The Clinic

Before we begin a discussion of my day in the clinic, let us reflect on where Rwanda was and where it is today. In 1994, the genocide took place which essentially destroyed the entire country. Rwanda in 1994, which was already one of the poorest in the world in the midst of a civil war went through an unfathomable trauma and was left with nothing. The government buildings were ransacked and pillaged. It was a civil war. Bodies everywhere. Over 99% of the population either participated, was a victim of, or witnessed the violence. They had to build Rwandan society from nothing. There was no educational system, no healthcare system, no commerce, nothing. A herculean task unequaled in scope and complexity in the history of the world in modern times. The modern Ministry of Health was created outside under a tree. And the Rwandan government over a period of time built a healthcare system where over 95% of the population has health care coverage. An interesting NY Times article to see.
https://www.nytimes.com/2017/07/18/business/economy/senate-obamacare-rwanda.html.

Overall lifespan has improved over the last several years from 40 to 66. Those are hard numbers to move. A lot hard to move than those pesky patient satisfaction scores Kaiser is always trying to improve that’s for sure. People are being seen throughout the country and getting good basic health care. Now, the impetus is to strengthen and improve the system by providing specialty care throughout the country by sending those that need to be seen by specialists to Kigali, the capital and then ultimately, place specialists throughout the country. The country is small, only the size of Maryland, and although it is very hilly with variegated topography, it has an excellent paved, and well maintained road system. It is true that many people live far from the roads, there is extensive cell phone coverage throughout the country. Buses can get one from many places to our hospital, CHUK, the main teaching hospital in the country. Based on this infrastructure, anyone can be seen by a specialist with a referral at their local clinic or district hospital and brought to CHUK, one of three main referral centers in the country. This is where I fit in and this is where our clinic lies.

It started to rain during our clinic. It is raining hard and you have to speak loudly to be heard. When I arrive at clinic, the patients are all here packed into small seats, waiting. There is no appointment time, only a day. Tuesday is specialty day, so there are many patients with orthopedic injuries, and lots of patients holding their catheter bags waiting in the waiting area. No modesty or privacy here. There are several uniformed guards in the waiting area armed with large military style weapons. They are here to keep the peace and guard the prisoners who are also waiting to be seen. No one complains about waiting to be seen. No one. There are also several people dressed in all pink with a pink button down polyester shirt and matching pink polyester shorts with another compliment of patients dressed the same except in orange. They are prisoners who come from the prison to be seen. They are men and women, not shackled, looking as the same as the other patients and their families except for their garb. Both the men and the women where pink and orange. The colors signify the significance of their crime. Orange for minor crimes and pink for major crimes. Some are common criminals, others, who wear pink, are genocidaires, perpetrators of the genocide who have been convicted of their crimes. Sometimes I see these prisoners walking freely through the hospital unescorted. However, they certainly are not free and came all together on a special green bus labeled RCS Prisoners. If a prisoner tries to run, he or she will not be captured, but will be shot and no one will question it. No one. As I walk through the waiting area many somber faces look at me, These patients have all been seen before somewhere in the country and were referred to urology. The patients come from all over the country. Some have some insurance whereas others do not.

The first patient comes in to be seen. Dr Emmanuael Muhawenimana is presiding, the second home grown urologist produced in the country. He is 6 months out of training, but don’t let that fool you. He is not green and is ready to rock, a serious professional who can handle whatever walks in the door, from a newborn to the elderly. It is 7:30 am. The residents are not yet here. Voiding dysfunction, BPH on alpha-blockers and finasteride. Patient is here for follow up. He is doing well. His son, a gynecologist at CHUK is here with him. The patient has to return ever 2-3 months to get another prescription. He cannot get a script with refills to last a year, so he keeps coming back. His son is very worried about prostate cancer in his father yet there is not indication the patient has any significant prostate cancer. A long discussion ensues and the father, who happens to be father of the faith, a priest, is agreeable to our discussion. The son, agrees as well but I can see in his expression that he is not satisfied with the visit and is still concerned about prostate cancer. There is no second opinion option unless he is willing to pay for it. Time for him to go. It’s been over 20 minutes. He leaves and as he does Dr. Emmanuel asks him to call out the next patient. The door opens and the priest calls out the name of the next patient, all of whom are waiting right outside. The next patient comes in and sits down. A very brief two syllable greeting ensues and it is straight to business. He hands Dr. Emmanuel a piece of ruffled piece of paper that is an ultrasound request with the results on the back. It is loculated hydrocele. There is a blue curtain with a patient bed behind the chair where the patient sits. Dr. Emmanuel directs him there fro examination. The bed has a sheet which is used throughout the day. If the sheet is visibly soiled or dirty, we get another one. Otherwise, it stays. After examination, the patient is booked for surgery. Next a young, unmarried man with ED and PME comes to be seen. He is counseled and given a prescription of Viagra. Patients pay for their medications here. Some take them, some do not due to cost. So far, it’s all typical urology that would be seen in my practice. Soon, a 62 year old woman comes in wearing a brightly blue and green colored dress with matching hat. Another brief hello. She hands the doctor a a CT report. Stage IV bladder cancer invading the vagina, rectum, and ureters with severe hydronephrosis on the left. She is thin and on exam she has an extremely large and dramatic mass protruding her abdomen. To the layman, her abdomen is reminiscent of the the groundbreaking scene in 1979 classic Alien just before the alien announces himself to the universe.
How could it get it this point? She was seen in April at the district hospital and was thought to have “fibroids,” had some type of surgery, and now she is here with CT showing terribly late stage bladder cancer. So many patients show up late with unresectable disease. I have seen two today.

Dr. Emmanuel does not take lunch, He just powers through. Just takes one mango juice to get through. He is tough. The Rwandans are tough. They are quiet and reserved, but don’t let that fool you. They have incredible stamina and patience. Me, I take lunch and take a break. The whole clinical experience is in Kinyarwanda, so a welcome lunch is great for me.

It’s almost the end of the day and another typical story. Patient came from the countryside in the far east of the country yesterday on a bus . He has a suprapubic tube which was placed in the district hospital by a GP. It was placed because a urinary catheter could not be placed. He has a hard, nodular prostate and looks very sick. He has trouble walking and is being helped by his son. they cannot afford any medications. No psa was done. plan is for prostate biopsy and then possible orchiectomy and turp. Patient’s son and Dr. Emmanuel get into a heated discussion. This patient wants to be taken care of now. So, we admit him and add him to the list for prostate biopsy (fingered guided in OR—no US probe) and cystoscopy. I recommend a chest X-ray and KUB to look for osteolytic lesions. No bone scan here. No radiotherapy either, but they do have MRI and CT. As soon as that plan is announced, patient perks up, does not look as sick and walks out of the door on his own two feet. An Oscar nominating performance.

Last patient of the day. He was here last week. He has been here waiting since 730 am. He is wearing the same clothes as last week. I don’t think he ate anything all day and is here with a foley catheter to discuss his psa results which he was supposed to get last week but was sent out because it was never done. Well, one week later and he returns with . . . a free psa result but not total! Medicine at this hospital is like putting a puzzle together but you don’t get all the pieces, so there is some guesstimating involved. The physician has to lean on the art much more here than in the USA where we rely on the technology and forgo the art.

Clinic is over, and I forgot to heed Dr. Emmanuel’s advice. Never leave home without an umbrella.