As March 9th approaches, my stress management strategy has been to find something, nay ANYTHING, else to think about. So, starting at the end of this sentence, you will not hear anything about CaRMS, decision-making or my future. Instead, we will talk about my past, and more specifically, about Rwanda.
To properly describe to you the impacts of this experience, I feel it is important to take you back to when I decided to go Rwanda. This was not a decision that came lightly; after all it is very far, reasonably risky from an infectious disease standpoint, and it was very much at my own expense. It is therefore reasonable to ask what would motivate a medical student to take this on? I should preface my answer by saying that I am in no way a pioneer. A significant number of Canadian medical students opt for these experiences, and I think the motivations for spending time in a developing nation are different for different people. That being said, my motivations were both personal and altruistic. 
On a personal level, the country fascinated me. This is a country that, at the time, was only 13 years removed from a massive genocide and was rebuilding at a pace that had them ranked as one of the fastest growing nations in the world. Needless to say, this sparked my sociological curiosity. In addition, I felt that I had a lot to gain from a medical perspective. Being thrust into a situation in which there are a variety of illnesses that we do not encounter here, as well as having to work in an environment where the only technology you have to rely in is your head and your hands, is an experience that does not come around too often in the Western world. As far as altruism goes, I did not go under the illusion that I was going to solve any major problems or cure any endemic diseases, but I figured that if I could do something to improve the quality of life of just one person, the whole experience would be well worth it.
Armed with these motivations, I contacted the Rwandan department of health, and through a series of e-mails and leads, put together a rotation that was deemed acceptable by the McGill faculty of medicine. And so, at the end of July 2007, I boarded a plane to Rwanda. Actually, I boarded a plane to Boston, Washington, Rome, Ethiopia and then Rwanda, but those are just details.
My actual experience is very difficult to sum up. There were so many facets, so many adventures, and so many trying moments. While I was there I kept a daily journal detailing all of the above. What I have decided to do in this blog is share with you what I wrote as my first impressions, talk about some highlights, and then share the final thoughts that I wrote on my flights back to Canada.
As far as my first impressions go, it took me a little while to get past the ‘what did I get myself into phase.’ I arrived at the airport in Kigali and had to take a vehicle to get into Butare, where I would be working. While waiting in the van for the driver, I had my first marking experience, which I would write about that evening. A boy of no more than four years old was walking by the car when he noticed me sitting by an open window. He walked up to me and I called out ‘bonjour.’ He looked back at me with a smile and said ‘bonjou!’ He then proceeded to stand there for about five minutes, not saying a word just staring. That night I wrote, “For the first time in my life, I was the visible minority, the one that didn’t belong, the one being watched to see what I would do next. It’s a sobering feeling… let me tell you!” My first night in Rwanda was very challenging. I had not yet found my permanent accommodations. I was alone in something that for the sake of saving time I will simply call temporary. As I lay awake in bed, I wrote, “ I feel alone. I know I will be alone a lot on this trip and I am sure I will get used to it but for now, I am quite anxious. I don’t feel settled or organized and I have no way of reaching anyone. I am also very nervous about what lies ahead. It will all become clearer in the morning, but tonight may not be an easy one.” And it was not. Luckily, I was wrong about everything else. I was not going to be alone, and what lay ahead was nothing to be anxious about. In fact, it was all uphill from there.
As far as highlights are concerned, they were abundant. I will divide this into highlights in the hospital, in the community, and in my travels. In the hospital, I functioned as a senior trainee. I worked on an inpatient general medicine unit which had medial issues included meningitis, tuberculosis, HIV/AIDS related complications, cirrhosis and tropical infections amongst others. I also spent time in outpatient clinics dealing with mental health consequences of the genocide, ulcers, hypertension, and other chronic diseases. The volume of cases was enormous, the severity of disease was astonishing, and the lack of resources available was both shocking and humbling. When getting a CT scan requires borrowing a car, putting your patient in the back seat and physically driving them to Kigali (the capital city) or a nearby country, your medical history and physical exam become much more crucial. Although challenging and at times frustrating, I believe I am a much better clinician for it. I had the thrill of successfully diagnosing and treating someone for high potassium levels without having access to a blood test that told me what their potassium level was, and the satisfaction of watching a young boy get better after being given the right antibiotic for bacterial meningitis without having a microbiology lab to tell me which antibiotic to use. Although I make it sound glorious, it is important to remember that these are the highlights. For every thrilling case like this, I had several patients die because we couldn’t figure out what was going on or we didn’t have access to the appropriate treatments. My hospital experience was also marked by the opportunity to observe how patients took care of each other. Unlike in Canada, being admitted to a hospital does not entitle you to be fed. It is the responsibility of your family or friends to bring you food. The problem is that most people are very poor and because of the genocide, many people have no families on which they can rely. However, much like Rwandan’s came together to thrive in the post-genocide era, they came together to ensure that all of their roommates did not go unfed. The one or two patients who had families would bring food to share with everybody. No matter how sick they were mealtime was a social event. The younger patients would help feed the older ones and the weaker would help the stronger. In my little hospital unit, I had a microcosm that embodied the unbelievable spirit that represented what it was to be Rwandan.
In the community, the highlights were plentiful. I lived in small house with 3 Europeans right in the middle of Butare. We ate our meals with the locals, attended the local church and involved ourselves in all community celebrations and events. Through this, we made many friends and had the unbelievable opportunity to be invited into several people’s homes for dinner and attend a wedding in Kigali. Through these experiences, we gained access into the lives of young men and women who had lived through the most horrific of atrocities. We heard story after story of families being torn apart, of people watching their friends, parents and siblings being murdered in cold blood, and of people fleeing the country and trying to seek refuge in Congo and Uganda. The tragedies were countless, but no matter how depressing the story, it always ended with a little speech about forgiveness, moving forward, and re-building. The message was not one of hate, but rather one of hope.
Finally, when not at work, I had the luxury of visiting a very beautiful country. I had weekends off which provided excellent time to travel. I visited Kigali, the Niangua (not sure about the spelling) forest, lake Kivu and the Congo border. The country is filled with beautiful mountains, lakes and wildlife. Having an opportunity to enjoy all of these natural wonders is not one that comes along often in medical education but when it did, I think I appreciated it that much more. In addition to the scenery, my travels also took me into some of the smallest villages in the country. And when I say small, I mean 10 huts, no electricity or running water and people who eat what they catch. It was like stepping into a time warp. What was also incredible about these experiences was that for the most part, I was the first white person (or Muzungu as they called me) that many of them had ever seen. It was quite something to have an elderly citizen touch my face to see if I was real, or having groups of children compete to see who could hold my hand as I walked through the area. They were all so friendly and so innocent, but also so very helpless against the forces that they did not even realize they were fighting. I suppose like all of the other experiences I have described, these represented both a mix of fascination, enjoyment and eventual realization of how unfortunate the reality really was.
My time in Rwanda is the experience in my life that I am the most proud of. As I sat on the plane back to Canada, I had a lot on my mind. I will end this blog with an excerpt of what I wrote at that time. It reads, “ Time is a very strange concept. We claim to live in the present, but the present is a fleeting second that immediately becomes the past. For one month, life in Butare was my present. A house in the Tabah district with no hot water or flushing toilets was home. A hospital with no CT scan, no electrolyte reagents and a ward called 3B, full of very sick patients was where I worked. A culture of belief and faith, love and kindness, friendship and hospitality was a culture that was becoming my own. It WAS wonderful… but it was, and no longer is. A transition filled with overwhelming significance, but one that occurs in a fleeting second without ceremony or drama. And all that is left are the memories.”