History Will Teach Us …?

3 weeks.

3 weeks of trying to make sense of things I saw on my last day in Rwanda.

This was after the 18 operations. After packing up the theatre. Around the same time as the intensive care was being decommissioned. A few of us went beyond the hospital to visit sites significant in the genocide of 1994. We came to play a small part in improving the lives of kids whose hearts would otherwise fail them before they’d really learnt to run into the world. We came to help with futures. But there were histories to learn.


The Million

In 1994 I registered the genocide like the insular teenager I was. Since then I have learnt numbers. 100 days. 1 million dead*. But numbers are both overwhelming and incomplete.

We drove up through the hills of Kigali then into the eastern areas. Our stop was at a local Catholic church that is just one of many sites where the stories of those who died are told in the hope those stories won’t have further chapters. There have been too many already as it turns out violence against the Tutsis started many decades before. At least as far back as the 1950s.

Through many outbreaks of killings where the Tutsi were the victims, Catholic churches offered safety. So Ntarama is just one they came to. 5000 of them. They were all killed.

Today there is a quiet garden gated behind the red dirt of the road. No photos are allowed inside the churches. I do not know that a photo of rows of skulls and other bones would help anyone else absorb the scene. Pictures wouldn’t really catalogue all the piles of clothes left from the victims.

5000 people.

When we leave three kids stop us to play a game in the international language of clapping. Inside there is the room where Sunday school took place. And a wall of dried blood where children were slaughtered.

The gardens at Ntarama

The gardens at Ntarama

*               *                 *

Around the time we were leaving this first church, we were missing a morning with our patients. They went down to the lawn to fly kites. I’m told the kites wouldn’t get up into the air. No one cared.

*              *                  *

After the first church we went to another. Here we could hear kids at the local school playing games as we walked amongst more piles of clothes. 10,000 died in one day here. 50,000 are buried in the graves. Our guide, again, was a survivor of 1994.

We drove back to the genocide museum in the city of Kigali. Here 250,000 are buried. They are still receiving remains.

There is a gallery at the top where photos of kids hang. They have the slight blurring of a small photo blown up to take over the memory. Each one has a story. Something like:


Favourite toy: His football.

Favourite food: Chips and ice cream.

Best friend: His mum.

Age at death: 7.

Killed by machete.”


I stand still for a long time before I leave.



Richard Flanagan, the much awarded Australian author, has no doubt spent much time thinking about how people come to view other humans as less than human.  His father was a prisoner of war and his Booker prize winning novel spends much time in the harsh jungles of Burma.

A while back he reflected on how you get to such a point, a point where war crimes are possible:

“… it begins years and decades before when terrible ideas are let loose upon a society that some people are less than human. And once you allow those ideas to take hold, at a certain point crimes like the death railway become inevitable.”

The genocide in Rwanda didn’t start in 1994. It started decades earlier. Is the curse of history that it is so vast that we struggle to take the lights it has left us to see the path in front of us? Or even where we are right now? Could the people who started burning the homes of Tutsi in 1959 see how much the flames would consume? Do we have the imagination to see where that first moment where we value another’s humanity as less than our own might lead?


I live somewhere that swelters in its own advantage. We have a proud narrative of believing in a fair go for all comers. Back in 1994 I do recall thinking that such barbarity defied all experience of the place I grew up.

Last week, a politician in Australia introduced the idea in parliament that he should have the power to decide in secret whether someone seeking an asylum can ever make a claim for protection under a definition of character or national interest known only to the relevant minister. It frees the local government from any pretence of obligation to the Refugees Convention. Anyone can be deported anywhere, without any consideration of whether they might be returned to danger or torture. Or even if it is known that is likely. There is no meaningful means for review or oversight of any of these new powers.

This is apparently to stop boats leaving foreign shores. Except they’re not stopping. At most they’re less visible from our beaches for now. Faced with the possibility that the parliament might not agree to these measures, the involved politician played a new card. He told others in the room that if they said yes, he would release children in detention from one offshore site, Christmas Island. He has had that power any time in the last 15 months. Of course if they said no, the children would stay locked up.

So I now live in a country where uses children, trapped in horrifying conditions described in terrible detail by  experienced paediatricians, are used as hostages. You could not treat someone you viewed as human like this. The ideas are loose.

