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I’ve been home from Rwanda and Kenya only a few days and I’m already on another flight, heading back to Aspen, this time for the Aspen Ideas Festival Spotlight: Health, co-sponsored by the Robert Wood Johnson Foundation.

It’s on flights that I have time to reflect on a few takeaways, drawn from the myriad impressions and experiences I gathered in Rwanda. I tell everyone that journeys to Africa are life-changing and indeed this one was for me, and hopefully those who joined me.

  • Partners in Health—that unique Boston-based nonprofit global health organization—is uniquely positioned in Rwanda to develop research-based health service models that can be applied around the world. In fact, we in the States have much to learn from these. It’s well on its way to doing innovative, PROVEN programs of science-based health delivery; creating disciplined training programs; and even taking aggressive cancer therapy to the rural poor in a way that is economical and effective.
  • Paul Farmer should get the Nobel Prize. He has demonstrated in Haiti and Rwanda and around the worldthat health care can be brought to the people who need it. He has shown the world that therapy once regarded as too expensive to buy and deliver—like HIV treatment—can be effectively and inexpensively administered to the poor and rural. And now he is addressing cancer treatment in rural Rwanda.
  • Gorilla health is like human health. My work with the gorilla health began at the National Zoo in Washington. Some mornings I would scrub in at 6 am over in Rock Creek Park to take care of a sick gorilla before opening the Senate as Majority Leader. My interest in gorilla health continues, and that is why I introduced our group at the base of the Virunga Mountains to the vets with the Mountain Gorilla Veterinary Project, on whose board I served for years. The upland gorilla, whose march toward extinction was reversed by Dian Fossey, has grown in number from 750 to 880 just over the years I have been involved. Animal conservation working hand in hand with animal health makes a difference. As an aside, I want to raise a red flag to the rapidly growing problem throughout Africa of elephants being massacred for ivory.
  • ONE health is a concept and a movement I hope others come to understand. It gives name to my conviction of focusing time and energies on human health, animal health, and environmental health. Health and healing applies to all—in Rwanda to the land around us, the farmers, the cows and buffalo, all interacting integrally with each other, as so clearly manifested at the base of the Virunga Mountains. Living side by side with mutual respect for each is the only answer. Gorillas are extremely susceptible to human-borne illness. Crowding brings buffalo in close contact with the gorillas, contaminating waterholes and leading to disease and death. Too many people still rely on bush meat for food, killing gorilla and monkeys. Gorillas are also threatened by hunters trying to trap antelopes for holidays and celebrations, unintentionally ensnaring baby gorillas. Health for one is health for all.
  • The HRH program in Kigali blew me away. It will work and I predict become the model of the future where governments are not corrupt. It is built around partnerships. Twenty-six US universities partner with USAID, the source of $33 million, to deliver and improve health services in Rwanda. The process through which the money flows goes like this: the American taxpayer gives his money to USAID who channels the money to government of Rwanda led by Paul Kagame who channels the money through the highly respected Minister of Health Dr. Agnes Binagwaho. Dr. Binagwaho distributes the money to the sites; 86 health professionals on the ground lead large programs to improve health service delivery. An orthopedic surgeon from the Brigham in Boston or a hospital administrator from Yale may then come to introduce systems to the Rwandan hospitals and district pharmaceutical distribution center. Over an eight year period, the goal is to train Rwandan workers with the skills and knowledge to build and sustain their own programs over years to come. It is working and it is a wise and smart use of the taxpayers’ dollars.
  • Paul Kagame is the man for the times. He has courageously taken a country that in 1994 was deeply divided by genocide, which claimed the lives of 20% of the population, and deeply divided by artificial colonial convictions, and though strong leadership has reconciled the people, formally achieving forgiveness in the immediate aftermath of neighbor-killing-neighbor, and establishing and maintaining remarkable peace. At the same time his belief in markets and investment has led to 29 years of annualized growth of 8% and is greatly expanding the middle class. His leadership is dramatic. He leads from above but implementation begins at the village level. When the president says thatched grass roofs lead to poor health and suggests replacement, it is each neighborhood that comes together every Friday over a two year period to assist in replacing the grass roofs with metal ones. When it is identified that wearing no shoes, the African custom, allows parasites to enter the body leading to disability and death, a proclamation from above to wear shoes was implemented at the community level almost immediately. The New York Times and New Yorker don’t like him, but I think he is an amazing man who has saved his country of 11 million people.
  • Journeys to Africa by Americans are a good thing. Our group of 10, half of whom had not been to Africa, bonded and shared our own perspectives in a close, personal, and intimate way. Africa touches one’s heart. It inspires. It cause one to dream. It changes your life.
  • Health care is improving fast in Rwanda. Vaccinations far surpass those in the US. Childhood mortality has been cut by 2/3. The basic district health clinics are accessible to all and they place a heavy emphasis on family planning, healthy pregnancies, and early childhood health and nutritionMaternal, newborn, and child health are the foundations of strong communities. The fledgling national health insurance system is solid and growing fast and has been received well. The system gets by with MRIs and CT scanners. It has only one urologist in the country and five pathologists. Heart surgery is rarely done. But all that will change as the economy improves. The new cancer center at Butero, established at the district hospital as a brainchild of Paul Farmer and the Ministry of Health, will greatly expand cancer therapy the county, heretofore lost in all of the attention on infectious or communicable diseases like HIV, malaria, and tuberculosis.
  • On my return journey, I stopped in Nairobi, Kenya. Crime in Nairobi is high—street crime and home invasions with burglary and carjacking. Al-Shabaab, the al-Qaeda-affiliated Somali terrorist group, is increasingly threatening the city. Tourists are not coming and hotel census is down. Corruption rules the government and police, it seems. But commerce continues and I spent a day in a wonderful market and had top notch service at the Tribe Hotel, where Jonathan, my son, introduced me to the wonderful family who has developed it.

