Inshuti Mu Buzima

Last Saturday I took three of the girls from our school’s Anti-AIDS Club to visit Paul Farmer’s clinic in Rwanda. Dr. Farmer is the founding director of Partners in Health, an organization that operates free health clinics for the poor in seven countries worldwide, works with governments, the WHO, pharmaceutical companies and others organizations to implement better health policies and lower the cost of medicine, and provides training and other support services to the communities and health ministries in which the organization operates. Dr. Farmer has been in the news recently as being considered by President Obama for a top position within US global health policy, but he is most renowned for his work as a physician-anthropologist who has set up these life saving clinics in the most rural and impoverished pockets of the world, starting in Cangé, Haiti in 1983. I initially learned about the work of Dr. Farmer through my mother, who came to admire his energy and selflessness in improving the health of the poor after hearing him speak in Boston several years ago. I read Tracy Kidder’s fantastic biography, Mountains Beyond Mountains, studied the Partners in Health model of care in a medical anthropology course at GW, and used data from Farmer’s most recent publication Pathologies of Power: Health, Human Rights and the New War on the Poor in my senior year honors thesis examining women’s roles in the aftermath of genocide. Dr. Farmer serves on the honorary committee for Maranyundo, and both Partners in Health (also based out of Boston) and The Maranyundo Initiative have collaborated in the past in fundraising and program development. Because of this relationship, I had no trouble setting up a visit to give some of our school’s future doctors a chance to tour the clinic and speak with some of the health workers.

Inshuti Mu Buzima (Partners in Health, in Kinyarwanda) is located in the eastern region of the country, roughly 20 minutes off a decrepit dirt road amidst the scores of hills that characterize Rwanda’s terrain. While the Rwandan Ministry of Health has made real strides in recent years to improve the country’s quality of care and availability of medication to those suffering from illness - especially within and surrounding Kigali - it continues to have a shortage of doctors, with one for every 30,000 people on average. Prior to the arrival of Partners in Health in March 2005, the Kayonza and Kirehe regions were home to half a million people with no doctor at all. The need for improved health care is dire: in Rwanda, over 130,000 people are living with HIV/AIDS; 60% of these cases are in women ages 15-49. Along with malnutrition, malaria and tuberculosis, maternal mortality is a serious (often preventable) casualty, as 1/25 women die in childbirth.

When we arrived at the clinic, we were greeted by PIH Rwanda’s outreach coordinator, Christina, who gave us a tour of the facility, introduced us to the chief pediatrician on staff and answered a wide range of questions prepared by my students in advance and in the course of the tour relevant to the happenings of the clinic. We first walked through the small laboratory where test results are developed. We learned from our guide that children and adults can have their blood tested for HIV and learn of the result very quickly, usually within 20 minutes of the test, although for infants the test must be sent to Kigali to go through a more elaborate process. The clinic is fortunate to own a machine which tests HIV+ patients’ CD4 (T-cell) count, essential for knowing what type/dosage of anti-retroviral medicine to administer to the patient in order to give him/her the best chance at living a healthy life. After visiting the laboratory, we passed through the maternity ward, pediatric ward, pharmacy (open 24/7) and men’s and women’s wards, in which the most common afflictions are HIV/AIDS, malnutrition, tuberculosis and malaria. Walking through the hospital and health clinic, Christina drew our attention to photos on the walls of before and after shots of children and adults who had been treated there. Adjacent to the maternity ward was a photograph of an emaciated baby girl named Jennifer, who had been left at the hospital’s entrance at 13 months of age weighing a mere seven pounds. Christina explained to us that to children that small they feed plumpy nut, a peanut butter based substance enriched with protein, vitamins and nutrients that causes rapid weight gain. She informed us that packets of plumpy nut are also often prescribed for malnourished patients after they leave the hospital in order for them to keep their weight up, as opposed to handing the patient food packets, which are usually distributed among all of the patient’s family members out of necessity. When a child like Jennifer is admitted to the hospital for malnutrition, (s)he spends two to three weeks living there, being fed regularly and monitored by doctors and health workers until (s)he regains strength. Patients are permitted to come with one family member (usually their mother), and in that recovery time, the parent takes classes at the clinic on making nutritious meals utilizing the food and resources available in the region. In those weeks the patient’s parent also gets trained in how to best maximize the space that the family has for gardening, even with a very small plot of land. Jennifer’s healthy “after” photo taken several few months later was remarkable, depicting a slightly chubby, smiling toddler. Even more remarkable is the story of her mother, who initially abandoned her because she thought that as an orphan Jennifer would be treated more expeditiously than if she had been brought in with a parent. After treatment and swift recovery, neighbors to PIH alerted the mother of Jennifer’s improved condition, which prompted her to come back to the hospital to find her child. Since reuniting with her there, Jennifer’s mother now lives and works at the hospital, teaching other Rwandans how to keep their children nourished and healthy.

