working at CHUK. They now have ventilators and monitors in the ED, which is new.  In addition, the emergency medicine residency is new. While those who work at CHUK every day sometimes get frustrated and feel progress is too slow, being away for a while, the change is clear.

While many other resources are limited, the one thing that is consistently available in Rwanda- both at CHUK and in the district hospitals is bedside ultrasound.  Providing the knowledge and skill set to use this tool appropriately has value.
Scanning with one of the EM residents in Rwanda

The high volume of road traffic accidents makes the ultrasound training very important for the EM residents.  Patients have to be able to pay for a CT scan in order to receive one, and often the scan still takes a day or more to receive after it is paid for.  Using ultrasound at the bedside can aid in a much faster, and more affordable diagnosis.  Finding signs of internal bleeding on an ultrasound can expedite a patient to the OR.

During our scan shifts, we have diagnosed ocular injuries, fractures, pleural effusions, pneumothoraxes, cholecystitis, pericardial tamponade, small bowel obstructions, TB and cancer.  Often ultrasound in developing worlds plays a huge role in cinching a more timely and accurate diagnosis.

As I wrap up my time here, I must say I found it to be a valuable experience.  While it is difficult to effect change in a short amount of time, I think having smaller goals is useful.  I am not necessarily going to get patients to come to the hospital earlier in their disease course, but I can arm physicians there with ultrasound skills to more accurately diagnosis them when they arrive looking for help.

Hand and Burn Surgery in Kigali, Rwanda- Week 2

Lydia Helliwell, MD
Resident in Plastic & Reconstructive Surgery, BWH

Our first week at the University Teaching Hospital of Kigali (aka CHUK) was a whirlwind of tough surgical cases. We completed 14 cases in just 3 days, covering a wide range of hand surgery problems- congenital, post-burn, tumor and fractures. We were exhausted by the end of the week, but after a couple days off for Easter (Catholicism is the dominant religion in Rwanda), we returned to the OR Monday morning refreshed and ready to tackle several complex burn and reconstructive cases.

The approach to burn care in Rwanda is different from ours in several ways, and likely because of several factors, but notably, where we prioritize early excision and grafting, this is not done here in Rwanda. This delayed approach may be secondary to staff, instruments and OR rooms being needed for more life-threatening issues. Therefore, burn excision and grafting is delayed and results in patients requiring several days to weeks of dressing changes prior to reconstruction, which is not only painful, but also leads to more complex post-burn contractures. Unfortunately, most of our burn patients were children, as they are a population very vulnerable to burn injuries in Rwanda. We also cared for a young woman who had been attacked and burned by acid during an argument. She suffered burns to her face, arms and legs and was developing very severe contractures. All of these patients had been admitted to the burn unit undergoing painful dressing changes until their wounds were ready for grafting.

In addition to the difficult burn cases, we undertook several large soft tissue reconstructions. One was a young woman who had been hit by a car, resulting in a large anterior knee wound with an exposed joint. Another was a young man who had developed necrotizing fasciitis of his anterior abdominal wall, resulting in a large soft tissue defect. A third was a young woman who developed a serious infection of her C-section incision, resulting in another large soft tissue defect. These were all patients who the only plastic surgeon at CHUK had been tasked with taking care of and we worked with him directly to develop and carry out complex reconstructive procedures for these 3 patients, as well as several burn patients.

Over the course of Monday and Tuesday, we performed several split and full thickness skin grafts, a medial gastrocnemius flap for knee coverage, an abdominoplasty for abdominal wound coverage, and even a circumcision to obtain a full-thickness skin graft for a severe hand burn. It was amazing to both help all of these patients, and also pass on some of our knowledge and experience with burn, hand and soft tissue reconstruction to the local surgeons, residents and medical students, so they may continue these difficult reconstructive procedures after we have gone.

We wrapped up our final full day in Kigali with a morning lecture to the medical students and residents on acute burn care. We followed this teaching session with a general plastic surgery clinic. In the course of one morning with Dr. Fausten, CHUK’s one plastic surgeon, we saw the full gamut of plastic surgery, including hand injuries, breast cancer, lower extremity reconstruction and various wounds. Although we will not be around to work on these problems ourselves, it was great to discuss with Dr. Fausten and formulate plans for future surgeries.

Overall my experience in Rwanda was one of the best I have had in residency. I not only gained further experience in hand, burn and plastic surgery, but I gained experience in resident & medical student teaching, as well as exposure to the ups and downs of global health collaborations.  I was greatly impressed with the determination and dedication of the doctors in Rwanda to take care of a very complex patient population with much fewer resources than are available in the United States. I am glad that we were able to directly help the patients we operated on, but I am also hopeful that some of the knowledge and skills we taught will be utilized after we have gone. Finally, it was incredibly eye opening to travel to a country that prior to planning this trip I knew very little about. I am thankful that I was able to learn about the history of Rwanda and its recent genocide from the people that live there. I finished this trip with a much greater understanding of hand surgery, global health and East African politics….which is certainly more than I learn in a typical two weeks back at home!