So the other politicians said yes. And we are told children will leave Christmas Island. But not the other detention centres. There we continue to imprison children. Where will these decades lead us if this carries on?



After the museum we returned to the hospital. King Faisal Hospital wasn’t quite open when the genocide began. Within a short time up to 6,000 sought safety on its grounds. The first operations performed there were undertaken by aid staff treating the wounded.

In the corridor on the ward, an infant is chasing a pink balloon. Unsteady on her feet, when she picks it up and turns, her naked chest wears a broad white shield. It is the dressing over the sutures and wire holding her mended breastbone together. Decades later there are smiles to hold on to.


A day later I’m part way through the hop-step-and-jump of a broken journey back to Australia. I have a day in Johannesburg and time to visit the street in Soweto where both Mandela and Tutu have lived. I’m not sure what I expected Soweto to be but it wasn’t this place where I cross between luxury cars and the minimalist concrete of modern restaurants. Why didn’t I expect change from the events of history?

On the way between the school where children marched and Mandela’s house, there are words on a wall:


They are worth believing.






Rwanda Day 7: Doing good when you’re trying to do good

It’s done. Day 7 of the trip (day 6 of the surgery) and 18 operations are done. We are OK with this.

Our local colleagues doing the heavy lifting during the final operation.

Our local colleagues doing the heavy lifting during the final operation.

It’s not the end of the work for everyone. There’s plenty of nursing still to come and some more work for the physic for starters and it will be days before the last of the team move on. We do try to get out of the way of the operations of the hospital as much as possible though. One hour after the end of that operation, this was the operating theatre …

2 hours later, it was being used for someone else's operation.

2 hours later, it was being used for someone else’s operation.

In a few spare moments today I had the chance to talk to an anaesthetist from Utah (sorry, anesthesiologist) who has been working around Africa for the last 3 years. He spent a year in Guinea working with the Mercy Ships organisation (and wow for the work they do). He’s been in Rwanda for a couple of years now.

At one point he used a very revealing turn of phrase.

“I’ve been on the receiving end of quite a few of these aid trips now …”

Hear that? “on the receiving end”. What? The presence of aid trips isn’t an unqualified story of joy, peace and goodwill?

Terrible Package Tourists

Turning up to do surgery in a less equipped place on the other side of the planet causes lots of problems if not done right. The hospital we’re at in Rwanda sees up to 5 aid groups in any one year.  If you’ve had a chance to read a few of these posts, you have probably noticed that we generate plenty of work. It doesn’t take long to figure out that that could lead to issues.

These short, sharp surgical trips have a particular reputation for sweeping in, doing some ego-boosting do-gooding and flying out into a sunset that blinds them from the reality of what they’ve left behind. Disaster situations are another example where well meaning but misguided aid workers, or worse, can cause real disruption. All sorts of people turn up promising to help, but turn out to be a liability as they buzz about like drunk bees. Useless helpers have a sting.

If you turn up to provide help and end up just leaving a different burden, that qualifies as pretty inappropriate and unethical. There are a few key things the aid trips I’ve been on have endeavoured to address. (Here’s the bit where I do a list to break up the reading monotony.)

1. Make Plans

Not just for surgery. As an aid group you need to tread as lightly as possible on the health system you’ve come to help. Every thing you don’t bring is something you’ll take off them. Preventable complications will probably fall to the locals to fix. Planning at first sounds like the sort of thing you’d discuss in “Financial Advisers Without Borders”. It really is the thing that guarantees mission success.

2. Don’t Let it Slide

You might be in a place without your usual stuff. You may have to work in with a system with different expectations. That doesn’t mean you can go easy on your own standards. If you can’t provide an acceptable level of care for a particular thing then it’s important to recognise that it is beyond even adjusted means of getting things done safely and appropriately. The manner in which this is weighed up will differ in each scenario and is very different in a disaster, but standards matter.

3. Make Sure It’s Not About Those on the Aid Trip

The reason you turn up is to offer some sort of care that the local health system can’t provide themselves. That means the job of those on the trip is to provide the care right now for the kids in a way which fits in to the health system you’ll leave behind. The locals are there before you arrive and still there when you leave. The aid trip is about 1% of the story. It’s about the kids and the locals, not making yourselves look good, or getting through as many cases as possible.

