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What a medical school on a Rwandan hilltop can teach the United States

Training global health professionals to deliver high quality care anywhere, reflects the Rwandan government’s stated commitment to equity — including health equity — and to prevent another rupture like the one that spurred the country’s 1994 genocide. | Stephanie Aglietti/AFP/Getty Images

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Doctors learn to treat patients without all the high-tech tools — and fairness and access are crucial.

BUTARO, Rwanda — Three hours along a bumpy dirt road from the capital of Rwanda, a new medical school is emerging from the unlikeliest of places — a small hilltop in the poor farming village of Butaro. The school’s name reveals its ambitious mission: The University of Global Health Equity. It aims to transform both medical education and medical care for the rural poor in central Africa and to serve as a model for more equitable health care around the globe.

The new university is setting out to achieve this from the poorest part of Rwanda, a nation still recovering and rebuilding from genocide and civil war a quarter-century ago.

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From this village, where only one in four residents finish primary school and the first doctor arrived just a decade ago, this new species of medical school aims to train doctors to treat the world’s people as they mostly live in the real world, without access to expensive and high-tech services. And its emphasis on equity, fairness and the social and economic factors that influence health holds more lessons than one might think for the United States — which spends $ 3.5 trillion a year on health care and still has one of the most unequal health systems in the world.

The uneven dirt roads winding through lush green mountains to Butaro from Rwanda’s capital, Kigali, yield spectacular views of a volcano, a crystal blue lake and stacks of perfectly cut rectangular terrace farms slicing through the hills. Most people around Butaro are subsistence farmers growing corn, carrots, cabbage and wheat; their cash crop is Irish potatoes. They climb steep rugged roads with enormous water jugs tied onto their bikes, or with forage for cows so thickly packed on their heads you can barely see their eyes. It’s lifetimes away from the bustling cities that medical schools and their students gravitate toward — and hardly seems a place that would hold lessons for rich countries awash in high-tech medicine like the United States.

That’s precisely why the university’s founders picked Butaro. Most people in the world live in rural areas like this, eking out a living on meager sums. To bring them health care, the medical school staff here believe, you have to go where they are, immerse yourself in their lives. You must understand what their houses look like, what they eat, how they work and care for their children.

“Our vision is a world where every individual no matter where they are, who they are and where they live can lead a healthy and productive life,” said Agnes Binagwaho, a Rwandan physician and vice chancellor of the university that opens its permanent campus this month. “Our mission is to radically change education, health education, so that we impact the way health care is delivered around the world.”

That mission, training global health professionals to deliver high quality care anywhere, reflects the Rwandan government’s stated commitment to equity — including health equity — and to prevent another rupture like the one that spurred the country’s 1994 genocide. The 100-day bloodbath killed about 1 million people and devastated the country’s health infrastructure, leaving Rwanda with the lowest life expectancy in the world. The university embodies the global community’s renewed commitment to Rwanda, after it failed to intervene against the genocide. The U.S.-based nonprofit Partners in Health leads the project, with initial funding from the Bill and Melinda Gates Foundation and the Cummings Foundation, a philanthropic organization founded by a Boston-based real estate family.

Lessons for the West: Fairness matters

The squat, one-to-two-story medical school buildings emerging from the hilltop in Butaro bear homage to Rwanda’s past. Their concrete walls are decorated in traditional Rwandan art called imigongo, black and white geometric patterns fashioned from cow dung, which symbolizes the university’s values: education, health, service and wisdom.

It would be easy to walk around Butaro as an American and dismiss the new university as almost quaintly low-tech, of little relevance to a rich country with top medical schools and hospitals. Patients in the Butaro hospital, built in 2011, lie in large open rooms with beds just a few feet apart, mosquito nets hanging overhead. The waiting room consists of rows of benches outside. Before the hospital the region had no electricity or indoor plumbing, let alone a chance at curing cancer.

But what’s happening here can resonate even in the world’s wealthiest countries. About 88.5 million Americans live in communities, often rural, that lack doctors and other health care providers. Like in Rwanda, rural U.S. populations tend to be older, poorer and have more chronic disease, obesity, mental illness and environmental and work-related injuries. These gaps in equity are precisely what the new Rwanda university aims to address.

Rwanda’s government has already made universal health insurance a reality, along with 12 years of basic education and universal access to HIV, malaria and tuberculosis medicine. The country rates higher than the United States in some key health measures like HPV vaccination rates and adherence to HIV medication. It’s the only country in sub-Saharan Africa to meet most of the United Nations’ millennium development health goals.

“Places like Rwanda can teach our broken health care system in the U.S. a lot, if we really open our eyes and our minds,” said Peter Drobac, an American physician who co-founded the school and envisions it as a model for the world. Drobac came to medicine after spending a year in the late 1990s working with orphans with AIDS in Tanzania who didn’t have access to the new life-saving drugs that had just become available in the West.

“It just felt really wrong,” he said. “And so that just kind of changed everything for me.”

Drobac, who directs the Skoll Center for Social Entrepreneurship at Oxford University’s business school, has spent more than a decade in Rwanda, and finds it rewarding to work in a country where the government recognizes how poverty and inequality fueled the genocide.

