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Rebecca Tinsman, RPA-C I’m volunteering for a month at the WE-ACTx Clinic, Kigali, Rwanda. This all came about when one of the clinic founders, Dr. Kathy Anastos, spoke at our HIV rounds. Kathy talked about her clinic in Rwanda, founded when she and Anne-Christine D’adesky, an HIV activist and Pulitzer-nominated writer, wanted to help the HIV-infected people of Rwanda after the 1994 genocide. More than 250,000 Tutsi women were raped by Hutu men during the 100 days of genocide. Today, many of the women infected with HIV during the genocide have AIDS and are in need of experienced medical care. Rwanda is now one of the most stable countries in Africa, but it is still struggling to meet the needs of the sick. When capable foreign aid is offered, it is often accepted. 7 AM I leave the house in the Kiyovu section of Kigali for the 25-minute walk to the clinic. The walk is all up hill and down and around. “Around” because President Kagame’s compound extends to the most direct route, and the road is blocked and heavily guarded. “Up hill and down” because Rwanda is known as “the land of one thousand hills” for good reason. If you should mention his country’s sobriquet to a Rwandan, he will tell you that whoever was counting the hills missed a few. We-Actx is on one of the main streets in Kigali, not far from the embassies and big NGO offices. The clinic is on the second floor of a new building and has a wide balcony overlooking the street. The women who come to the clinic for their semiannual visits often sit there and talk while they eat the breakfast that the clinic provides. Some of the women walk for hours to get their care. Others take “mini-buses,” which are actually vans into which 16 to 20 people are crammed. The buses cost about 75 cents. Nothing to you and me, but that’s nearly the average daily income in Rwanda! I get to the clinic and climb the steep stairs. The women in the waiting room are singing hymns. Ambient clinic and street noise disappear behind their voices. Before setting up the exam room with Bosco, the Rwandan nurse I work with, I go to the bathroom. No water today. The water comes via an artesian system, and the water table is too low now. Someone brings up water in a 5-gallon plastic jug. That water is used to flush the toilet, to wash hands, and to hand wash the clinic laundry. WE-ACTx stands for Women’s Equity in Access to Care and Treatment (www.we-actx.org). WE-ACTx has two parts: the RWISA study clinic and the ambulatory HIV clinic. We are working on the RWISA study—the Rwanda Women’s Inter-Association Study, a sister to the stateside Women’s Interagency HIV Study (WIHS). In addition to examining the women, we measure to document any corporal changes HIV may effect. The study at WE-ACTx has 800 HIV- positive women and 200 HIV-negative controls. HIV infection is generally not treated in Rwanda until the CD4 cell count drops below 200/mL or the patient suffers an opportunistic infection. At that point, antiretroviral therapy is usually instituted. At WE-ACTx, most of the women I meet are on a fixed-dose regimen containing nevirapine (Viramune). 8 AM TO NOON Bosco and I call in the first woman we are to see. Phlebotomy for fasting labs is the first order of business in the morning. The labs are the usual—CD4 cell count, viral load, CBC, urinalysis, and comprehensive panel. Just as I am ready to insert my butterfly into my first patient’s vein, the electricity goes out, as it does nearly every day, and we are thrown into near darkness. Bosco puts a miner’s lamp on my head, and I resume work. We draw blood from six women, and after they eat, we call them back for their exams.  As I put the blood pressure cuff around one woman’s arm, she says something to Bosco in Kinyarwanda. Bosco laughs and tells me, “She says her pressure will be high because she has never been touched by a muzungu (white person) before.” That possibility has never occurred to me. I find that whites, especially outside Kigali, are a rarity and a source of much interest. No matter where I walk, I hear “Muzungu! Muzungu!” inevitably followed by the patter of running feet as children excitedly run to look at me, and to touch me if possible. I have long, bright red hair, which increases my “museum specimen” quotient exponentially. By the end of my stay in Rwanda, I am used to having my hair pulled—not as a prank, but out of curiosity. Most Rwandans have never seen or felt anything like it. They are fascinated. Walking alone through a village in the Nyungwe National Forest, I don’t get more than 50 yards before I have about 20 children walking with me. The brave ones grab my hands and actually fight over who gets to touch me as we walk. I look at them, shake a finger, and say, “No fighting!” They don’t understand the words, but they definitely get the message because the rest of the walk is quiet, albeit weird. I feel like the Pied Piper of Hamelin. The women Bosco and I see at the RWISA clinic all get very basic exams, which include breast and pelvic exams. We do Pap smears and cervical lavages. It is not routine for women to have pelvic exams in Rwanda, and right now, even if Paps were routine, there are few doctors to treat any abnormalities. While I am in Kigali, a WE-ACTx patient dies of cervical cancer because there was no treatment available to her when it was detected. Many of my patients have scars, physical as well as emotional, from the genocide. I see an arm missing a hand; machete hash marks across a chest and abdomen; slash wounds across faces. One woman has a prosthetic leg, which, incongruously, is white. In the streets, I see legless teenage boys perched on hand-operated tricycles. I see another boy whose legs were amputated at the top of the thigh. He puts oven mitts on his hands and gets around by leap-frogging through the streets of Kigali. A man with one leg pole-vaults from place to place. The genocide is still visible everywhere you look in Rwanda. If any of the RWISA women are sick, they are referred immediately to the WE-ACTx side of the clinic to be treated by Rwandan doctors. During my stay, I see malaria, tuberculosis, and odd, bullous insect-bite lesions. I see an inordinately high number of breast disorders—deformities as well as masses. One woman I examine has a machete scar on one breast that is still infected 12 years after the fact! 12 NOON Lunchtime. Lunch is usually goat meat samosas and tea, followed by a walk to the market and shops, or just a rest on the balcony watching the people below go about their daily business. 1 TO 5 PM No patients in the afternoon. I usually work on the talk I give to the nurses each Friday. I keep it short and relevant—about how the different antiretroviral classes work, for instance, or about sexually transmitted diseases. I hire a translator and make slides. The nurses are really curious and want to learn, but they don’t have the resources to research on their own. Books are scarce, clinic computers are rarely free, and the computer café downstairs is expensive. One afternoon, I went to the clinic’s food program distribution center. There, all the women in the RWISA study are given 50-pound bags of corn meal fortified with soy protein out of which they make a thick porridge. Each month they receive a bag. For some families this grain is the only source of food they have, other than the food they can grow for themselves. In a drought, it may be the only food, period. At the center, there is a small shop where widows whose husbands were killed in the genocide and one widower work together to make pretty aprons and dolls in traditional Rwandan dress. They sell these items, which gives them a reasonable income. More important than the income, however, the shop applies President Kagame’s plan for reconciliation by employing both Hutu and Tutsi survivors—who now call themselves, simply, Rwandans. Today, I go to Icyzuzo to teach future HIV health educators about viral replication and where antiretrovirals interfere with that process. There are about 50 teenagers in the classroom. They look at me so intently I am disconcerted for a while, but eventually I relax. I have a great translator, a college student who is studying medicine at the state university in Butare. Together, we manage to present the lecture intelligibly, I think. Afterwards, the questions are just astounding: Is it true that all HIV-positive people in America are isolated from the rest of the population to prevent the spread of HIV? Why do T-cells get higher in the US and stay there, compared to Rwanda? Why is the spread of HIV so much higher in sub-Saharan Africa than in the US? 5 PM It’s the end of my work day. I take a packed mini-bus from Icyzuzo to the center of Kigali and walk the rest of the way back, up hill and down and around, to my digs on the outskirts of town. |
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