4. Choose Wisely

You have to set some form of limit. If you turn up to do orthopaedics, doing plastic surgery isn’t appropriate. Likewise you want to do the sort of operations that provide benefit but don’t require weeks of intensive care. You can’t tread lightly in an intensive care unit. If you do work on the absolute sickest with minimal chance of success, you end up leaving untreated many more who would be much more likely to gain benefit.

There will also be complications on these trips and that has to be taken into consideration or the local teams end up dealing with chronic long-term issues that may sap resources better used elsewhere.

5. Leave More Than The Sutures

This is not so much about the equipment you should also leave where you can. There have been those who used to go on aid trips and didn’t engage beyond the specific stuff placed in front of them. It is more important to help build a system than it is to just turn up. What happens for the other 350 days of the year you aren’t there?

We’ve been invited to come to provide something that isn’t feasible right now in Rwanda. We would hope at some point we’ll be given the job of hanging out in the corner while the locals get straight into it. Through education, services or modelling, aid teams should be able to have people feeling like they can kick us out of the room. Then at some point they will and that would be the best we could ask for.

6. The Next Trip Starts Yesterday

Each trip has to develop expertise in your team and in those you’re helping. The moment we finished operating yesterday we packed. We packed equipment for the ongoing trip to Tanzania but we started packing and planning for the next Rwanda team. Better supplies of equipment left at the hospital. A review of things that could be done better. Not doing it better is just a lot of treading water.


You may have had the joy of a young kid offering to help in the kitchen. It can go well. It can get pretty messy and that kid will be likely to notice the greater joys of the lizard in the back yard when it’s time to clean up.

Aid trips can be their own disaster. Do-gooders are good at not doing good. It’s not enough that the kids are now smiling at us on the ward and planning to fly kites on the lawn in the morning. We need to have more kids and our hosts smiling when we come back.


Interested in reading other bits on ethics and aid work? You could try this thing by Wolfberg  or this thing on the early Haiti disaster response.


I’ll be leaving Rwanda today but other members of the team (plus new members) are off to Tanzania. The guys from Open Heart International will be sharing more from this trip over at www.ohi.org.au where you can also consider donating or volunteering (which is easier if you are in Oz).

If you’ve dropped by any of these posts and had a read or shared them with others, a very sincere thank you.  



Rwanda Day 6: The Bigger Team

Through day 6 and cases 14, 15 and 16 all done. One more day of operating and the theatre team’s work is finished.

So far the only technical casualty has been the theatres coffee machine. At the moment it is more like a hissing, spitting alley cat than the booster of tired souls it has been through the week. The biomedical engineer is being tested.

It would be easy from these posts to get an idea of the work being mostly about the surgical team. I guess it is true to say that offering heart surgery is difficult without them.

To do this sort of work there’s a much bigger team required. My only previous aid trips have been with a team of about 12 people so the 34 or so we’ve got here feels massive. There are no freeloaders though.

We work within the system here as much as possible but we also have to tread lightly. This means bringing lots of people as staff. That’s staff to keep a ward with lots of patients going 24 hours a day. Our cardiologist, who already had the tough job of selecting the shortlist of patients who might get an operation oversees the plan for ongoing care and integrates with the local doctors and staff to make a plan for each kid once we move on. He started with a question to answer.

“Which kids won’t get to school without an operation?”

That’s our job in simple terms and he’s still making sure we get the answer right.

The ICU nurses work in shifts looking after 5 patients at a time with 3 new patients every day. There are medical types helping them but the progress of the patients has a lot more to do with the nurses and the kids.

The physio is doing rounds of the patients numerous times a day to keep everybody moving and coughing, the vital post-operative dance. Our pharmacist is redoing inventories and stocks every day, while planning for the future.

You could maybe understand why sometimes you need to use a few minutes spare to catch up on rest.

Well, when you're waiting for the sleep doctors ...

Well, when you’re waiting for the sleep doctors …

Tomorrow and tomorrow …

We’ll move on though. The bigger part of the journey for the kids is shared by local health staff. The ones who found them in the first place and got them ready for our assessment team to have a look. The nurses who have worked alongside our guys and shown us just as much about how they get things done here as we’ve shown them.

