June 1, 2013
Volume 77, Number 6
Committee News: Teaching Anesthesiology in Rwanda: A Multi-pronged Approach
Stewart L. Chritton, M.D., Brigham and Women’s Hospital, Harvard Medical School
Julia Weinkauf, M.D., University of Virginia
Craig D. McClain, M.D. M.P.H., Boston Childrens’ Hospital, Harvard Medical School
Jennifer E. O’Flaherty, M.D. M.P.H., Dartmouth Hitchcock Medical Center
Patricia Livingston, M.D., F.R.C.P.C., Dalhousie University
Faye M. Evans, M.D., Emory University
Sarah Kessler, Lifebox Foundation
Emily P. Nelson, M.D., Brigham and Women’s Hospital, Harvard Medical School
Marcel E. Durieux, M.D. Ph.D., University of Virginia
The opportunity to help train the future teachers of a country’s medical foundation is inherently uplifting.
– Stewart Chritton, M.D. (Kigali, Rwanda)
I brought home with me more than I left in Rwanda.
– Emily Nelson, M.D. (Butaro, Rwanda)
ASA members are extraordinarily active in teaching anesthesiology in the small central African country of Rwanda. This article gives an overview of related activities.
Human Resources for Health (HRH)
The HRH program is a large-scale effort to increase residency training capability in a sustainable manner, as described by
Craig McClain, Jennifer O’Flaherty and Marcel Durieux.
The HRH program in Rwanda is a bold initiative to dramatically improve health care capacity and quality throughout Rwanda. The primary goal of the anesthesiology component of this project is developing capacity and improving delivery of perioperative care in the country. Currently, there are only 14 anesthesiologists for a country of approximately 11 million people. At the 41 district hospitals, the first line of hospital-based care, with 81.5 percent of the functioning operating rooms (O.R.s) in the country, anesthesia technicians with two years of training after high school render the anesthetics.1 Over a seven-year period, HRH plans to improve indigenous capacity to the point where foreign assistance is no longer necessary and Rwandan physicians have the numbers to be self-sufficient with regard to care provision, education and research.
The Rwandan government partnered with three U.S. medical schools (Dartmouth University, Harvard Medical School and the University of Virginia) to recruit and support U.S. anesthesiology faculty to live and work in Rwanda
(see also the June 2012 ASA NEWSLETTER). Two U.S. anesthesiologists have since relocated to Kigali for one year to offer academic mentorship to existing Rwandan faculty and help teach Rwandan anesthesiology residents. They actively participate in didactic and bedside teaching in the O.R.s and the ICU, and they work closely with the Canadian Anesthesiologists’ Society International Education Foundation/ASA Global Humanitarian Outreach (CASIEF/ASAGHO) program that has been active in Rwanda since 2006.
In addition to the longer-term faculty, the University of Virginia has sent two anesthesiologists for shorter stays. These anesthesiologists have helped develop a program for education in thoracic anesthesia.
The three medical schools listed above continue to recruit faculty to work in Rwanda as part of HRH. The financial package the faculty member receives is quite generous for such an opportunity and includes housing and travel allowances, in addition to salary and fringe benefits. Longer-term placements (one year or more) are preferred, but interested individuals who can spend at least three months are encouraged to apply.
Canadian Anesthesiologists’ Society International Education Foundation/ASA Global Humanitarian Outreach (CASIEF/ASAGHO)
The HRH program started in August 2012. But for many years before, ASA has collaborated with CAS in supporting the
Rwanda anesthesiology residency program. Patricia Livingston describes the program.
CASIEF/ASAGHO has contributed to a highly successful anesthesia residency program in Rwanda since January 2006. As a result of the program, Rwanda now has eight new anesthesiologists and another 12 anesthesia residents in training. In addition to residency training, this year a multi-disciplinary simulation and skills center has been established and the SAFE Obstetrical Anesthesia Course was delivered to 116 Rwandan anesthesia providers.
Volunteer anesthesiologists from Canada and the U.S. spend one month at a time teaching anesthesia residents in Rwanda. Senior anesthesia residents with an interest in teaching and global health often accompany the volunteers. This has led to a rich cultural exchange between Rwandan and North American residents. In 2012, eight Canadian and five American anesthesiologists, and 10 North American anesthesia residents, taught in Rwanda.
The presence of the CASIEF/ASAGHO program greatly eased the start-up of HRH anesthesiology, as infrastructure and a well-organized teaching curriculum were already in place.
Now that HRH is up and running, the CASIEF/ASAGHO program may shift direction. HRH focuses on resident training and mentorship of faculty, but huge unmet educational needs remain for the anesthesia technicians. CASIEF/ASAGHO volunteers have begun to address education for this group through the SAFE Obstetrical Anesthesia Course and implementation of a countrywide Anesthesia Practice Network. This network allows technicians, who often work in isolation, to have access to mentors who are able to encourage and support safe anesthesia practice.
SAFE and LifeBox
Teaching residents is the primary responsibility of the CASIEF/ASAGHO and HRH programs. But the vast majority of anesthetics in Rwanda are administered by anesthesia technicians, and several approaches are taken to make anesthesia safer in these settings, as explained by Faye Evans
and Sarah Kessler.
