Dr. Livingston returns to Rwanda (3rd edition)

Connections – Wednesday, January 16, 2019 (from Patty)

The best part of global health work is bringing likeminded people together. Then the magic happens. Rediet, an Ethiopian anesthesiologist, has come to learn about how Gaston set up the effective pain management program in Butare. She is hoping to implement a similar program in Addis Abba. Mary, pain specialist from Halifax, has been supporting Gaston for years and now she has bonded with Rediet. It is so rewarding to be part of this exciting network.

Gaston and the Butare team have done a marvellous job of organizing the first pain conference in Rwanda. There are 230 people attending – a mixed group of health professionals from around Rwanda (plus some visiting Canadians and Rediet from Ethiopia).

We were warmly welcomed by medical students in traditional Rwandan dress. Gaston had prepared beautiful conference packages for the attendees.

We heard a range of perspectives today with a good discussion about barriers to pain management in this context. One I hadn’t anticipated was a religious view that suffering pain is God’s will. I gave two short presentations with the key messages being that pain is complex, touches many aspects of a person’s being and treatments must be comprehensive. I encouraged everyone to remember non-pharmacologic options (working with patient expectations, listening, distraction for kids, physical modalities etc.).

Jon co-taught a regional anesthesia workshop with Alain, a Rwandan resident and expert in regional anesthesia. It was a pleasure to see how Alain has matured into the role of confident and skillful teacher.

At one time, anesthesia was the least desirable specialty. Alain was recently on the selection committee for new anesthesia residents. The tides have turned and now they pick the best. Indeed, they were not able to offer places to many of the applicants. This is truly a success story.

We have been busy working but found time yesterday to visit one of my favourite sandwich shops, Inzozi Nziza, run by a women’s drumming cooperative. Superb cinnamon ice cream with cookie crumbles was a hit with our team.

The pain conference continues tomorrow and then we have a VAST Butare refresher course. I hope we can squeeze in one more visit to Inzozi Nziza.

Suffering through pain in Rwanda – Wednesday, January 16, 2019 (from Chris)

The first day of the inaugural Rwandan “Zero Pain Conference” kicked off this morning in the beautiful town of Butare, nearly 3 hours drive from Kigali. The two day conference brings together MDs, non-physician anesthetists, physiotherapists, psychologists, researchers and many others interested in pain management. Delegates will have the opportunity to hear from experts in the field of pain medicine, and learn about novel ways to tackle pain both in and out of hospital, with the goal of reaching a “Zero Pain” Rwandan state – a lofty goal, but one that may benefit thousands while striving to reach it.

Since arriving here last week I’ve heard many times that Rwandans are expected to suffer through pain – whether that be labour and child birth, post-surgical, traumatic, or chronic type pain. The relationship to pain here is unlike any that I have experienced elsewhere. Many feel that pain is something that is meant to be endured, and that in time this may actually lead oneself to become stronger spiritually, physically and psychologically. Many Rwandans are deeply religious and feel that suffering through pain may allow them to become closer to faith. As such, most patients in hospital here do not complain of pain, and would not think to speak with their healthcare team if they felt that the pain regime prescribed to them was inadequate. Chronic pain, in particular, is not a well-known nor discussed topic, and there are currently only fledging programs hoping to change this.

Access to medications to treat pain are limited by stock-outs, and outpatients who must purchase their only prescriptions often lack the funds to do so. Fentanyl, morphine and ketamine are *usually* available, but these medications are not frequently prescribed on patient discharge, leaving post-surgical patients with limited options to manage their pain upon returning home. It is clear that stigma still exists around the use of these medications for pain management, and given the lack of multimodel analgesia options available, patients are not just accepting of suffering, but are in fact forced to suffer.

The concept of opioid addiction is complex, and sometimes poorly understood by patients and even their healthcare providers around the world, and that is no different here in Rwanda. Throughout this mornings discussions, the myths around opioid dependence, tolerance and addiction have begun to be broken down. Moving forward, patients and their doctors need to understand that one not need suffer in agony from acute pain purely to avoid the small possibility of dependence or tolerance. Opioids should not be feared, particularly if other options continue to be so limited. Frequent assessment and iterative treatment of pain is essential to ensure that patients do not suffer needlessly, and to prevent the development of chronic post-surgical and post-traumatic pain.

