The next day would be my last with this cohort of students, so I bid them all good luck in their rotation when I boarded the Friday afternoon bus back for Kigali. This Friday evening was a special occasion: I was invited to the year-end party.

You know Juan Lopez loves a party.

So much does he love a party that he elects to wear his newly purchased Rwanda national team futbol jersey provisioned from the local market. However, it is only on arriving to the impressively chic Marriott Hotel conference centre for over 200 people that he realizes everyone around him is wearing a suit or cocktail dress.

Turns out it was more of a gala than a party, per se. And I’m in a jersey. Chagrin!

Thankfully, I showed up a little late (classic pez), and was able to hide myself in the back of the hall by the door for the ceremonial talks. Sitting there alongside Solomon, the Ethiopian Director of Medicine Education, I listened to the Vice Dean, a British guy, giving a sermon of sorts.

‘Without the help of all of you this would not be possible,’ he said before listing off names and singling people out from different divisions. ‘This is why I am happy to announce that we have just signed a new deal with MasterCard to the tune of 40 million US dollars to support our continued development of the university.’

Applause rang out.

Right, I thought to myself, that’s how a project like this comes together. I looked around and saw hundreds of people, local and foreign, filling the hall. This was a massive enterprise, and probably the single best funded medical school in the country. In my few weeks alone I worked with staff from Harvard, Stanford, Northwestern, Oxford, and other centres of academic excellence from around the world. . Partners in Health started here 15 years ago with a narrow project to build a cancer centre, which then became an active relationship with the Department of Health, with the genesis of the medical school coming years later. The people involved had tethers to big academic centres in the US already, and the know-how to secure grants from big name foundations like Gates and Cummings. It takes a big name, a lot of financial muscle, and a long period of relationship building to make something like this come together, akin to my experience at the ceremony for the University of Botswana-UPenn partnership with the US ambassador

I was seeing the process at the bedside from the bottom up, but if I want to be the one someday moving mountains, I have to understand the machinations from the top-down as well. This far beyond the larval stage where the project lived and breathed its own sustenance. I recognize that these entries probably read like I am front and centre doing the hard work and training the clerks, but that isn’t necessarily the case. Simultaneous to all of my anecdotes, Adeline, Solomon, Olana, Zahir, Kelsey, Chandler, and numerous other staff members scattered across multiple sites were doing more than I was. That’s only on the clinical end of things; in parallel there was an army of lecturers, tutors, and administrative staff running a University. They were the main characters here, and I just got to tag along for one episode and drop a pearl or two in the process. With or without me, the work here was already done, now they just had to let the snowball keep rolling.

The night that followed was as jovial as can be for a corporate work party. I got to learn a lot of song-specific dance moves imitating buffalo horns and other animals of the Rwandan lineage. I ate Jollof until I had severe gastric reflux, and there may have been a drink or two followed by an after party at a local bar. Life isn’t so bad.

The festivities paired with more cultural exploration of Rwanda in my off time. On our first weekend, Alex, Kelsey, Chandler, and I went to the National Park near the border with Congo and hiked a volcano, coming face to face with a family of silverbacks on the way down. The next weekend we ate Ethiopian food, visited a milk bar (yes, in Rwanda they have bars that only serve milk; imagine my elation.), and went to the cinema for $2 USD each. On Alex’s last day before he parted to return home, we went to the Rwandan genocide museum.

It’s impossible to understand that darkness of the genocide, no matter how hard we want to try. The scale of brutality and vitriol that circled during that period seems almost like too much to ever overcome. The way that Rwanda has been able to grow into this beautiful, safe, and economically evolving place is commendable and needs to be studied for generations. Part of their reconciliation, I learned, is a national month of genocide remembrance that brings conversations of the atrocities to the forefront of national psyche year after year. No longer are divisions denoted between the tribes, however real those divisions ever were to begin with.

‘There is no Tutsi or Hutu,’ one of the students told me. ‘We are all Rwandan.’

It is this sense of unity that I think the world is missing in so many places. The èus versus themè mentality, which may well have its roots in our stone age development in generating strong internal unity for nomadic hunter-gatherer groups, lends itself to the dehumanization of the ‘other,’ which seems like the only way we could possibly bring such harm to innocent civilians. So often I ask myself if medicine really should be where I place my efforts to try and improve conditions for the less fortunate, when really I would trade saving any amount of lives to find a way to bring compassion and community to the darkest corners of the world.

Such philosophical ruminations are inevitable when you’re in the field, otherwise you are doing something wrong. Still, although I would love to bring peace and kumbaya into the hearts of the ruthless, this was a pipe-dream and I would have to make do with my stethoscope. So how to go forward? For Butaro district hospital I had some ideas.

It started on the Friday of my second week in Butaro, when Nelly, one of the clerks, presented the case of our typhoid patient who died at the first iteration of the M and M conference. For those not in the healthcare space, M and M, or Morbidity and Mortality conference, is an exercise in breaking down cases in which patients had a suboptimal hospital outcome. Whether everything was done correctly or not in the process isn’t necessarily the point, but basically someone from the hospital will take a case that ended in a bad outcome and comb through all of the details from the moment the patient entered the facility until the end of their course. Embedded in this review is analyzing where the system, either at the level of individuals or at the level of processes, failed to prevent said bad outcome. When I was a senior resident, I did my M and M case on a young patient with sickle cell disease who went into a bad crisis and died, even though the patient was managed as well as any facility could have. I took care of patients that became M and M conferences, and it’s not something that should be taken personally. Nelly did a great job pointing out the many areas where the system failed to act and prevent our patient from dying of a perforated abdomen, and the whole thing got me thinking about how to provide more support to nurses and medical officers handling sick patients.

A series of conversations with Olana, Adeline, and a few others prompted me to write a proposal for a new sepsis recognition tool for nurses and medical officers to recognize patients that should be escalated to a specialist based on vital signs or worsening trends. The proposal was built on something called the National Early Warning Score (NEWS), that had been in use in the UK and Ireland for some time for this exact purpose. I sent the proposal, and step by step implementation plan to hospital and academic leadership while I was in Kigali. We later met as group when I went back to Butaro. Implementing such a tool takes a lot of time and effort, as you bring together leaders from several departments to avoid stepping on any toes. I knew that all I could do was place it in front of them, and the rest would have to be carried by someone here on the ground. As far as I know there hasn’t been much movement on it since I left Rwanda.        

Such is life.