Dr. Calvin Wilson Associate Professor of Family Medicine University of Colorado National University of Rwanda

Dr. Calvin Wilson Associate Professor of Family Medicine University of Colorado National University of Rwanda

Past decades have seen an explosion of technologic advances in medical practice: 1948 contact lens 1953 heart/lung bypass machine 1962 hip replacement 1973 CT scanner 1983 Cyclosporin approved 1995 LASIK eye surgery 2006 HPV vaccine

Medical innovations have improved many aspects of medical care over the years: Precise diagnoses More efficient and targeted therapies Quicker recovery and rehabilitation Better cosmetic results Better function with less disability

But, in resource constrained countries, medical technology can be problematic: High investment costs Inadequate repair and maintenance skills Poor access to consumable supplies (single-use supplies, recording paper, batteries, special tubing) Electrical supply insecure, irregular, or poorly accessible (1 plug/room)

Is it possible to practice high quality medicine in a low tech environment, such as countries that comprise the Majority World?? Case of Rwanda

Most densely populated country in Africa 11.3 million people in country the size of Maryland 45% of population under 15 years of age Average life expectancy in 2010-58 years (42 years in 2002) Urban population 19% Electricity access 20% GDP (2010) - $550/person Ethnicities Hutu 84%, Tutsi 15%, Twa 1%

Ministry of Health cares for 95% of population 5 referral hospitals 44 district hospitals 480 Health Centers and Health Posts >50,000 Community Health Workers (CHW) Community insurance system covers 90% of all population

Laboratory CBC, ESR, UA, Creat., Urea, Glucose, LFT, malaria smear, stool exam Diagnostic equipment BP, temperature, FHT, O 2 saturation (some) Xray chest, abd, extremities, skull Ultrasound (about 50-60% of hospitals) ECG machine, but no paper

Is it possible to practice high quality medicine in a low tech environment, such as Rwanda??

Back to Basics! History Empathy and culturally appropriate communication skills are critical Graphic descriptions will be given, but timeframe difficult Physical Exam Resurrect obscure clinical signs Old textbooks Use lab findings that are available Time Clinical evolution under observation or followup

Basic but not necessarily low quality! Meds from national generic list Eg. Sepsis use triple antibiotics rather than 3 rd generation cephalosporin Difficult diagnosis initiate treatment for 2 best possibilities, watch evolution Eg. Malaria vs. typhoid fever Time - Constantly re-evaluate clinical evolution and exam findings Eg. Persistent vomiting and weakness disease Addison's

Most patients recover completely and return to full function Average hospital stay or convalescence is longer than U.S. expectations Total cost to patient (and to government) is a fraction of U.S. costs Average 10 day hospital stay cost to insured patient - $18

Definition of high quality care Rapid discharge, quick return to work, minimal scarring, good cosmetic result, minimal rehabilitation OR Resolution of the illness, return to functional state of well-being

Time required for recovery Time off work, hospital stays very much longer than U.S. expectations BUT Rwandan worldview has more flexible view of time Nursing care Most classic nursing care (feeding, laundry, bathing) provided by family members or friends Nurses administer meds and monitor patients only Eg. Discharge of premature infants

Very little community-based or Health Center-based care available Eg. Patients must stay in hospital for full course of IV meds, or for fracture healing in traction Death and disability Eg. Congenital heart disease, renal disease, cancer Fracture disabilities

It IS possible to practice high quality medicine in a low tech environment, such as Rwanda, AND to see excellent results Our definition and expectation of high quality medicine may be refined by the culture in which we are working and the expectation of those patients

The most basic medical skills are still more important than technology: Empathic communication with patient and family Thorough history of illness and context of patient Detailed, targeted physical exam utilizing historical signs Close followup of the evolution of the illness

There will be a small percentage of patients whose lives might have been prolonged or could have been helped much more effectively if access to new medical innovations were available to them. It is personally humbling to watch how African patients accept long time-frames of illness and medical uncertainties with patience and on-going happiness.