Gene Bukhman

Rwanda 20 years on: investing in life

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwandas health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda

BackgroundOver the last decade, the diffusion of ultrasound technology to nontraditional users has been rapid and far-reaching. Much research and effort has been focused on developing an ultrasound curriculum and training and practice guidelines for these users. The potential for this diagnostic tool is not limited to the developed world and in many respects ultrasound is adaptable to limited resource international settings. However, needs-based curriculum development, training guidelines, impact on resource utilization, and sustainability are not well studied in the developing world setting.AimsWe review one method of introducing applicable curriculum, training local providers, and sustaining a comprehensive ultrasound program.MethodsTwo rural Rwandan hospitals affiliated with a US nongovernmental organization participated in a pilot ultrasound training program. Prior to introduction of ultrasound, local physicians completed a survey to determine the perceived importance of various ultrasound scan types. Hospital records were also reviewed to determine disease and presenting complaint prevalence as part of an initial needs assessment and to define our curriculum. We hypothesized certain studies would be more utilized and have a greater impact given available treatment resources.ResultsWe review here the choice of curriculum, the training plan, helpful equipment specifications, and implementation of ongoing measures of quality assessment and sustainability. Our 9-week lecture and practice-based ultrasound curriculum included obstetrics, abdominal, renal, hepatobiliary, cardiac, pleural, vascular, and procedural ultrasound.ConclusionsWhile ultrasound as a diagnostic modality for resource-poor parts of the world has generated interest for years, recent advances in technology have brought ultrasound again to the forefront as a sustainable and high impact technology for resource-poor developing world nations. From our experience in rural Rwanda, we conclude that ultrasound remains helpful in patient care and the diagnostic impact is enhanced by choosing the correct applications to implement. We also conclude that ultrasound is a teachable skill, with a several week intensive training period involving hands-on practice skills and plans for long-term learning and have begun a second phase of evaluating knowledge retention for this introductory program.

Endomyocardial Fibrosis: Still a Mystery after 60 Years

The pathologist Jack N. P. Davies identified endomyocardial fibrosis in Uganda in 1947. Since that time, reports of this restrictive cardiomyopathy have come from other parts of tropical Africa, South Asia, and South America. In Kampala, the disease accounts for 20% of heart disease patients referred for echocardiography. We conducted a systematic review of research on the epidemiology and etiology of endomyocardial fibrosis. We relied primarily on articles in the MEDLINE database with either “endomyocardial fibrosis” or “endomyocardial sclerosis” in the title. The volume of publications on endomyocardial fibrosis has declined since the 1980s. Despite several hypotheses regarding cause, no account of the etiology of this disease has yet fully explained its unique geographical distribution.

Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008

BackgroundOver the last decade, utilization of ultrasound technology by non-radiologist physicians has grown. Recent advances in affordability, durability, and portability have brought ultrasound to the forefront as a sustainable and high impact technology for use in developing world clinical settings as well. However, ultrasounds impact on patient management plans, program sustainability, and which ultrasound applications are useful in this setting has not been well studied.MethodsUltrasound services were introduced at two rural Rwandan district hospitals affiliated with Partners in Health, a US nongovernmental organization. Data sheets for each ultrasound scan performed during routine clinical care were collected and analyzed to determine patient demographics, which ultrasound applications were most frequently used, and whether the use of the ultrasound changed patient management plans. Ultrasound scans performed by the local physicians during the post-training period were reviewed for accuracy of interpretation and image quality by an ultrasound fellowship trained emergency medicine physician from the United States who was blinded to the original interpretation.ResultsAdult women appeared to benefit most from the presence of ultrasound services. Of the 345 scans performed during the study period, obstetrical scanning was the most frequently used application. Evaluation of gestational age, fetal head position, and placental positioning were the most common findings. However, other applications used included abdominal, cardiac, renal, pleural, procedural guidance, and vascular ultrasounds.Ultrasound changed patient management plans in 43% of total patients scanned. The most common change was to plan a surgical procedure. The ultrasound program appears sustainable; local staff performed 245 ultrasound scans in the 11 weeks after the departure of the ultrasound instructor. Post-training scan review showed the concordance rate of interpretation between the Rwandese physicians and the ultrasound-trained quality review physicians was 96%.ConclusionWe suggest ultrasound is a useful modality that particularly benefits womens health and obstetrical care in the developing world. Ultrasound services significantly impact patient management plans especially with regards to potential surgical interventions. After an initial training period, it appears that an ultrasound program led by local health care providers is sustainable and lead to accurate diagnoses in a rural international setting.

Global, Regional, and National Burden of Rheumatic Heart Disease, 1990-2015.