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and blogs from MondayTuesday, and Wednesday

Today we went to see some of Rwanda’s natural treasures: mountain gorillas.

Rwanda has a long history of gorilla conservation. Dian Fossey, author of Gorillas in the Mist, founded the Karisoke Research Center in Rwanda in 1967 and studied gorillas in the Virunga Volcanoes until her death in 1985.

We were hosted by Gorilla Doctors, a mountain gorilla veterinary project supported by the UC Davis Wildlife Health Center and dedicated to saving the mountain gorilla species one gorilla patient at a time. Gorilla Doctors serve the mountain gorillas throughout the Virunga Volcano Mountain Range that spans Uganda, Rwanda, and the Democratic Republic of Congo (DRC).

With Gorilla Doctor guides, we spent six rainy hours trekking through Volcanoes National Park looking for the Titus family of 10 gorillas—including one silverback and one 3 month old newborn. We finally caught up with them at about 9,000 feet.

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These incredible creatures are monogamous vegetarians. Each mother has 4-5 children during her lifetime, starting when she’s about eight years old. They can live to be 43 years.

At one point, the gorilla population here was down to 250 animals. When I visited in 2008, there were 750. Today, Gorilla Doctors estimates that there are 880 gorillas.

But gorillas are not quite the departure from human health that they may seem.

Dr. Jan Ramer, regional manager of the Mountain Gorilla Veterinary Project, explained that Gorilla Doctors approach their work from the “one health” perspective, a belief that the health of one species is inextricably linked to that of its entire ecosystem, including humans and other animal species.

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It’s easy to see how closely the species connect.

The number one killer of gorillas is trauma. On our walk we came across three rope and wire snares. Though meant for antelope, gorillas, especially infants and juveniles, sometimes get caught in these snares. Gorillas may lose limbs or digits to snares, or die as a result of infection or strangulation. Gorilla Doctors respond to reports of gorillas in snares and work to treat their wounds and release them.

The number two killer of gorillas is infectious diseases, and humans and gorillas are susceptible to the same diseases. In fact, the most common infection in gorillas is respiratory disease, which can range from a mild cold to severe pneumonia, in individuals or in whole groups. These diseases are often passed from human to gorilla.

I’ve worked with these animals before, even doing some gorilla surgery, but seeing them in their homes never gets old. Amazing creatures.

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*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughtsMonday’s blog, and Tuesday’s notes.

This morning we met with patients and physicians at Centre Hospitalier Universitaire de Kigali (CHUK), the urban hospital equivalent. For the past few days we have explored Paul Farmer’s vision of taking health care to the people in rural areas, so often neglected around the world.  Today we looked at health care in the city.

CHUK is the primary teaching hospital, located in the heart of Kigali. With 25 departments—17 clinical and 8 administrative—CHUK provides training, clinical research, and technical support to Rwanda’s 39 district hospitals.