“The thinking is, if everyone’s lives are getting better and if no one’s left behind, that’s the only way we can make sure this never happens again. And so, it makes better health care a national security priority,” he said.

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Reversing the brain drain — and getting doctors to rural areas

Getting health care to all Rwandans means getting doctors to serve rural areas — a challenge in much of the world, but a particularly acute one here.

Rwanda currently has limited training for future doctors; the existing med school in Kigali, for instance, educates general practitioners but anyone who wants to specialize must go abroad. Many don’t return to Rwanda, let alone to places like Butaro. If they do, they find they have been given skills at odds with the reality they encounter as they practice.

The new university aims to change that. Its founders want to rethink medical education — and medical thinking — more broadly, in part by merging public health training with the more traditional med school curriculum. They plan to equip doctors, nurses and public health providers with the tools to care for their patients regardless of whether they have electricity or running water. And they want that care to be good — as good or better than anywhere in the world.

“I can’t tell you how many conferences I’ve been to where a bunch of well-off, privileged people like myself are sitting around a room talking about how to solve the problems of poor people and there are no poor people in the room,” Drobac said. “By really embedding this university within a relatively poor, rural community, it gives us the proximity to understand the problems that we’re trying to help address, and hopefully get different voices and recognize different kinds of expertise.”

The school opened in 2015 with a Masters of Public Health or MPH program, temporarily located in Rwanda’s capital, Kigali, and its first class graduated in 2017. This month it opens the permanent Butaro campus and in late spring welcomes its first medical students. The plan is to eventually add nursing and dental care, both of which, like the med school, will be joint programs with the global health degree.

The curriculum at Butaro evolved out of the frustrations the founders experienced themselves after they left Western medical schools and set out to treat people in remote areas.

Vice Chancellor Binagwaho, for instance, left Rwanda for Europe with her family when she was just four years old. She got her medical education in Belgium, but knew she must return home if she really wanted to save lives. She arrived in Rwanda in 1996, just two years after the genocide, in which a government-led Hutu nationalist movement had aimed to exterminate the Tutsi minority. Binagwaho knew she was a good clinician. But she was unprepared for the challenges she faced at a Rwanda hospital.

She did not know how to procure basic medications, let alone how to rebuild clinics and hospitals almost from scratch. She didn’t know the exact specifications of every piece of equipment she needed to order, or how to advocate so the director of her hospital would get what was required. “I was supposed to … do things I wasn’t educated for.” And she was supposed to do all that and more without money.

Frustrated, she almost returned to Europe after just a few days, but couldn’t get a flight right away, she recalled in a TEDMED talk. During the wait, she realized she had a moral obligation to remain in Rwanda if she wanted to save lives. Binagwaho would lead the country’s ministry of health from 2011 to 2016 before turning her attention to creating the school.

The U.S.-trained Drobac faced similar obstacles when he moved to Rwanda.

“There’s nothing more disempowering than having the knowledge where you know what to do for the patient in front of you, but not being able to do it,” he said, because the X-ray machine is broken or the supply trucks haven’t been able to make it to the hospitals.

These frustrations, part and parcel of practicing medicine here, are what drove many of the health university’s first students to its doors. Christian Mazimpaka was working as a doctor at a military hospital in the Southern Province of Rwanda that lacked essential supplies. He enrolled in the masters program to learn “how to complain, how to do advocacy, how to write about it and give voice to the challenge.”

History, before anatomy

The school’s first dean, Abebe Bekele, has developed a curriculum that addresses that. It doesn’t start with anatomy — or even health care economics. Students will start with six months of African history, Bekele said, and coursework on human rights, gender studies and social justice. Students will be expected to embed themselves in the community for a few weeks to a few months each year to see how their patients actually live and work — and why, for instance, a child treated for malnutrition will get sick over and over again.

“Children come to the hospital and they are very weak,” Bekele said. Doctors treat them; the children gain weight. But then they go back to their community, their poverty, and the disease returns. “Unless you try to understand the [causes] of malnutrition in the community, you cannot say you are treating the children,” he said.

Similar problems plague treatment of tuberculosis, a growing public health threat. Patients are sent home with a regimen of nine tablets a day for six months. Doctors then wonder why it didn’t work — without considering whether a patient has food, clean water, or a place to store the drugs.

Student training will also take place at every kind of Rwandan medical facility, from larger referral hospitals — the closest thing to an academic medical center here — to tiny community health centers. The idea is not just to expose doctors-in-training to a wide array of patients, but to force them to practice without tools like MRI or CT machines, and to gain skills not traditionally provided in the first level of medical education, like performing cesarean sections, appendectomies and other common surgeries.

“It used to be said surgery is a very expensive health care, only the privileged few can access,” Bekele said. “Not anymore. We have proven time and again that essential surgery should be there for everybody.”