There’s workers in the lab getting tests done and arranging our blood products. Half the team in the operating theatre is local and they’ll be the ones we hope take new skills to their next operation.

There will still be kids in hospital when we pack up and it will be the local health workers who finish the job we’ve started.

The Bigger Team

The thing is there’s an even bigger team than that.

There’s a small and dedicated team at Open Heart International who make arrangements happen at home. There are other volunteers who helped pack rooms of equipment to be freighted though they weren’t coming. There are huge numbers of donors, big and small, individuals and businesses, who donate money so we can come and do fun stuff.

Then there are others. There are colleagues at home who’ve made space in rosters or made leave requests happen. Then most of us have the people around us who support the stuff we do without getting much of the good bit.

To get me here we shifted a 3rd birthday celebration early. My phenomenal wife juggles work and looking after three kids at home. Extended family help with childcare and shift their own time around. That’s just my snapshot. There are 34 people here. The work here happens many places at once.

The Even Bigger Team

The other thing this reminds me of is that this is just one team doing one trip.

This year other colleagues I know have been on heart surgery trips. Some have been on plastic surgery trips. Some have been on burns care trips. Some are heading off on orthopaedic surgery trips.

Every one of those trips happens with those big teams.

All to get some more kids to school.

Every one of those trips happens with those big teams.

All to get some more kids to school.

5 Highlights from Rwanda Day 5

This is beyond half way. Two days left of operating before the packing begins and the wagons move on to Tanzania. For the operative team things have hit a pretty steady pattern. Breakfast at the hotel and an amble down the hill, past the dancing security guard into the hospital. Yes, he protects the hospital with the power of dance.

This walk has actually felt routine since the first day of operating. Except that when you look up at a lamp post there isn’t a pigeon sitting and cocking an eye at the surrounds. There is a bird of prey who you can imagine is eyeing off your ears a little too eagerly.

Operating days have been extending out to 14 hours so some highlights come in handy to keep things going.

1. Operations 11, 12 and 13

3 more cases done.

Hands that say an operation might help.

Hands that say an operation might help.


This also means more kids out of intensive care and out on the ward. Speaking of which …

2. The Ward

I got to visit the ward properly for the first time in the evening. It’s an old style ward, a long room with beds lined up. The operating theatre is a place for adults. There is chat and machines that go bing and music in equal measures excellent and awful. We don’t hear kids much though.

The ward is full of kids who have had an operation on their heart within the last few days. There are also balloons and laughter and laughter at the clueless white guy who looks lost when spoken to. It is joy.

3. Indian

At the end of yesterday’s operating (which was a bit after most restaurants would take us), our colleagues brought us back Indian food to eat in the intensive care tea room. Who would think Rwanda would be where you would find some of the best Indian restaurant dining I’ve had?

Improved further by sharing the only version of Game of Thrones I’ve ever seen.

4. Quote from the Locals

The Open Heart International team can only do work because the locals at the hospital make it happen. We also know there are good people who will keep looking after these kids once we’re on the plane.

The team at the hospital coordinate getting the patients, help with the  assessment, arrange tests, obtain blood products if we need them and do all our interpreting. We couldn’t get anything done without them and we get the chance to slot into their system.

The local theatre team have a particular talent for straight talking and I haven’t been outside the hospital enough yet to know if that’s a national characteristic. At home if someone said

“I think this makes me look a bit fat.”

you might expect a stranger to enact social nicety training. Here the response is,

“Yes, it does.”

No malice or judgment. Unadorned honesty.

The local coordinating anaesthetist also came out with my favourite quote of the trip so far:

“You see, we are lucky enough here in Africa to have more than 24 hours in each day. So there is no rush. Let us sit.”

5. Can we put ourselves out of a job?
There might be more on this topic to come, but if you’re going on these sort of surgical aid trips the aim can’t just be to do a casual bit of operating. The aim has to be to help contribute to the system beyond the couple of weeks you are there. The best outcome is to become obsolete.

This means a key role for us is also education. The Open Heart International trips to Papua New Guinea are a good example. After many visits, they are at the point where local surgeons do a lot of the operative work.

We’re also particularly lucky to have with us a surgeon who has done some paediatric cardiac surgery training in Israel and who will be working long-term in Tanzania. Dr Godfrey Godwin has already been responsible for some of our work and it might just be that we can support him in setting up a service in Tanzania that makes us irrelevant. Definitely a highlight.