Again we were able to meet patients and hospital staff. I was particularly impressed with this three-year-old little firecracker. He fractured his hip falling out of tree, but that wasn’t keeping him down! I also had the honor of meeting this dedicated woman. She’s served as a nurse in all of CHUK’s departments over the past 11 years.

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Over and over I’m impressed with how much Rwanda, with PIH and other groups, has accomplished.

For instance, Rwanda has one of the highest vaccination rates in the world—a status they have achieved through very hard work over the past eight years.

Vaccines for children here are a series of six individual vaccines that begin at birth over the first two years of life. In a country with about 11.5 million people—the majority of whom are very poor, a 94% vaccination rate has been achieved through national campaigns centered in communities. The vaccines are administered through community health centers in each of the villages. This is really, truly remarkable.

Breast and cervical cancer have been on the rise in Rwanda, so in 2010, a national campaign to vaccinate schoolgirls against HPV began that is gradually making it across the country through community health centers. The hospital at Butaro—where we were yesterday—is participating in research and the collection of data around this vaccine.

It works; it’s a great vaccine. For cervical cancer it’s very important. And Rwanda is taking a leadership role. As you can imagine, cancer is not treated well in the developing parts of the world. So it’s pretty remarkable that both a vaccine program and cancer care are coming together here.

Of course Rwanda’s remarkable progress is contrasted by the genocide that took place here 20 years ago.

This afternoon we visited the moving Kigali Genocide Memorial, where the history of genocide worldwide is powerfully presented. It was a return visit for me, but no less humbling.

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Last time I was here, a bipartisan group of Senators laid a memorial wreath. This time, I considered what Rwanda has accomplished in those 20 years:

  • a dedicated nurse spending 11 years caring for the sick;
  • Partners in Health Rwanda’s work over the past nine years;
  • a nationwide vaccine program against polio, tuberculosis, and measles, for the past eight years; and
  • the PIH Women’s and Girls Initiative training women for the past six years.

But these are only the beginning.

Maybe the most hopeful thing I saw today was the work of Human Resources for Health (HRH). We had the privilege of meeting physicians from this innovative Rwanda-U.S. joint partnership to strengthen the Rwandan health care system.

Harvard Medical School, USAID and other US government programs are funding about 70 to 100 clinicians and administrators and planners through the Rwandan Ministry of Health to develop the clinical service infrastructure.

These are inspiring mid-career physicians from Harvard-affiliated hospitals who are changing the world. Our tour was conducted by an American orthopedic surgeon who is dedicating a period of her life to serving the hospital and the training program of young Rwandan physicians.  They are all heroes.

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The program, funded by the American Taxpayer and in its second year of an eight year commitment, is a tremendously powerful and smart investment in the future.

What is needed in Rwanda—and globally!—is a long term plan. HRH is building up infrastructure which is so badly needed to lift up the health sector here. But equally importantly, their work will make health care in Rwanda sustainable and prepared for the future.

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and Monday’s blog

Who says you can’t treat patients suffering from cancer in the poorest, most rural parts of the world?

I’m writing on my iPhone on a bumpy dirt road that I am told will be paved next year. It winds for two hours through gorgeous green mountains sculpted with terraced plots of land and scattered homes stepped up and down the hillside.

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But 30 minutes ago I was on a mountain top in a cancer ward listening to the heart sounds of a 6-year-old boy with leukemia and examining the slowly disappearing lumps on the chest of a 20 year old man with non-Hodgkin’s lymphoma—both being treated with state of the art intravenous chemotherapy.

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Butaro Hospital, based in Burera District, Northern Province, is a PIH-supported facility and home to the Cancer Center of Excellence, a cancer-referral site for all of Rwanda. The cancer ward was opened up in this rural district hospital two years ago. As we toured the wards, we saw children with leukemia, women with breast cancer and men with bowel cancer.

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Paul Farmer introduced to the world the fact that HIV treatment does not have to be expensive and that it can be successfully treated in the poorest parts of the world. No one believed him at first. But he proved them all wrong.

Now he is doing the same for cancer diagnosis and treatment. If it can be pulled off in rural, mountainous, and hard-to-reach Burera, it can be done anywhere.

One third of the patients come from the local district, a third come from outside the district, and a third from around the country and even neighboring countries.

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The hospital has only the essentials: a simple plain film x-ray machine, one ultrasound machine, and basic blood chemistries but nothing like blood cultures. There are no pathologists there—photographs or iPhone pictures can be sent to partner hospitals in Boston, Brigham and Women’s and Dana Farber Cancer Center, when needed.