BACKGROUND Rheumatic heart disease remains an important preventable cause of cardiovascular death and disability, particularly in low‐income and middle‐income countries. We estimated global, regional, and national trends in the prevalence of and mortality due to rheumatic heart disease as part of the 2015 Global Burden of Disease study. METHODS We systematically reviewed data on fatal and nonfatal rheumatic heart disease for the period from 1990 through 2015. Two Global Burden of Disease analytic tools, the Cause of Death Ensemble model and DisMod‐MR 2.1, were used to produce estimates of mortality and prevalence, including estimates of uncertainty. RESULTS We estimated that there were 319,400 (95% uncertainty interval, 297,300 to 337,300) deaths due to rheumatic heart disease in 2015. Global age‐standardized mortality due to rheumatic heart disease decreased by 47.8% (95% uncertainty interval, 44.7 to 50.9) from 1990 to 2015, but large differences were observed across regions. In 2015, the highest age‐standardized mortality due to and prevalence of rheumatic heart disease were observed in Oceania, South Asia, and central sub‐Saharan Africa. We estimated that in 2015 there were 33.4 million (95% uncertainty interval, 29.7 million to 43.1 million) cases of rheumatic heart disease and 10.5 million (95% uncertainty interval, 9.6 million to 11.5 million) disability‐adjusted life‐years due to rheumatic heart disease globally. CONCLUSIONS We estimated the global disease prevalence of and mortality due to rheumatic heart disease over a 25‐year period. The health‐related burden of rheumatic heart disease has declined worldwide, but high rates of disease persist in some of the poorest regions in the world. (Funded by the Bill and Melinda Gates Foundation and the Medtronic Foundation.)

Seven key actions to eradicate rheumatic heart disease in Africa: the Addis Ababa communiqué.

Abstract Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain major causes of heart failure, stroke and death among African women and children, despite being preventable and imminently treatable. From 21 to 22 February 2015, the Social Cluster of the Africa Union Commission (AUC) hosted a consultation with RHD experts convened by the Pan-African Society of Cardiology (PASCAR) in Addis Ababa, Ethiopia, to develop a ‘roadmap’ of key actions that need to be taken by governments to eliminate ARF and eradicate RHD in Africa. Seven priority areas for action were adopted: (1) create prospective disease registers at sentinel sites in affected countries to measure disease burden and track progress towards the reduction of mortality by 25% by the year 2025, (2) ensure an adequate supply of high-quality benzathine penicillin for the primary and secondary prevention of ARF/RHD, (3) improve access to reproductive health services for women with RHD and other non-communicable diseases (NCD), (4) decentralise technical expertise and technology for diagnosing and managing ARF and RHD (including ultrasound of the heart), (5) establish national and regional centres of excellence for essential cardiac surgery for the treatment of affected patients and training of cardiovascular practitioners of the future, (6) initiate national multi-sectoral RHD programmes within NCD control programmes of affected countries, and (7) foster international partnerships with multinational organsations for resource mobilisation, monitoring and evaluation of the programme to end RHD in Africa. This Addis Ababa communiqué has since been endorsed by African Union heads of state, and plans are underway to implement the roadmap in order to end ARF and RHD in Africa in our lifetime.

80 under 40 by 2020: an equity agenda for NCDs and injuries

In May, 2013, the World Health Assembly approved a global monitoring and evaluation framework for prevention and control of non-communicable diseases (NCDs). This framework calls for a 25% reduction in deaths from cardiovascular diseases, chronic respiratory diseases, cancer, and diabetes in individuals aged 30–70 years by 2025, or “25 × 25”. Although we applaud this eff ort, we do not feel that it adequately addresses the specifi c health and economic burdens aff ecting lowincome countries, nor those of poor people in middleincome countries. We propose a complementary agenda to reduce premature mortality from all NCDs and injuries (including neuropsychiatric disorders) by 80% in individuals younger than 40 years by the year 2020, or “80 × 40 × 20”. This ambitious target was announced in July, 2013, at the inaugural meeting of the NCD Synergies Network in Kigali, Rwanda, hosted by the Rwandan Ministry of Health and attended by representatives from 18 countries, including policy makers from 13 African health ministries. The Global Burden of Disease Study 2010 showed that two-thirds of life-years lost and disability-adjusted lifeyears (DALYs) due to NCDs and injuries in sub-Saharan Africa were in individuals younger than 40 years. NCDs causing the unacceptable deaths of children and young adults in this population were generally not driven by classic lifestyle risk factors. Disorders included rheumatic and congenital heart diseases, post-infectious renal failure, malignancies, sickle-cell anaemia, type 1 diabetes, asthma, appendicitis, suicide, epilepsy, and road traffi c or workplace injuries. Collectively, these disorders accounted for 36% of the deaths, 33% of years of life lost, and 44% of DALYs in those younger than 40 years in developing countries. Indeed, compared with high-income populations in the Global Burden of Disease Study, the poorest billion people suff ered about 800 000 excess deaths in 2010 from NCDs and injuries in those younger than 40 years, with about half of these premature deaths due to NCDs alone. This represents a problem of comparable magnitude to other global health priorities. To meet the 80 × 40 × 20 target will require additional strategies complementing those identifi ed in the global framework. However, progress towards the global 25 × 25 goal will be quicker if developing countries simultaneously focus on the 80 × 40 × 20 target, which refl ects the epidemiology of these countries and is synergistic with the Millennium Development Goals. Rwanda has adopted this target and has made progress towards it through its integrated health-system strengthening eff orts. Data from the Global Burden of Disease Study 2010 suggest that, from 2000–10, Rwanda achieved a 49% reduction in NCD and injury-related mortality in individuals younger than 40 years (fi gure). These gains seem to have occurred in the context of a 54% decline in all-cause mortality within this age group, and include all NCD subgroups (ranging from 21% for cancers, to 70% for chronic respiratory diseases). In this timeframe, Rwanda’s average annual health expenditure was less than US

