Nyamata

Today marked my third day exploring the Rwandan medical system.  Per usual, I’ll start with some background.  Rwanda has a universal healthcare system, with each citizen receiving government aid.  The hospitals are set up with a tiered approach, with more people being served by higher level hospitals.  At the bottom of the ladder are (very) low educated health workers who each cover 10-20 homes.  At the next level are health centers that cover 25-30,000 people; these centers include departments for family planning (showing education videos), vaccinations, normal delivery, nutrition, HIV patients, general consults for adults and peds, and pharmaceuticals.  Patients can be referred from there to district hospitals that cover 6-15 health centers.  From there, patients can be referred to university teaching hospitals (for the nasty stuff). 

Since we have lined up three hospitals at which to visit this summer, our group of 15 has been split into three groups of five, with my group starting at a district hospital in Nyamata.  It’s all open air, which is to be expected in a warm climate (same approach in Florida and Costa Rica).  Patients are packed into the rooms, with up to ten beds in a room.  The wards have a particular stench about them that you can’t really pinpoint (pediatrics in particular), and it looked as though there was vomit or feces splattered on the walls.  Lines of patients wait outside of the two outpatient rooms, and a guard with an AK-47 sits outside of the building housing ill prisoners (dressed in orange or pink scrubs).  Since there are no hospital staff to feed or care for in-house patients, family members may be found out back cooking food, sitting on beds with patients, or waiting on benches outside of the buildings. Even though the country is moving to English, all of the signs are written in French or Kinyarwanda, and the medical personnel speak entirely in French in the morning meetings.  With all of that said, many of the doctors speak English well, they are quite knowledgeable, they seem proud of their system compared to others in the region, and they love to teach. 

Although I’ve heard stories of strange congenital abnormalities and extreme cases coming from students at one of the teaching hospitals in Kigali (where I’ll be next week), Nyamata has been great for learning about tropical diseases, anemias, and malnutrition.  Although rarely seen stateside, it’s actually quite common to see patients with various parasitic infections like amoebiasis and malaria (malaria is actually high up on the differential in cases of fever).  I also had a doctor teach me about different kinds of tuberculosis using X-rays of patients that he currently had under his watch.  Over in maternity, the rest of the group observed births and C-sections (I’ll hopefully head over to that department in the next hospital), and I observed a number of ultrasounds of both live and dead fetuses (fetal death seems to happen too often, with pregnant mothers displaying varying emotions ranging from upset to apparent disinterest). 

Over in the outpatient department (OPD), we primarily get to observe the paternal approach of the physicians in full effect.  Patients are called into an office one at a time, and the doctor will ask questions of the patient in French or Kinyarwanda.  After a brief discussion, the doctor will either write a script as the patient sits quietly or tell the patient to sit on the exam table.  If the doctor writes a script, he will hand it to the patient with specific instructions and little conversation.  If the patient is told to sit on the table, they will do whatever they are told without hesitation, including disrobing (both tops and bottoms).  As one example, another male student and I observed as a male doctor manually examined a woman’s cervix without a speculum or female observer in the room.  Going along with limited discussion, I also learned today that patients are not told if they are being tested for “cancer.”  Instead, they are told that the biopsy is testing for neoplasm, adenocarcinoma, etc.  It’s far from what you’d see (or I’ve seen) in the U.S., but it’s just they way they operate here. While the American patient is generally becoming more knowledgeable, empowered, and demanding, I’m told the Rwandan patient would likely question the doctor’s competence if asked about opinions on treatments.  Once again, it’s different, but not necessarily wrong in this context. 

Along with many Rwandans supposedly lacking the knowledge to have a meaningful clinical discussion, “traditional” and herbal medications are commonplace among some patients.  Just this morning I saw a sick baby whose abdomen was covered in scars from an attempt at traditional healing.  I also saw a toddler whose forehead was scarred from the mother pressing hot knives against her head in an attempt to alleviate a fever/headache.  In another case, a man with malaria had stopped taking his prescribed medication in favor of herbal medications.  He had such and extreme case of splenomegaly that the spleen extended down below his umbilicus (it should normally be tucked up within the rib cage).  And in yet another case, I met an HIV patient who had stopped taking her antiretrovirals a few months ago but continued to breastfeed her child without hesitation in front of us.  While we are taught to respect such traditional practices and attempt to work alongside them if possible, it’s as saddening as it is frustrating to see children covered in scars and fed tainted breast milk. 

In addition to my time at Nyamata, I was also given the opportunity to travel to one of the health centers in a village 45 minutes from the district hospital.  A doctor will visit a given center once a week (it’s primarily run by nurses), and I rode out with one this afternoon.  Our stay was actually shorter than the ride out there, but I was able to meet some patients in the HIV department and see some cute kids around the facility.  In reality, though, I’d say the best parts of the experience were just flying (read bouncing) across dirt roads and seeing Rwanda outside of the city.  The thousand hills aren’t reserved solely for Kigali.

I was without internet for the majority of yesterday for whatever reason (seems to happen here), so I attempted to fit some of today’s experiences into the blog I wrote up yesterday.  I proofed it once, but it could still be an iffy read as a result.  

-Scott

Along with seeing TB on X-ray at Nyamata, we also came across a patient with silicosis. The man had been working in a mine for only a few years but claimed that eight of his coworkers had already died from complications.  He was only in his 20s.  For those interested, a normal long should look more like this.  Wikipedia side note: Pneumonoultramicroscopicsilicovolcanoconiosis, apparently the longest English word in the world, describes a particular type of silicosis.)