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At the heart of general practice since 1960

Saving life and limb in Rwanda

The genocide of 1994 has left physical and mental scars on Rwanda, as GP Dr Sharon Bennett discovered when she worked there recently as a medical missionary

The genocide of 1994 has left physical and mental scars on Rwanda, as GP Dr Sharon Bennett discovered when she worked there recently as a medical missionary

The recovery of the Rwandese after the genocide of 1994 has been remarkable, although there are immense residual problems, not least of all in healthcare.

There are about 400 doctors for a population of over 8 million. It is a small country with a length and breadth of around 150 miles – but this disguises the transport difficulties presented by the "one thousand hills".

To reach Kirambi Health Centre, my destination, meant driving from the capital Kigali over pristine tarmac and then for about two hours along narrow rough roads, up and down steep hills and over log bridges spanning deep gullies.

The Medical Missionaries of Mary ran the health centre with a staff of Rwandan nurses. There had never been any regular doctor input.

When you arrive in Rwanda, the poverty is a real shock. An essential part of the work from the Centre was the Community Outreach Team which consisted of agronomists, social workers, nutritionists and nurses.

This team dealt with public health issues: housing, malnutrition, immunisation, antenatal and postnatal care, HIV / AIDS, food production and, most importantly, post genocide mental trauma.

Together with Dr David Tibbutt, I spent my first two days with this team.

Dr Tibbutt is a retired consultant physician from the Worcester Royal Infirmary. He was latterly adviser for Continuing Medical Education to the Ministry of Health in Uganda and Visiting Physician to Kitovu Hospital (Masaka), Uganda.

What we saw was shocking: overcrowded homes with seven or more sharing a single room. There was no acceptable sanitation, no reliable clean water supply, no electricity and only food that you could grow yourself. Average life expectancy is 48 years.

The work of the Outreach Team was crucial, from teaching simple hygiene to building compost heaps. We visited one class of a hundred people learning the technique of composting and were assured that the compost would be ready within six months! So life is tough - but not a grumble to be heard.

This introduction to the poverty of life in a rural area, where most people in Rwanda live, was important for our understanding of the health needs of the patients we were to see later in the Health Centre.

How the centre works

In the Centre were wards for malnourished children, maternity, medicine and tuberculosis.

These were supported by a pharmacy that had a good supply of basic drugs and a laboratory where blood could be examined for haemoglobin, cell counts and malaria parasites.

Stool and urine samples could be examined microscopically and sputum could be examined for tubercle bacilli.

While there we introduced to use of simple Gram staining and urine "stix" testing.

The out-patient facilities were mainly for "walk-in" patients, many of whom had walked for hours. The nurses dealt with everything.

Those patients who were very sick or needed more specialist care were sent to the nearest government hospital at Nyanza. This meant a walk of four hours for those who could manage but in extreme cases arrangements were made for ambulance transfer.

The cost of such transport was paid from the meagre resources of the Medical Missionaries of Mary.

Our role was to look at how the nurses were coping with the local health needs.

The nurses joined us in the clinics which we ran with the help of excellent interpreters from Butare University. We worked until it was too dark to see: there was no electricity.

We saw about 500 patients in total, spread over six all-day clinics – a busy week, with between 70 and 100 patients a day.

Our visit had been announced in the local church and we were overwhelmed by 150 patients on the first day. It was interesting to note that a large proportion of the presenting problems were of a musculo-skeletal nature: backache and arthritis.

Such problems may seem, at first, rather trivial. However, put into the social context of many hours of daily hard work on the land and walking across hilly terrain it becomes clear how important the management of these problems is.

Common ailments

There were, of course, numerous other conditions: abdominal pains probably associated with parasitic infections, symptoms suggesting peptic ulcer disease, untreated chronic ear infections in young children, poorly controlled epilepsy, suspected tuberculosis, a wide variety of eye conditions, joint and bone infections.

Very little malaria was seen, probably because of it not being the rainy season. Generally the people were in remarkably good physical condition, with almost no obesity reflecting their hard manual work.

HIV infection and AIDS was not a significant problem among the patients presenting to us.

However the health centre was providing an essential service to the known infected population: blood specimens were taken regularly and transported to Kigali or Butare for special tests (CD4 blood cell counts) to inform the use of antiretroviral therapy.

We carried out ward rounds on the in-patients and in particular on the wards for tuberculosis. We were struck by the exemplary care of these patients: the protocols for treatment and observations for the TB patients were adhered to in detail.

There is no doubt that this Medical Missionaries of Mary health centre is saving life and limb with limited resources and no medical (i.e. doctor) assistance.

This is the result of the dedication of the staff and the combination of the service at the health centre and the community work. There are numerous such health units scattered throughout Rwanda.

An important part of our visit was to teach the nurses "on the job". This included the key points in history taking and physical examination followed by common sense problem solving aiming at optimum treatment. It was clear that some rationalisation of drug prescribing was needed to achieve greater effectiveness and economy.

This we achieved around the use of drugs for musculo-skeletal disorders and peptic ulcer disease and the use of antibiotics. In addition advice was given about the use of simple remedies without significant cost - e.g. inhalations for minor respiratory ailments using eucalyptus leaves in hot water and the use of homemade salty (saline) water for cleansing eyes.

Dr Tibbutt has over forty years' experience of working from time to time in Uganda. In spite of this there was a steep learning curve for practicing in Rwanda.

We feel that we have had the privilege to be involved with a process that we hope will be sustained. The Rwandese are keen to help themselves. We can assist with this but need your help.

The Ministry of Health and Medical School authorities would welcome another visit.

Ideally we would like a team of specialists to go to two tertiary hospitals: one in Kigali and one at the Medical School in Butare.

At these hospitals they would work alongside Rwandan colleagues and teach under- and post-graduate students. Others, perhaps general practitioners, could go to a number of rural hospitals or health centres and do what we did at Kirambi.

A key feature of this next visit is to build upon plans for a national continuing medical education programme, and wherever you go in Rwanda you could be part of that.

As a result of my work in Rwanda, I have re-doubled my efforts to avoid waste in my practice in London. Also I am more than ever aware how important primary care is – in Rwanda it really is saving life, and it is done for the most part by nurses.

I think it is a pity more doctors don't do overseas work now. Medicine is now such a structured career – a carefully directed career pathway – that work in developing countries is harder to do.

But doctors should try to do it. And you needn't be away from your practice for long. These trips to developing countries can be for quite short spans. Bodies like Medecins Sans Frontiers can be approached. Also VSO. And of course Jess Lever.

• The project is being organised by the British Conservative Party, and is open to anyone who is sympathetic to the Party. If you are interested and would like further details about a fortnight's visit (26th. July – 9th. August 2008) please contact Jess Lever (leverj@parliament.uk) who is organising the project.

Dr Sharon Bennett is a GP in north London

Dr Sharon Bennett: "It's a pity more doctors don't do overseas work." Dr Sharon Bennett

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