Enhancing formal educational and in-service training programs in rural Rwanda: a partnership among the public sector, a nongovernmental organization, and academia.

27 per head. We believe that 80 × 40 × 20 can be achieved through shifts from prioritisation of specifi c diseases to building of integrated health-service delivery platforms at com munity, health-centre, district hospital, and referral-centre levels. Equitable access to these services, including vaccin ations, diagnostics, medical and surgical care, and palliation, should be assured through universal health coverage. In addition, multisectoral action will be needed to mitigate indoor air pollution, and improve household, workplace, and road safety as part of a global movement for eradication of extreme poverty. Many countries have already made substantial investments in health systems as part of their response to the HIV epidemic. We anticipate that high-quality interven tions to prevent premature deaths from NCDs and injuries could be implemented even more quickly through leveraging of these existing investments.

Endemic Cardiovascular Diseases of the Poorest Billion.

Global disparities in the distribution, specialization, diversity, and competency of the health workforce are striking. Countries with fewer health professionals have poorer health outcomes compared with countries that have more. Despite major gains in health indicators, Rwanda still suffers from a severe shortage of health professionals. This article describes a partnership launched in 2005 by Rwanda’s Ministry of Health with the U.S. nongovernmental organization Partners In Health and with Harvard Medical School and Brigham and Women’s Hospital. The partnership has expanded to include the Faculty of Medicine and the School of Public Health at the National University of Rwanda and other Harvard-affiliated academic medical centers. The partnership prioritizes local ownership and—with the ultimate goals of strengthening health service delivery and achieving health equity for poor and underserved populations—it has helped establish new or strengthen existing formal educational programs (conferring advanced degrees) and in-service training programs (fostering continuing professional development) targeting the local health workforce. Harvard Medical School and Brigham and Women’s Hospital have also benefited from the partnership, expanding the opportunities for training and research in global health available to their faculty and trainees. The partnership has enabled Rwandan health professionals at partnership-supported district hospitals to acquire new competencies and deliver better health services to rural and underserved populations by leveraging resources, expertise, and growing interest in global health within the participating U.S. academic institutions. Best practices implemented during the partnership’s first nine years can inform similar formal educational and in-service training programs in other low-income countries.

Neglected Tropical Diseases as Hidden Causes of Cardiovascular Disease

The poorest billion people are distributed throughout the world, though most are concentrated in rural sub-Saharan Africa and South Asia. Cardiovascular disease (CVD) data can be sparse in low- and middle-income countries beyond urban centers. Despite this urban bias, CVD registries from the poorest countries have long revealed a predominance of nonatherosclerotic stroke, hypertensive heart disease, nonischemic and Chagas cardiomyopathies, rheumatic heart disease, and congenital heart anomalies, among others. Ischemic heart disease has been relatively uncommon. Here, we summarize what is known about the epidemiology of CVDs among the world’s poorest people and evaluate the relevance of global targets for CVD control in this population. We assessed both primary data sources, and the 2013 Global Burden of Disease Study modeled estimates in the world’s 16 poorest countries where 62% of the population are among the poorest billion. We found that ischemic heart disease accounted for only 12% of the combined CVD and congenital heart anomaly disability-adjusted life years (DALYs) in the poorest countries, compared with 51% of DALYs in high-income countries. We found that as little as 53% of the combined CVD and congenital heart anomaly burden (1629/3049 DALYs per 100 000) was attributed to behavioral or metabolic risk factors in the poorest countries (eg, in Niger, 82% of the population among the poorest billion) compared with 85% of the combined CVD and congenital heart anomaly burden (4439/5199 DALYs) in high-income countries. Further, of the combined CVD and congenital heart anomaly burden, 34% was accrued in people under age 30 years in the poorest countries, while only 3% is accrued under age 30 years in high-income countries. We conclude although the current global targets for noncommunicable disease and CVD control will help diminish premature CVD death in the poorest populations, they are not sufficient. Specifically, the current framework (1) excludes deaths of people <30 years of age and deaths attributable to congenital heart anomalies, and (2) emphasizes interventions to prevent and treat conditions attributed to behavioral and metabolic risks factors. We recommend a complementary strategy for the poorest populations that targets premature death at younger ages, addresses environmental and infectious risks, and introduces broader integrated health system interventions, including cardiac surgery for congenital and rheumatic heart disease.