Tuesday, July 17, 2012

Mountains Beyond Mountains

I just finished reading the book, Mountains Beyond Mountains by Tracy Kidder.  Although the title makes it sound like a story about Rwanda and it's Land of A Thousand Hills, as it is widely known to have, it is mostly about Haiti.  The story is an inspiring account, following Dr. Paul Farmer as he tackles some of the world’s most pressing medical issues by bringing modern medicine to those who need it most in developing countries.  It documents the trials and tribulations of his quest and illustrates that one person truly can make a difference in the world.  I am not a non-fiction buff, but this book was passed along to me because I was invited to visit one of Dr. Farmer’s projects in Rwanda – Partners In Health (PIH) Rwinkwavu (Southern Kayonza District), or Inshuti Mu Buzima as it is called in Kinyarwanda.  One PIH motto is “providing a preferential option for the poor in health care,” and that is precisely what I saw in action when I spent a day in the rural area that surrounds PIH Rwinkwavu. 

In partnership with the Rwandan Government and the Clinton Health Access Initiative, PIH is working to build upon and enhance the public health system in three rural districts in Rwanda.  The project was designed as a comprehensive primary health care model within the public sector.   There is a 150-bed state-of-the-art hospital and cancer center (opened in January 2011) along with 15 health centers in Butaro, a 120-bed hospital and 14 health centers in Kirehe, and a 110-bed hospital and 8 health centers in Rwinkwavu.   The entire Rwandan project serves a catchment area of 800,000 people through three district hospitals and 37 health centers.

The tiny nation of Rwanda is the most densely populated country in Africa, with a population of more than 10 million in an area smaller than the state of Maryland. Rwanda is one of the poorest countries in the world, ranking 166 out of 187 countries listed in the U.N. Development Program's Human Development Index.  As if it didn’t have enough challenges to overcome, the 1994 Genocide Against the Tutsis resulted in a massive loss of health professionals and the collapse of health infrastructure. The prevalence of AIDS in Rwanda today is in part, a consequence of the genocide. Estimates vary, but it is believed that between 8 and 13 percent of the population is infected with HIV.

Rwanda faces an acute shortage of medical personnel, with only one doctor for every 18,000 people. In the rural districts where PIH is based, the shortage is even greater.  When PIH began work in 2005 in two districts in southeastern Rwanda, there were an estimated 500,000 residents living there, without a single doctor.  PIH’s first order of business when they began working in Rwanda, at the request of the Rwandan Ministry of Health, was to introduce quality AIDS prevention and care to these rural districts, while at the same time addressing other medical and social issues, such as the following:

·         Malaria is a major cause of death among children and adults in the area
·         Maternal mortality rates are high. One out of every 25 women die during childbirth, because family planning and obstetric care are unavailable in rural regions
·         Common illnesses that can be prevented with vaccines, treated with antibiotics and survived by those who are well-nourished continue to kill thousands of Rwandan children
·         Tuberculosis is currently the leading cause of death among Rwandans with AIDS and kills many others who are not infected with HIV
·         Hunger and malnutrition are major contributors to many deaths and are the principal cause of death for many Rwandan toddlers

Rwanda's Inshuti Mu Buzima (IMB) Project Timeline (taken from www.pih.org)
2004 – The Rwandan government invites PIH to reinforce the national HIV prevention and treatment program in rural areas

          The Rwinkwavu hospital is reconstructed and reequipped (see photos below), and training begins for clinical staff and community health workers. 
          HIV testing is offered, and by the end of the year, 17,000+ people have been tested and nearly 700 started antiretroviral therapy (ART). 
          1,000+ patients visit the clinics each month and nearly 5,000 women receive prenatal counseling, 700 food packets per month are being distributed per month to HIV and TB patients and their families.  

          A 30-bed pediatric center is built at Rwinkwavu Hospital (see photos above), fully renovated operating rooms open, and workers begin working in four health centers in Kirehe district, where there are an additional 350,000 people. 
           1,500+ food packages are distributed each month, and the World Food Program distributes an additional 1,000 per month.
           IMB builds more than 35 houses to support social and economic rights, pays secondary school fees for nearly 400 students, and creates skill-building workshops which provide jobs. 
           At the end of 2006, 2,000 patients are enrolled in ART, 800+ community health workers are visiting patients daily to distribute and monitor medications, and a total of 91,325 patients visit IMB.

          IMB, along with the Ministry of Health launch a rural health initiative to bring quality health care to every rural district in Rwanda.
          Burera hospital is renovated, and plans for a new hospital are made.  Burera is home to 400,000 people, who had previously been served by 1 doctor and no functioning hospital.
          1,200 community health workers begin staffing the community-based model of care.
          IMB expands to a seventh site in southeastern Rwanda, and establishes chronic care clinics at all of its sites.

           A new district hospital in Kirehe is completed
           An agricultural training center at Rwinkwavu Hospital begins producing food for hospital patients and provides free agricultural education for parents of malnourished children and HIV/AIDS patients (see garden and sapling photos below)

    IMB provides training and salary support for community health nurses, supervisors and workers to care for Burera’s 400,000 people and 13 health centers  

2012 – 

Although my visit to the PIH/IMB Rwinkwavu Hospital and training facility moved and inspired me, the part of the day that left an indelible impression on me was when I went along with PIH workers on a site visit to one of their patients, who they have been working with for over 5 years.  It was there when I met the little boy (pictured above, to the left), who was featured in one of my previous blogs.  This little boy’s mother faced unfathomable challenges when she returned from exile in Tanzania after the Genocide.            
PIH built her a house (pictured below), provided her with antiretroviral treatment, provided clothing for her family, along with prenatal care (she was 6 months pregnant with the little guy pictured below), and professional development skills which ultimately led to her successful agricultural business.  She is now a model citizen in her rural village, welcoming less fortunate neighbors who have fewer resources into her home. I spent time in her aluminum-roofed house where she, her elderly mother and four children share three rooms, sleep on mattresses on the concrete floor (under mosquito nets), and run a small business.  PIH saved this woman’s life, gave her children a mother, her mother a daughter, and rescued her from a calamitous situation.  Her son ran into my arms during my visit to the home, and stood, mesmerized, staring into my eyes for most of my stay.  I saw the value of PIH’s work in his eyes.  Where many would have seen dirt and poverty and sadness, I saw hope and love, and a future – not just for this family, but for Rwanda as a whole.

In addition to Rwanda, Partners In Health works in some of the most dire parts of the world – Haiti, Lesotho, Malawi, Mexico, Peru, Russia, Kazakhstan, with additional partner projects (projects that are working to implement the PIH model across the globe) in Burundi, Guatemala, Liberia, Mali, Mexico, and Nepal.  

For more information on Partners In Health and their projects all over the world, visit www.pih.org


  1. Thanks for adding some perspective to those of us living in the 'first world,' Barre. Love the photos!

  2. Thanks so much, Barre. I had heard of PIH but didn't know much about their work. I am really enjoying experiencing this year through your eyes and experiences. Thanks so much for taking the time to post these stories. Curious - where do the medical professionals who work for PIH receive their training?