How it all works

Rwanda’s medical system is a hybrid social medicine model.  It looks a bit like managed care.  They have multiple layers of medical “buildings.” 

Lowest layer is called a Health Center, maybe we would call it a clinic.  I will be visiting one of those next week.  All people with any sort of medical issue is required to go to a Health Center for ANY problem, no matter how severe.  Health Centers provide as much care as they can, and if the patients’ problems are beyond the Health Centers’ abilities, the Health Centers refer the patients to a District Hospital.  [NOTE:  any clinic of any type is called a “hospital” here if a doctor is on staff.  Thus, if a doctor goes to work at a Health Center, the Health Center then becomes a hospital.  I am told most Health Centers are nothing more than a one-room building.]  In the same way, District Hospitals (there are 32 in the country) do as much care as they can.  Once the patients’ problems go beyond the District Hospitals’ abilities, they refer the patients to a Referral Hospital (4 in the country).  The Referral Hospitals are the highest level of care available in the country.  For patients who have no means of transportation, the referring agency calls the ambulance (each District Hospital has one ambulance).  Because ambulances are transporting patients from Health Centers to District Hospitals and from District Hospitals to Referral Hospitals, it normally takes 2-3 days before an ambulance arrives.  Ambulances operate on a first-come-first-served basis (no triaging is done) and they have an average of 300 people on their list at any given time. 

We did a more intensive visit of Kibagabaga yesterday.  It is a District Hospital.  Remember, “hospital” means that doctors work there.  I would say that they provide the same level of care as private physicians or clinics in the USA.  Because of this, my suspicion is that Health Centers probably provide the same level of care as what we normally do at home:  bandages, cough syrup, antibiotic ointment, splinter removal, etc.  The District Hospital provides what we would normally expect a clinic to do:  stitches, wounds, pain management, cyst removal, etc. 

The one thing they do that is beyond a typical USA clinic is that they deliver babies.  Consider this:  they think of birthing as mundane as stitches.  We think of birthing as high risk and complicated as brain surgery.  A note of interest:  I found that our doctors were somewhat mortified by this, but our nurses found the Rwandan approach refreshing.  Isn’t birthing as natural as breathing?  It reminds me of a Bill Cosby commentary where he states the obvious oxymoron:  in the USA we take classes on “natural childbirth.”  Doesn’t the word “natural” imply that the process is natural, not complicated?  Why do we require pregnant women (and their partners) to take courses in order for them to have a natural experience?  Why do we have such strong sentiments against home births? 

I think a related issue is the USA worship of youth versus Rwanda’s honor of age.  50% of Rwanda’s population is under 18.  The life expectancy is 47.  I am 45 years old.  I am considered an old man.  In fact, I have not yet seen anyone who looks old to me.  Of course, Rwandans’ amazingly beautiful skin hides their age a bit. 

In the USA, even though we think of ourselves as reverent and respectful of our parents and grandparents, it is not uncommon for us to whine and complain about taking care of our parents.  It is difficult, to be sure, to transition from our roles as children who depend upon our parents to adults who must care for our aging parents.  However, we seem to have the freedom, maybe even the expectation that our peers will have sympathy for our troubles regarding caring for our dependent parents. 

Our worship of youth includes the expectations that we must provided education for our kids.  We are expected to do all we can to leave some sort of inheritance for our kids, whether it have monetary or sentimental value. 

In Rwanda, the immense reverence for the elderly shows up in the following ways . . .  Deaths of children are somewhat commonplace.  People have many children, partly because of cultural/religious values (Rwanda is over 50% Roman Catholic).  But they also expect to have 6 children so that they will have at least 2 who survive, hopefully more.  At some level, they have mixed feelings about having all of their children survive (as in “how can I feed all these kids?”).  Therefore, a death of a child is not nearly as devastating here as it would be in the USA. 

In Rwanda, it is such an immense privilege to have one’s parents live a long life, so much so that no child would complain about the difficulties of caring for an aging parent.  All care for an aging parent would be done with pride and joy – without complaint.

When one considers the high mortality rate here coupled with the extreme poverty, it is no wonder that the cultural norm is fatalism.  Fatalism + reverence of the poor (to the detriment of youth) = no concern for medical problems with babies.  I will give an example of this in my next blog. 

So much more for me to say, but we are off to a medical leader’s wedding now.

Ciao,

Christopher

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