<p>Bed nets, rehydration supplies, bandages, medicines, health education materials — all are necessary, all are welcome for public health efforts in the Third World. But to all that, add the crucial element of education, training, and mentoring for local health care workers. Investment in human resources must be part of the way forward. Adam Levine, assistant professor of emergency medicine and co-director of the Brown University Global Emergency Medicine Fellowship, spends several months a year working in Rwanda. His essay appeared first <a href="http://www.huffingtonpost.com/adam-c-levine/resources-for-health-program-rwanda_b_2482017.html">in the Huffington Post</a>, Jan. 15, 2013.</p>

Adam Levine: “All the medications and supplies in the world won’t do patients much good if there aren’t doctors and nurses and paramedical staff and community health workers trained to use them.”
Adam Levine “All the medications and supplies in the world won’t do patients much good if there aren’t doctors and nurses and paramedical staff and community health workers trained to use them.”
On a recent sunny afternoon in Rwinkwavu, a rural town in the small African country of Rwanda, I found myself rushing over to the pediatrics ward of the hospital where I have been volunteering off and on for several years. I had just received a text from one of the young Rwandan physicians I work with there asking me to come right away. Usually this meant that a child was about to die, and I tried to suppress the anxiety and fear bubbling up inside me as I hurried over.

I could hear the child in question before I even saw him — each breath he took created a deep honking sound as though a flock of geese were circling his bed. His thin frame was covered by a damp sheet, and beads of sweat gathered across his face. He was drowsy and delirious, foam spilling out of his slightly parted lips, and his eyelids were twitching spasmodically. As the ward nurse struggled to place an intravenous line and start up the sole oxygen concentrator machine we had available at the hospital, I turned to the young Rwandan doctor at the bedside and asked him what he thought was going on.

“Poisoning?” the doctor asked.

“Yes,” I said, “but what kind?”

He wasn’t sure, but I thought I knew. I had spent a fair amount of time learning about pesticide poisoning during my emergency medicine training in the United States, though I had never seen an actual case until I started working in Rwanda, where it was common for many rural families to keep relatively toxic pesticides on their farm. I could tell by the way this child was struggling to breathe and his declining level of alertness, that he would not survive more than a few hours without treatment. I asked the nurse to go to the pharmacy and bring back several vials of atropine, one of the oldest and cheapest medications and the antidote for this poisoning. While we waited for the nurse to return I spent the next several minutes with my Rwandan colleague going over the aspects of the child’s presentation that were consistent with pesticide poisoning, as well as the protocol for atropine administration. “Sometimes you have to give a lot,” I explained. “Don’t be daunted if doesn’t work at first.”

The nurse returned with the atropine and we quickly gave the first dose to the child. No response. We gave a second dose and a third — still no response. Meanwhile the child’s oxygen saturation was starting to drop despite the oxygen we were giving him, and both the doctor and the nurse were beginning to look doubtful. I began to feel a wave of fear rise up from my belly into my chest. What if I was wrong? What if it didn’t work? I told them to give a fourth dose — and then, over the course of a few minutes, the honking sound faded and the child began to breathe easier. I could feel the tension in the ward melting away as we all began to realize that he was going to be OK. The boy’s life was saved, but even more importantly, the doctor and nurse there that day would know how to save the next child who came in with similar symptoms, and the one after that, and the one after that.

For much of the last several decades, the field of global health has focused on the material aspects of healthcare delivery in poor countries: building clinics and hospitals, increasing access to cheap medications and vaccinations, distributing bed nets to prevent malaria or packets of oral rehydration solution to treat diarrhea. All of these things are incredibly important and have certainly saved many millions of lives, but in recent years there has been an increasing focus on what is arguably the most valuable resource within any healthcare system: human resources. All the medications and supplies in the world won’t do patients much good if there aren’t doctors and nurses and paramedical staff and community health workers trained to use them, and to teach patients to use them. Unfortunately, in much of the developing world, these very same healthcare workers are in incredibly short supply. Where I work in Rwanda, for instance, there is about 1 doctor and 10 nurses for every 15,000 people — more than an order of magnitude fewer than in the United States and other developed countries. Compounding this problem, the training programs for doctors and nurses in much of the developing world are of relatively poor quality, leaving otherwise bright people without the knowledge and skills necessary to maximize their effectiveness as healthcare providers.

Almost since finishing my own training in emergency medicine four years ago, I have been spending several months a year working with newly minted doctors and nurses at several rural hospitals in Rwanda, teaching them what I know about emergency care for children and adults, and learning more than a few things from them about providing medical care in extremely resource-limited environments. It has been incredibly heartening over the years to slowly watch the standard of medical care climb at these hospitals. One of the wonderful things about knowledge and training is that they are inherently renewable resources. Unlike drugs and equipment, knowledge never has a stock-out, never breaks down, and never stops working when the power goes out. In my experience, improving medical provider training also has the effect of improving other components of the healthcare system, since trained doctors and nurses feel empowered to demand the medications, equipment, and efficient systems that they know they need in order to save patients’ lives.

This trip back to Rwanda, though, I have the opportunity for the first time to be part of a much larger national effort to improve medical education. Just a few months ago, the government of Rwanda, with funding from USAID and in partnership with 17 medical, nursing, dental, and health management schools in the United States, launched an ambitious, $160-million, seven-year program to scale up healthcare training nationwide. The goal is to increase the overall numbers of healthcare providers in the country as well as their average level of knowledge and skills, all the while improving the effectiveness and efficiency of the overall healthcare system. It is essentially an “all of the above” approach to health development, as opposed to the much more common programs seen in poor countries that focus on a single disease or intervention. While its success is far from guaranteed — and there will be many difficult years ahead as the Human Resources for Health (HRH) Program in Rwanda is fully implemented — there are many reasons to be optimistic. Rwanda has shown that it has the capacity to bring prior health development programs to scale at the national level, such as a recent program to train community health workers in all 15,000 villages nationwide, with maximal efficiency and limited corruption.

As part of the much larger HRH program, I am now working with a small team of Rwandan physicians and faculty from several U.S. medical schools to develop the first emergency medicine physician, nursing, and paramedic training programs in Rwanda. Though the logistics of the project are complex and certainly many challenges lie ahead, we now anticipate enrolling our first class of trainees in just a few short weeks. With continued investment from the government and other partners, hopefully we can create a sustainable system for emergency training to ensure that Rwanda has all the medical professionals it needs in the future, and that they in turn have the training they require, in order to save many, many more lives in the years to come.



Dr. Adam Levine, assistant professor of emergency medicine at the Warren Alpert Medical School of Brown University, has worked or conducted research in Mexico, India, Zambia, South Africa, Bangladesh, Rwanda, Haiti, Libya, and South Sudan. He currently serves as clinical adviser for emergency and trauma care for Partners In Health–Rwanda, a Boston-based nonprofit working to improve healthcare in nearly a dozen countries.