Another success story that we learned in viewing before and after pictures was of Peter, a six foot tall man in his forties whose body – which resembled that of an emaciated 85 year old - was wasting away due to an advanced case of Tuberculosis. This common infectious disease, the number one cause of death among Rwandans with AIDS, primarily attacks a person’s lungs but can also cause destruction to ones bones, joints and skin, as in the case of Peter. Despite the pleas of family, friends and neighbors for him to visit the clinic and seek treatment, prior to arrival Peter was convinced that his death was imminent and inevitable. He asked his loved ones to leave him alone to die. Fortunately, they insisted that he visit the clinic. After a quick diagnosis of the illness and monitored antibiotic treatment over the course of a year, his health was restored and he has resumed a normal life. His “after” photo was hardly recognizable, depicting a strong, smiling middle-aged man who gained over 100 pounds since he was first admitted to the clinic.

Hearing about the treatment of TB patients made me wonder what the hospital did to minimize the spread of germs, illness and most importantly, contagious disease like TB. Our guide Christina explained that not only does Partners in Health have some of the world’s finest doctors caring for its patients, but they also use students from Harvard’s architecture programs to design the facility so that its structure and airflow minimizes the spread of disease and bacteria. She went on to note that when she first arrived to work there she didn’t understand why the hospital seemed to put so much emphasis on it structures and grounds maintained so well, with gardens, assorted plant life, bamboo shoots and trellises lining the buildings and walkways. While it clearly made the clinic and hospital look nice, it seemed a bit frivolous when there were so many larger problems to address in treating the surrounding community’s patients for AIDS, malnutrition and malaria. But she explained to us that in fact, the hospital looking nice and well maintained serves a dual purpose: it shows the community that PIH cares about the property, and it presents itself as a welcoming, comfortable place that is conducive to healing.

The most meaningful aspect of our visit to Rwinkwavu happened towards the end of our tour, when we met with a group of HIV+ children who come to the clinic every two weeks for group support and counseling. Each of these children has been living with HIV since birth, having been infected with the virus by their mother. Just prior to meeting with these 30 children, we learned that when an HIV+ expectant mother is on antiretroviral medicine and the clinic is involved in the pregnancy and birthing process, the mother-child transmission rate at Rwinkwavu is a mere 2%. Evidently, none of these children were fortunate enough to have such close medical monitoring when they were born; some mothers did not even know they themselves carried the virus and may have been infected (and in some cases impregnated) via rape during the genocide. Despite the hardship of being born with HIV, these children were smiling, bounding with energy and extremely affectionate toward us visitors. As soon as we walked into the large playroom where they convene, we were greeted with singing, clapping and dancing. We spoke to the children in Kinyarwanda and English, asking them their names, ages, favorite foods, favorite school subjects and why they liked meeting together at Rwinkwavu. Our three students from the Anti-AIDS club were especially good with the children in conversing with them in Kinya and responding to questions about where they came from in Rwanda, why they dressed alike (in school uniform) and if they were Ababikira – nuns of the Benibikira order! Our girls laughed and explained that although they were not nuns, they do attend a school administered by them. When we eventually left the playroom to talk with Dr. Sarah, the chief pediatrician at Rwinkwavu, the children followed us out, clinging hands and giving hugs as we walked. After parting ways with the children, we were surprised to learn that while most of them appeared to be anywhere between 5 and 7 years old, almost all are in fact between the ages of 9 and 12. HIV+ children who are treated at Rwinkwavu are told of their condition and what it means at the age of 5, and of course put on antiretroviral treatment that should allow them to live long and productive lives. Because of the opportunities afforded to them by the clinic, we are quite certain that some of these children will one day study at Maranyundo.


References: Rwanda/Inshuti Mu Buzima, Partners in Health. http://www.pih.org/where/Rwanda/Rwanda.html
English, Bella. “In Rwanda, Visionary Doctor is Moving Mountains Again.” The Boston Globe, 13 April 2008. http://www.boston.com/news/world/articles/2008/04/13/in_rwanda_visionary_doctor_is_moving_mountains_again/?sid=ST2008051504314&s_pos=