Rwanda’s maternal mortality rate fell by almost 60 percent in the last decade.2 Nevertheless, with an average of 340 deaths per 100,000 live births (as compared to 21 in the U.S.3), it is still unacceptably high.
Qualified anesthesia providers are vital in a team response to obstetric emergencies. But a small district hospital in rural Rwanda may have just one anesthesia technician on call for the whole facility. It is into this environment that two exciting programs, one familiar to ASA members and one that we hope soon will be, rolled out across Rwanda in January 2013: the oximeter distribution facilitated by Lifebox, and the SAFE Obstetrical Anesthesia Course.
SAFE is a three-day refresher course, developed by the Ugandan Society of Anaesthesia, the Association of Anaesthetists of Great Britain and Ireland, and the World Federation of Societies of Anaesthesiologists, to improve the skills of anesthesia providers managing obstetric patients in low-resource settings. Through a highly structured and interactive series of short lectures, discussion, role play and simulation, the course provides a systematic approach to routine, urgent and emergent obstetrical anesthesia issues. An additional “Building Safe Teams” day was added to the Rwanda program, focused on team building, an introduction to the World Health Organization Surgical Safety Checklist, and skills for safe anesthesia practice, such as communication and equipment handling.
Ongoing professional training is difficult to come by for anesthesiologists in low-resource settings, but it is virtually non-existent for Rwandan anesthesia technicians. Therefore, the SAFE course, which was run back-to-back over two weeks in the small city of Rwamagana, was a golden opportunity. Twenty-six anesthesia providers were educated to be trainers of the course itself, and 90 anesthesia providers – from long-serving providers, to young mothers still nursing – from 20 district hospitals attended.
Implementing the SAFE course was also a good example of the various programs working together. CASIEF/ASAGHO volunteers participated in SAFE teaching, and during their absence, HRH volunteers filled gaps in the teaching schedule
The second program rolled out in Rwanda this year is led by Lifebox, the global health charity improving the safety of surgery worldwide through distribution of pulse oximeters, training and the World Health Organization’s Surgical Safety Checklist. The Canadian Anesthesiologists’ Society has adopted Rwanda for Lifebox and, through the generosity of its members, raised funds for 250 monitors to be distributed – enough for every single O.R. in the country. These were delivered, alongside the Lifebox education program, as part of the SAFE course.
In a joyful ceremony at the end of each SAFE course, technicians from the represented district hospitals stood up to receive their oximeters and their training certificates. They left with an essential piece of equipment and skills that will have an immediate impact. And while they may have returned by themselves to their district hospitals, they are a little less alone: the introduction of a countrywide Anesthesia Practice Network, which set up geographic clusters of providers and mentors, is intended to develop a long-term system of support for anesthesia technicians.
Partners in Health (PIH)
In addition to the programs described above that are reaching out to the district hospitals, Partners in Health also has volunteers working in these settings, as described by
Partners in Health (PIH) is a Boston-based non-profit organization whose mission is to partner with governments to provide health care for the poor, particularly for people in rural, underserved areas. PIH was invited to Rwanda and began work in 2005. Although PIH has focused traditionally on pediatrics and internal medicine issues, the organization has recently expanded its work to improving surgical and anesthesia care in Rwanda.
I moved to Rwanda in October 2011 to work and teach at Butaro Hospital. Located in northern Rwanda, the hospital is a 125-bed district hospital serving a catchment area of 400,000 people, which opened in January 2011. My work has been highly varied. In addition to delivering and teaching anesthesia, I have assisted with improving obstetric anesthesia skills and emergency airway skills; taught the use of peripheral nerve blocks under ultrasound-guidance; improved accessibility of emergency equipment, oxygen and blood products in the hospital; created a surgical schedule; set up a postanesthesia care unit; and taught preoperative assessment and postoperative care! I also taught the WHO Surgical Safety Checklist, neonatal resuscitation, pain management and Basic Life Support.
Stewart Chritton, M.D., Ph.D. teaches subarachnoid block technique with the Human Resources for Health program.
Marcel L. Durieux, M.D., Ph.D. gives a lecture on cerebral hemodynamics to Rwandan anesthesia residents with the CASIEF/ASAGHO program.
Patricia Livingston, M.D., F.R.C.P.C. (right) teaches obstetric anesthesia to anesthesia technicians at the SAFE course
Emily P. Nelson, M.D. teaches ultrasound regional anesthesia with Partners in Health.
For further information, visit:
Human Resources for Health: firstname.lastname@example.org, http://rwandahrhprogram.wikispaces.com
Partners in Health: http://www.pih.org/priority-programs/surgery, or contact Jonathan Lawson, Cross-site Surgical Program Coordinator, at email@example.com.
1. Petroze RT, Nzayisenga A, Rusanganwa V, Ntakiyiruta G, Calland JF. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg. 2012; 99(3):436-443.
2. Farmer PE, Nutt CT, Wagner CM, et al. Reduced premature mortality in Rwanda: lessons from success. BMJ. 2013 Jan 18;346:f65. http://www.bmj.com/content/346/bmj.f65. Accessed April 19, 2013.
3. World Health Organization; United Nations Children’s Fund; United Nations Population Fund; World Bank. Trends in
Maternal Mortality: 1990 to 2010. Geneva, Switzerland:
9789241503631_eng.pdf. Accessed April 19, 2013.