Dr G in action. Extra points for hanging out with the anaesthetists between cases.

Dr G in action. Extra points for hanging out with the anaesthetists between cases.

So it’s back to the ICU where I’m actually hoping there’s just the standard 24 hours in the African day …


Rwanda Day 4: We didn’t bring a robot

Day 4 and we’re 10 operations in. A few challenges along the way but that’s sort of the nature of the game. Although it’s been easy enough to mention the stuff about all the fancy gear and big machines, it’s actually probably more important that we brought people.

There’s more than just those you might have guessed as well. In addition to anaesthetists, physicians, nurses and physios, there is someone just to look after all the technical equipment, someone to manage pathology, a pharmacist and someone providing all that excellent info over at www.ohi.org.au.

They’re all vital and none of them could be replaced by machines. I wouldn’t even trade in the surgeon for a robot.

But Robots Are Cool

Well, robots are sort of cool. Or sometimes freaky. This self-folding origami one is kind of freaky.

In medicine though they’re getting popular and that includes in surgery. For an aid trip they are a bit big and cumbersome and expensive (like millions of dollars too expensive). We’re also not talking about fully autonomous humanoid things with temperament chips that happen to cut. The robots involved in surgery are mostly of the variety where a human still operates them.

The advantage that gets mentioned is that superior control for the surgeon can mean less tissue trauma to impose on the patient and that means less pain and better recovery for the patient. Sounds good, right?

I’ve mentioned before that I’m not convinced robots have found their niche yet. Part of the reason is that for every clinical situation where evidence appears to be mounting that they are of benefit, as in prostate surgery there are other areas where people have been overzealous. Situations like some forms of gynaecological surgery (see also here), or where there is evidence that lots of complications from robot-assisted surgery go underreported.

There are people already using these machines for cardiac surgery and examples of researchers trying to figure out if there might be benefits. What I am fairly confident of is that we are a long way off robots being able to do much without the input of the human brain (not that many are suggesting that really).

The Upsides of the Human Brain

You’ll have to gather that I am effectively whispering this online, as it’s not traditional to spend too much time telling the surgeons they are impressive at what they do. And having humans involved in stuff comes with issues with the way humans think and act in challenging situations. On this trip I’ve even heard a couple of stories of people behaving colourfully in healthcare situations that left me with this look…

Yep, pretty wide-eyed.  [Via reddit.com]

Yep, pretty wide-eyed. [Via reddit.com]

The things I find super impressive about the human brain are demonstrated in the way the surgeons repair the heart.

For some of the repairs there might be holes in the heart to fix, or valves to repair or replace (we’re not doing so much in the way of replacements here). When the surgeon is doing that though they’ve already put the patient onto the bypass machine, drained it of blood and given a dose of a solution to stop the heart from beating at all.

So surgeons work in an empty, blood-free heart to produce a repair that has to work in a heart that is pumping away and full of blood. In the meantime they also fundamentally alter the way the heart has been working.

That’s partly a testament to the impressive ability of the heart to adapt to the new state of affairs (in most cases pretty easily). The surgeon though has to judge how to do their repair to deal with an entirely different set of conditions once they get that heart going again. It’s a bit about experience and a bit about the ability to see the structure in front of them and visualise it under a different future reality and a lot about judgment.

So we’ll all be saddled with old jokes, occasional interpersonal challenges and some fairly ordinary musical choices for a while before robots can do all that.

And most of the time we’ll be quietly impressed.

But definitely not mention it.

Honestly sometimes I think it's better not to ask.

Honestly sometimes I think it’s better not to ask.

Rwanda Day 3 – Little Hearts, Big Machines and Scuba Diving

Day 3 count:

– “7, 7 operations done, ah, ah, ah.” (Actually I can’t maintain that nod to Count von Count.)

– 6 coffees. Probably only 6.

– 1 AC/DC playlist deployed.

Those 7 operations include a range of things that need fixing. From blood vessels that should have closed themselves to ones that should be wider and lots of holes in hearts that need patching. With a bit of good planning and a room full of gear you can get plenty done and, more importantly, we don’t need to think about scuba diving in the process.

Wait, I should probably explain the scuba diving comment.

