As I progress in this journey, I continue to ask myself how best to approach this mission to bring about positive change. One of my primary goals for this phase of my career is to see as many different models of humanitarian medicine as I can. Healthcare delivery projects like in Jordan, bedside clinical work and teaching like in Botswana, community-based clinics like in Panama, or skill-specific capacity building like in Afghanistan. In the process, I am taking notes, seeing which models feel sustainable and which ones don’t. If there is one thing I have learned, it’s that nobody can ever do this alone. Prominent involvement and support from local structures is key.

In Rwanda, this idea couldn’t be better represented than by the University of Global Health Equity (UGHE). UGHE is a medical and public health school birthed from an agreement between the Rwandan government and the US-based NGO Partners in Health as well as the Gates and Cummings foundations.

The aims of the project are simple: create the capacity to train the next generation of health leaders in Rwanda with a skillset and attitude tailored to reducing health disparity. So, after an initial proposal in 2014, the University was built and opened its doors to the first cohort of medical students in 2019.

The curriculum is tailored to meet this goal of reducing health disparity. As such, enrolled medical students get clinical training and also an integrated Master’s degree in Global Health Delivery. Visiting faculty from all over the world come to contribute in various capacities, from classroom to clinical teaching. With every passing year, the curriculum is refined and pieces added. One recent addition: a point of care ultrasound curriculum.

Enter Dr Bozo.

As fortune would have it, the active director of the point of care ultrasound curriculum was a former co-resident of my Butterfly Boy partner in crime Alex (from Kyangwali Refugee Settlement). So, as Alex and I brainstormed more ways to take our talents for capacity building abroad, we reached out and coordinated in the summer months of 2024. The end result was us meeting in Istanbul during my post-Afghanistan decompression to get slapped with suds at a Turkish bath house before boarding a plane to Kigali as internal medicine visiting faculty with a focus on the ultrasound.

Rwanda’s journey is a remarkable story of progress. Following the genocide of 1994, which claimed the lives of over 800,000 people, Rwanda’s economy was on the brink of collapse. Despite this, the post genocide government sought a path to reconciliation and recovery. They stamped out corruption and focused on rebuilding infrastructure, promoting economic growth, and investing in human capital. The finer details of this are lost on me (Damnit Jim, I’m a doctor not an economist), but the point is that they made the right moves in using their money intelligently to create a foreign investment friendly space. As a result, Rwanda’s economy has grown steadily through the new millennium, with GDP increasing by an average of 7.5% per annum between 2010 and 2019. Along with this have come improvements in poverty rates and crime reduction (Rwanda consistently ranks as one of the safest countries in Africa) with a clearly laid out plan to continue improving services across multiple sectors.

It was through this plan that the partnership with UGHE to increase the number of high quality leaders in healthcare came to be. With the backing of the local government and the muscle of money from high profile donors like the Gates and Cummings foundations, the environment was set for a prosperous partnership.

The evidence for all of the above was clear on my arrival to Kigali. The city is incredibly tidy, with robust and clean roadwork, countless development projects, and an overall respect for order which mirrored that of the West. Our stay in the capital was short, with a same day pickup that drove us to Butaro in the north where the UGHE campus was located. The ride was lengthy, starting with 90 minutes on clean paved roads before crossing into treacherous dirt and mud. Hugging the hillsides as we slowly crested up the mountains, some of the most intense greens I have ever seen provided delight to the senses. Just as the sun was coming down, we pulled up to a gated complex atop one of the many hills.

Small, the university has roughly 200 students, and its education facilities are not any larger than what you might see at a small boarding school. The facilities are new, with a few auditoriums, several classrooms, a simulation lab, library, and ample study space; the students have all they need. I learned immediately that being perched atop a large hill in rural Rwanda means there’s isn’t much to do in the evenings except to get dinner in the cafeteria, maybe use the gym, and then find ways to entertain yourself in the dorms.

Such is life.

At dinner I met Kelsey, one of the main educators and director of the ultrasound program who was the friend of Alex’s from residency, and Chandler, her long haired husband and also friend of Alex. They were residents together and embarked on a career in Global Health as a tandem, splitting their time between clinical duties in Alaska and research/teaching projects in Butaro. We were briefed on our expected role for the next weeks. Like always, as the ultrasound program got off the ground, we’d have to be adaptable and tolerate some growing pains in the process.

Such is life times two.

The next morning we took the shuttle at 7:15 for Butaro District Hospital.

Butaro district hospital is a 237 bed facility that serves a catchment population of around 340,000. Rwanda’s healthcare system is organized in a pyramid structure, with community health posts that feed into district hospitals followed by provincial hospitals and then national hospitals as the referral sites for higher levels of care. Most recently renovated and expanded in 2023 to include more beds, a CT scanner, and a cafeteria that provides free meals to all patients, the hospital has the footprints of Partners in Health all over it. Although the hospital is the main teaching site for UGHE, it is not technically a UGHE hospital as the Ministry of Health still employs the clinical staff independently from the university.

This time of year was the senior clerkship in internal medicine, which meant that the medical students were functionally serving as interns on the medicine service. In the mornings we would take the bus to the hospital and start with morning report from one of the med students who presented patients from the prior evening. In a fashion akin to how teaching was done in Botswana and Ireland, the medicine specialists (of which there were a few of us), would pick apart the presentations as a teaching exercise. After the overnight med student had presented all the new admissions, the students would go on to their pre-rounds for an hour or so until we convened on the wards to round.

We typically rounded in two teams, splitting up the butterfly boys on either side. Joining us were the other visiting faculty, such that both teams had two attendings. On the first morning of rounds I met Adeline, a Rwandan national and recently hired full time faculty member who trained at the University of Rwanda. She was still young, only a few years removed from her residency, but had the aura of experience akin to the world-beating clinical detectives I met in Botswana. We also had Zaheer, a Canadian-Indian in his early fifties who worked in the Harvard network. He would go on to become good friends with Alex and I over the next few weeks working together. On this particular morning, I was paired with Adeline as we stood at the bedside while a clerk presented one of the cases from the previous day.

‘This is a 28 year old male patient who presented with a one week history of fevers, abdominal pain, and diarrhea,’ she said.

She then went on to summarize all the relevant details of the case. The diarrhea started watery and then turned to constipation, and his symptoms were worsening at home before presenting to our emergency room. On arrival, his exam was notable for abdominal tenderness, a fever, and sweats. His vital signs were not particularly eye-catching, without any overt shock, low oxygen, or heart rate changes. Most of his labwork was still pending, with the exception of a cell count showing low white and red cells. I would go on to learn that this complaint was one of the bread and butter admissions in this region, a historic foe of our immune system dating back to antiquity: typhoid fever.