With the growing community of pain practitioners here in Rwanda, this country is set up to drastically alter the Rwanda experience (and indeed expectation) of pain and suffering. In discussions with the conference delegates today, it’s clear that a wave of change is upon the country – more and more healthcare workers are interested in learning about the pathophysiology, pharmacologic, and importantly non-pharmacologic ways to treat pain. We must continue to support these efforts moving forward, and while we may never see a Rwanda with zero pain, we can certainly strive for amelioration of the suffering that is so pervasive today.

Rwandan Pain Conference: From need to opportunity – Thursday, January 17, 2019 (from Stephen)

This week finds our team in the beautiful Butare (Huye). Long the academic hub of the country, the city’s highland setting provides for cooler breezes and more temperate weather than frenetic Kigali. The contemplative weather plays welcome host to this week’s latest adventure: the first ever international pain conference held in Rwanda.

Another achievement in the long collaboration between CASIEF and the Rwandan anaesthesia residency programme, the ZeroPain conference has been organized in its entirety through local expertise. Pain experts among our team, Drs. Mary, Patty, and Jon, stand as equals amongst other local and international invitees to deliver locally tailored content and solicit ideas on future research needs. ZeroPain is truly a coming of age for the Butare Pain Team and their ability to chart their own course as they set out to conquer unrecognized and untreated pain in Rwanda.

With topics from safety in regional anaesthesia, to empowering nurse led recognition of pain, locally informed pain pharmacology, to the vast potential of micro-research, the conference has had broad appeal. Equally broad has been its reach! In polling the audience, we discovered that the conference is playing host to nurses, physiotherapists, social workers, non-physician anaesthetists, residents and staff anaesthetists, and researchers!

In reflecting on the accomplishment this conference represents, I feel something needs be said about the dedication of the attendees themselves. Despite a very busy conference schedule (grueling might actually be more apt), the attendees were unflagging in their attention. While my concentration drifted, the attendees were busy scribbling notes; there was hardly a distracted cell phone scrawl to be seen. The need for a paradigm shift towards the recognition and treatment of pain in stoic Rwanda is desperate; if the indefatigable attention of the conference attendees is any indication, the appetite for change is clearly equal to the task.

Familiar and foreign – Friday, January 18, 2019 (from Jon)

The moment I step off the plane the warmth and humidity settle on my skin as I smell the slightly smoky air of a major city which is at the same time fresh – infused with eucalyptus. The tactile and olfactory essence of this place immediately takes me back to the last time I was here. Even though I anxiously wait for my bags to appear on the carousel, the knowledge that there is a friend waiting for me outside settles my nerves. The drive from the airport is relaxed. Christophe and I catch up on the last few years as I gaze out the window at the galaxy of lights running through the valley and up the hills.

Although the apartment is new (and beautiful), I quickly reorient to the city and landmarks. The remainder of the weekend – aside from sleeping – is sent visiting favorite restaurants, coffee shops, and bars. The downtown core feels comfortable, my pace slows to match the locals and the heat – except for when I cross the street, timing my stride to the meet the gaps between motos and cars. Our good friend Emmy comes to pick me up for a chat over a Mutzig at the famed Guma Guma bar in Nyamirambo just under the old apartment.

Returning to Rwanda gets easier every time. It’s a unique experience for me to visit another country where we know so many friends. The Dal Health Office and Anesthesia and CASIEF have created an amazing interconnected group of people. There is a completely different feeling when you’ve known local staff for years, met their families, hosted them in your home, and been hosted by them in their home. All plans and discussions start with the background of mutual respect and a shared history. This obviously changes how priorities are set and plans are executed.

Even in minor ways these relationships make things easier. If I’m lost, I’m a whatsapp message away from someone to pick me up. If I need a favour, someone is there and happy to help. We are supplied with advice about transport, restaurants, tourism, and avoiding problems in general. In short, the experience of Rwanda is increasingly comfortable. Yet, it remains an enigma.

Culture underlies everything we do. Despite our experience and interpretation by our friends, we have misunderstandings and missteps. Even Patty on her 14th trip to Rwanda emphasizes that she’ll likely never fully understand the intricacies of the culture here. We try our best, but we will never replace the knowledge of our Rwandan colleagues.

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Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.