But the staff is Rwandan and they have been trained in concert with Partners who place a heavy emphasis on fact-based science, research, and clinical training with certification. Pride among the staff bursts forth. People are living and have hope where they were dying in despair.

It’s truly an amazing thing to see.

Kigali, Rwanda

Why are we in Rwanda? What makes it a unique place to learn about health policy, and health care delivery? What will we learn that can make us smarter as we address health issues back at home?

I thought through these questions on the flight to Rwanda, and I had plenty of time. It’s been a long series of flights—Aspen to Denver to Chicago to New York to Amsterdam to Kigali. But the real journey began today as we saw our first health facilities.

Today (Monday), the delegation piled into a Land Rover after breakfast for the 2.5 hour drive to our first stop: the Partners in Health (PIH) headquarters at Rwinkwavu. We toured the Rwinkwavu District Hospital & Health Center, which was funded in part by the Rwandan government, PIH, and Bill & Melinda Gates.

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Formally, I’m here as the Chairman of Hope Through Healing Hands, the global health nonprofit I founded. Having been both a surgeon and a public servant, I am convinced that health and medicine are the best currency for peace and healing worldwide. I started Hope Through Healing Hands to put that belief into action.

It’s a vision that is shared by Dr. Paul Farmer, PIH’s founder and director. Paul has been a friend and like-minded champion for global health for years. He has always had the vision to see things that others could not, the audacity to dream big, and the commitment, dedication, hard work to make his visions–whether a nursing school, hospital, outpatient clinic, or even an entire medical school–a reality. It’s an honor to tour Rwanda with him, and see the progress being made.

When I was last in Rwanda, in the summer of 2008, I was impressed to see how diligently international funds were used (in that case, PEPFAR funding focused on HIV, malaria, and tuberculosis care and prevention). I said then, I wish all Americans could join our delegation to see how wisely their contributions have been spent, and with accountability.

I have seen the same today in the Rwinkwavu District Hospital.

When Rwinkwavu District Hospital first opened, Paul planted several trees there on the property. Standing in their shade today, they are a visual reminder of the growth and progress that PIH—and Rwanda as a whole—has made.

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With Paul Farmer under the trees he planted.

The district hospital is in Southern Kayonza District, one of three that PIH serves. The 110-bed Rwinkwavu District Hospital and its eight health centers are in remote, rural area, and yet it is delivering care to the poor with both compassion and excellent science.

The highlight of my day was meeting the young researchers at Rwinkwavu who were learning how to conduct sophisticated clinical studies that are and will continue to be published in peer-reviewed journals. They are pushing medicine forward not only in their hospital, but globally as well!

Increasingly the hospitals in Rwanda are seeing surgical disease including cancer. For so many years, the African continent has concentrated on infectious diseases. Now that most of those are under control, the most dramatic emergence is of chronic disease of the heart and lung. In addition, there is a huge need for trauma treatment centers, which are generally nonexistent.

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After our hospital tour, we visited the PIH Women and Girl’s Initiative, a wonderful artisanal cooperative that had been started specifically for teenage girls, ages 12 to 18, an age group that has been neglected a bit in Rwandan society. The 20 young women that we met had dropped out of school for various reasons, but had banded together to start a cooperative and learn about small business. They manufacture purses, robes, aprons, gloves that are truly magnificent.

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While the medicine being done compels the surgeon in me, from a global health perspective, the most exciting thing about PIH’s work in Rwanda is that it truly is being taken up by the Rwandan people.

Initially, PIH was a health care provider in these hospitals and health centers. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at Rwinkwavu District Hospital and two other hospitals and 41 health centers, with the help of 4,500 community health workers.

At dinner I had the opportunity to sit beside Dr. Agnes Binagwaho, Rwanda’s Minister of Health. Dr. Binagwaho and I have met several times on my previous trips. She’s been championing public health in Africa since 1994. Tonight she, I, and David Vreeland, discussed the role of information technology in healthcare and the transformation it promises. Rwanda has made outstanding progress implementing health IT to support clinical decision making–a challenge we struggle with in the US as well.

This is the power of global health diplomacy—empowering a community to achieve health, healing, and peace, and seeing incredible gains for the entire global community.

Tomorrow we head North to another province, another hospital, and a cancer center of excellence. I’m excited to see what we learn there.

I was in Aspen earlier this week working on some of the challenges facing healthcare and the health industry in the US, but it’s time to switch gears.

