Field work in Rwanda, February 2010

Christine Pace
Medicine PGY-3, BWH
April, 2010

With the support of the Center of Excellence in Global Health, I traveled to Rwanda for the month of February, 2010, to work with Partners in Health (PIH) at two of the rural district hospital sites where they work. This was my second trip to Rwanda, where I have been involved in helping develop mental health programming at PIH’s three sites. In the wake of the 1994-1995 genocide, mental illness, including depression and PTDS, is a significant public health problem in Rwanda. The Ministry of Health recognized this early on, and has tried to staff all district hospitals with psychologists and mental health nurses to address the significant need all around the country. In its mental health work, PIH aims to support existing Ministry of Health mental health programs and is also in the early stages of collaboration with MOH to pilot new programs.


During my first trip to Rwanda I conducted an informal needs assessment of the mental health services available at the three sites PIH works. I also developed training materials to help acquaint health care providers working in medicine, surgery and obstetrics with basic principles of psychiatric illness, and developed clinical protocols to help medical doctors and nurses distinguish between medical and psychiatric causes of psychiatric symptoms, such as psychosis. This year, I continued work on these protocols and conducted some pre-testing of them in the wards. In addition, with Ildephonse Fayida, a Rwandan psychologist who direct’s PIH-Rwanda mental health program, and Giuseppe Raviola, a psychiatrist at Children’s Hospital and PIH, I began to develop protocols for management of the most common psychiatric conditions encountered in Rwanda. As I did last year, I also had the opportunity to round on the medical wards with Rwandan physicians.

I have learned a tremendous amount from this experience. Clinically, I always both enjoy and deeply value the chance to round in the medicine wards, to work through difficult cases with the Rwandan doctors, and to learn from their experience. Obviously, the majority of the diseases we encounter there, such as malaria and typhoid, are seldom seen at BWH. However, as Rwanda develops its ability to diagnose and treat chronic diseases such as heart failure and diabetes, there are indeed overlaps with the diseases we see most commonly here—as well, of course, as fascinating contrasts between the epidemiology and presentations of such conditions in the two settings. It has been fascinating to work with Ildephonse Fayida, and learn more from him about the epidemiology and clinical manifestations of mental illness in Rwanda. In particular he helped me think about the ways that culture affects these manifestations. Culture differences aside, I valued the chance to review basic psychiatric disorders and their treatment; we have few opportunities to formally review psychiatry in our internal medicine training, and yet we work with patients who have psychiatric comorbidities all the time, particularly in primary care. Thus, having had the opportunity to develop clinical protocols in Rwanda will actually benefit my clinical practice back in the States as well. Finally, working alongside PIH staff on some programmatic issues allowed me the chance to better understand the ways that the program interfaces with the Rwandan Ministry of Health, and better appreciate the importance of such collaboration in global health. I had a wonderful experience in Rwanda and greatly appreciate the COE’s generosity in making my trip possible.