The university’s medical program is starting small, around 25 to 30 students, carefully curated to select those who are likely to work in underserved areas after graduation. Binagwaho’s aims to reverse the brain drain, and her ideal student is one who would be a competitive candidate at the top medical schools in the West — but who is more committed to serving needy communities. Financial aid will help students avoid the “loan trap” that would propel them to wealthier areas and higher salaries. That’s an idea beginning to catch on in the U.S. too; NYU recently made its medical school free, and some other top tier schools are introducing various aid programs to encourage a more diverse and primary care-oriented medical workforce.

The school’s founders want to attract more historically disadvantaged students, including women, refugees and people who have not had access to a good education. They believe the best way to reach the most vulnerable patients is to create a health care staff from within those same communities. About 70 percent of the first class will be women. And the health university is building a remedial program so that poorer applicants can fill in gaps in their secondary schooling. (In Rwanda and some other parts of the world, students enter med school directly from high school, and their medical education includes some of what undergraduates would be taught in a U.S. college.)

The faculty will also be non-traditional. Community health workers – local volunteers with minimal or no formal health training — will be among the teachers, showing how expertise can come from the grass roots, not just the ivory tower.

In Rwanda, community health workers are elected by their neighbors. They make house calls, give nutritional advice, diagnose and treat diseases like malaria and diarrhea, and ensure people get vaccinated. Perhaps most importantly, they serve as the eyes and ears for the local health system. They know who doesn’t have enough food or a job, whose house needs repair, or who needs child care so they can get to the doctor — what the American health care system is just beginning to recognize as the “social determinants” that contribute to health.

“It will teach them the importance of providing quality care where the people live,” explained Binagwaho. And, she added, it instills cultural humility and empathy.

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For years, a single refrigerator housed a country’s worth of insulin

A small strip mall in Kigali gives a taste of the kind of health care envisioned for graduates of the new medical school. The small Rwanda Diabetes Association building looks like a mid-sized U.S. doctor’s office from 30 years ago. Two doctors and a handful of nurses on the dozen-person staff keep the clinic open 24/7. The director, Crispin Gishoma, and one of its physicians, Arsène-Florent Hobabagabo, both graduated from the university’s master in global health delivery program this past May. Even before that, the clinic modeled the type of care the University of Global Health Equity wants its students to practice.

The diabetes association was founded by Gishoma’s father, who was diagnosed with Type 2 diabetes in 1996 after falling into a coma. A construction worker, he had the means to get treatment but he realized that most diabetics in Rwanda did not. He set up a clinic to help. Though it’s called the “Diabetes Association,” the clinic helps with almost any medical problem — on occasion, even delivering babies. In a country like Rwanda, medical facilities must accept all patients.

The diabetes center also houses a refrigerator-freezer, a single ordinary kitchen-size appliance which, until the mid-2000s, in a country the size of Maryland, was the main method of storing insulin at the proper temperature. The doctors take that insulin with them as they make multiple trips each year to regional hospitals, assisting local medical staff and making house calls to reach patients where they are.

The younger Gishoma started out as a volunteer in his father’s clinic, and later took over its management. He’s developed a special knack for recognizing when patients need more than medical care and how to empower them, with dignity and grace.

He talks about a man who brought him two rabbits as a gift after receiving care at the clinic. Gishoma knew the patient couldn’t afford to give away the rabbits. Instead of refusing the gift, he invited the man to join the diabetes’s association’s vocational training programs, where patients learn a job skill while also learning to manage their diabetes. His gift was used to teach rabbit breeding, and patients today still receive rabbits, to eat or to sell.

“He got a chance to see his rabbits growing and served to other people,” Gishoma adds. “I wanted him to know that he is not just someone who is going to be helped, but he is helping others.”

Gishoma and Hobabagabo aim to use the data and research skills they gained at the university’s masters in global health program to improve patient care. They want to pull the association’s patient records to figure out, for example, how well they are doing at preventing or delaying complications from diabetes. This is crucial in a country where kidney transplants are unavailable and only the very wealthy can access dialysis. More important, they want to understand what causes Type 2 diabetes in their patients. In the western world, lack of exercise, and sugary diets and obesity are often deemed top culprits — but those are not common problems for Rwandans.

Idealism, out of a dark past

Despite the huge tasks ahead of them, the university’s founders are astonishingly idealistic — a position starkly challenging the country’s dark and violent past.

“Ubumwe,” Binagwaho said at the public health program graduation ceremony last May, asking the audience to say it out loud. “The root of the word means we are one. We are one, around one agenda, to improve the world.”

Ubumwe — it translates to “one people” — is an omnipresent word in Rwanda, where people have been urged to drop their ethnic identifies and identify as Rwandans. And this concept of unity drew Partners in Health to help start the school in Rwanda, says Binagwaho.

“You get knocked down. But you get back up. And then, then you help someone else,” said Paul Farmer, the MacArthur grant-winning Partners in Health founder, who had a hand in creating this school, told the public health graduates at a ceremony in June. “That’s an amazing thing to do. To take bitter adversity and turn it into something good and something good for others not just yourself. That’s the heart of global health equity.”

This reporting was supported by the International Women’s Media Foundation as part of its African Great Lakes Reporting Initiative.

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