From my 2008 trip to Rwanda with the ONE Campaign

Sunday, I leave for Rwanda to lead a one week group trip with my friend Dr. Paul Farmer to see some of the work being done byPartners in Health (PIH) in the country. I haven’t been in countrysince 2008, and I’m anxious to see the progress PIH and other groups are making in health.

Since the spring of 2005, Paul’s PIH organization has been in Rwanda working closely with the government and the Ministry of Health to reach the rural, underserved areas of the country. PIH began by focusing on HIV/AIDS work, but has now expanded to full healthcare offerings. Today, over 800,000 people are served by PIH’s 40 health facilities.

But the health challenges in Rwanda are still vast! Next week with PIH we’ll be considering many aspects of health in Rwanda, but one in particular that I’ll be looking at while I’m there is nutrition.

I firmly believe–and have seen firsthand!–that global health diplomacy works as a real and powerful currency of peace worldwide. And a healthy start to life–a mother enjoying a safe and healthy pregnancy leading to a safe birth and healthy infancy–is crucial to building a foundation that leads to stable communities and global peace.

Food insecurity and malnutrition account for more than half of the deaths of children under 5 in developing countries, and Rwanda has had its fare share of nutrition challenges. In 2005, 18% of children in the country were underweight.

But Rwanda’s government has made real progress in child nutrition since 2009. That year, a Presidential Initiative launched to address malnutrition. The country also joined forces with the US in the Feed the Future initiative.

A 2010 health survey showed that chronic malnutrition and stunting affect 44% of children under the age of 5 in Rwanda.

In September of last year, the Right Honorable Prime Minister, Dr. Pierre Damien Habumuremyi launched a 1,000 Days Campaign, focusing on food availability and a balanced diet for pregnant women through the first two years of life of their babies.

The first 1,000 days may seem like such a small window of opportunity for global change, but the data are clear that childhood undernutrition has long-lasting consequences.

WHO models estimate that over half of adults in the prime working age group–20-29 year olds in Rwanda–have been affected by childhood stunting. Many of these adults wear the visible badges of malnutrition: shorter height or lessened muscular development. And for just as many, malnutrition has exacted a mental toll as well, diminishing the cognitive function of the working age population.

Along with the rest of what we’ll see–including a bit of gorilla trekking and possibly gorilla surgery–I’m anxious to see what progress Rwanda’s 1,000 Days Campaign has made, and the returns realized on nutrition investment.

I’ll be sure to keep you updated.

Motherhood is a dangerous journey to take in most of the world. Nearly 300,000 women die each year from complications due to pregnancy, and 99 percent of those women are in the developing world. In Malawi, an estimated 510 out of 100,000 women will die giving birth. But Chief Kwataine, a former English teacher, has become well-known in the country for his work developing safe motherhood activities for nearly the last twenty years.

Watch this short, two-minute video to learn more about how women's (and children's) lives are being saved in Malawi. It's well worth your time.


“If you don’t practice family planning, you will have a child on your back, in your belly, on your shoulders and in a baby basket on your head.” Malawi nurse Mercy Chikhosi Nyirongo describing the song and dance from a women’s health meeting in Madisi, Malawi 2013.

Behavior change communications take many forms throughout a lifetime . . . from the parent who scolds a child for doing something harmful, to government warning labels about health hazards. Somewhere in between are the messages from this video that rise up from women simply wanting to build healthy families by practicing family planning. With one in 39 women on the continent of Africa dying from pregnancy complications, it is easy to understand this group putting family planning at the top of their health priorities.

The channels through which these messages travel are increasing through the use of technology. Mobile phones, now accessible in over 90% of the world, provide a means for health education by caregivers who put messages into local language and context. The Reverend Betty Kazadi Musau, United Methodist clergy in the Democratic Republic of the Congo, utilizes a system that does not require Internet to reach her community. The results for sending text message cholera alerts is witnessed immediately:

“People are changing their behavior. They start boiling water to drink instead of taking unclean water from the river. They drink clean water. I think this is a life transformation!” [Listen to full interview]

Mercy Neely HicksUnited Methodist Communications provides best practices in the use of technology for wellbeing by working with global communicators and leading technologists. You are invited to attend the upcoming Game Changers Summit in Nashville, Tennessee which will demonstrate the link between technology and health, and help participants put a plan into action for the messages that matter to them the most.

The right messages reaching people at the right time can save lives and build a world where all – from mother to infant – can thrive.

For more information, contact Rev. Neelley Hicks at [email protected].

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