Sen. Bill Frist

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.

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.

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.

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.

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.

Sen. William H. Frist, MD

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.

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.

Kate Etue, Director of Communications

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.

Courtney Massaro

November 15

Most days (or I should say nights rather)—I forget I’m working in Haiti. We have normal, beautiful deliveries with happy, healthy moms and babies. I got to catch twins the other day (!!), and the first was breech—which was quite exciting/stressful for me, as breech babies typically are sectioned in the U.S. and so the breech delivery skill-set is a dying art. Sure we have the occasional loss of power, or we run out of gloves, but overall things at the maternity run in a manner pretty similar to how they would back in the U.S.

And then there are nights where I am harshly reminded that I’m in a developing country, in a hospital with limited resources, where standards of patient care are—at times—very different, and where things happen that wouldn’t occur in the developed world. Below is a sad, frustrating, and a bit graphic example of such a case.

Last night a woman was carried into the delivery room with an IV already in place and fluid dripping. She had been brought from another hospital that was about 45 min away from Cayes. She had had an obstructed labor for the past three days. As a result, when she arrived her baby’s head (the baby had died—how long ago no one knows) was right at her perineum, but wouldn’t come out. Her vulva was terribly swollen and she looked incredibly worn out (which was more than understandable given what she’d been through). She was still having contractions—probably due to the fact that she was getting pitocin through her IV—but they weren’t doing anything but causing pain.

We called the doctor on call to see what he wanted to do about this woman. It was clear to me—and the nurses—that no amount of pitocin was going to make that baby come out (unless the baby decomposed enough to be able to be pushed out with the pitocin induced contractions). I was concerned about her increasing risk for infection and for fistula formation—among other problems—and so was hoping the doctor would come in to perform a c-section (given that we had no vacuum or any other way I could think of to try to extract the baby vaginally). The doctor however, got mad at the intern for calling him, and said that the woman just needed pitocin and that was that. After the call, the nurses all lamented the doctor’s decision, but said that this was just how it was in Haiti—that women suffered. They were much more laissez-faire about it than I was—in large part I think because this is normal/expected to them, and (obviously) not for me.  I think also because I knew what materials we didn’t have, and how they could have changed the situation—and the nurses probably didn’t as well—that it made it that much more frustrating for me.

I struggled with trying to think of something we could do for her—but I couldn’t think of anything. (Being a new/inexperienced midwife is hard at times because I wanted to help this woman so very much, but have never been taught about how to address obstructed labor—I’ve only read about it and its consequences—and don’t have any experience with it (until now), or anyone to offer me advice as to the best treatment plan.)

In the end we—tragically—monitored the woman all night. She made no progress and didn’t get any rest because of her contractions. I happened to be at the hospital this afternoon (around 3pm) and saw her finally heading back for a c-section. I can only hope that she has no long-term consequences of this birth—though I’m not too optimistic about that.

I realize this is not an uplifting post, but it is a reality that any healthcare worker who has the privilege to work—or wants to work—in the developing world will have to continually confront. My hope is that with time the norms will change, and appropriate resources/trainings will be provided to decrease the frequency of such cases, and ensure that women don’t have to just suffer.