The team looking busy.

The team looking busy.

Underwater Surgery

Imagine for a second you’re given the job of closing up a hole between the ventricles of the heart. The ventricles are the larger chambers with the job of pushing blood out to the body – the right ventricle sends blood out to the lungs to pick up oxygen that you’ve breathed in while the left ventricle sends it out to all the other bits of your body.

In some people those two big chambers don’t entirely divide off like the standard blueprint and blood can jet across that hole. It’s not a big deal for most immediately. If you leave it though, it can cause issues. So sometimes a patch to close that hole is needed. That’s sometimes where surgery can come in.

If you stop and think about the challenges of operating on the heart, a couple of things are obvious. The heart gets visited by all the blood the body has. You have to get inside those chambers to work on it but having blood everywhere might not help with the sewing. And spilling blood everywhere while you sew might not be productive.

So let’s say you plan to operate without the blood pumping around. What next? How does the oxygen the organs need get there?


The Big Chamber

Before the machines we use now, there was diving. When you go 10 metres below the surface of the water, you add a whole atmosphere of pressure of the gases you breathe. Delivering pressurised gases is a big part of SCUBA diving. If you don’t have water to dive into to get your pressurised gas, you can use a very particular kind of chamber. A hyperbaric chamber.

When you exploit the extra pressure from a hyperbaric chamber in medicine, it’s a bit like you’re cramming all the oxygen from extra atmospheres  into the patient’s blood. You can supersaturate the patient with oxygen.

It’s not that long ago that it was suggested that putting patients inside a hyperbaric chamber with an interested surgical team might be  a way to lengthen the amount of time you could do surgery on a heart removed from all flow of blood around the body. Those extra few minutes might just buy you the time to do a more complex heart operation.

Complete with period fashion, the hyperbaric chamber at Sydney's Prince Henry Hospital (later sent elsewhere).

Complete with period fashion, the hyperbaric chamber at Sydney’s Prince Henry Hospital (later sent elsewhere).

One Small Problem

There was one little thing getting in the way. It wasn’t even the cost. It was the occasional explosion.

Add the smallest ignition to an environment that already has massive amounts of oxygen and things that can burn and you can start a very nasty fire. From 1923 to 1996 there were 39 reported fires in hyperbaric chambers and 25 of those occurred where clinical work looking after patients was happening.

24 of those clinical fires happened between 1967 and 1996. 60 people died. On at least one occasion, not only did the patient inside the chamber die from their burns, the ends of the chamber exploded outward from the rapid rise in pressure inside the chamber. The patient’s wife was killed by the flying debris.

It was one factor that pushed people away from hyperbaric chambers. The thought of losing whole surgical teams was probably a bit of a worry.

So if you can’t use compressed gas, how much space do you need to replace a kid’s little heart?

Different Wheels of Steel

One of the members of the team is here to drive the wheels of steel. (He’s not a DJ. In fact the thought of him being a DJ is pretty disconcerting.)

When you come on an aid trip to do open heart surgery, you need to pack one of these devices.

Elegant, yes?

Elegant, yes?

This is the cardiopulmonary bypass machine. While it has to do some clever things like cool and heat circulating blood and deliver doses of medicine to stop the heart it has one big job. It has to take over the job of the heart in making blood flow around the body to carry oxygen. For the time that the heart is open and having things fixed, this takes over.

The perfusionist who makes it work is an extremely well trained part of the team. The machine, with all that tubing and so many roller pumps, is what is required to do the work of the heart inside of the patient (even a 5 kg child).

All that to do the job of the heart. It doesn’t even pick up satellite TV.

It’s also just one part of what you need to take to do open heart surgery in another country. Just in case it wasn’t clear that mounting an aid trip to do heart surgery overseas wasn’t a fair bit of effort.

Of course it’s still easier than taking a massive explosion chamber half way around the world.



If you care to look up source literature to get a sense of what was being tried in hyperbaric chambers, you can look up this paper:

Bernhard WF, Frittelli G, Tank ES and Carr JG. Surgery Under Hyperbaric Oxygenation in Infants with Congenital Cardiac Disease. Circulation. Supplement 1964;91-4.

The review of fires in hyperbaric chambers is a bit more modern and was published by the Undersea and Hyperbaric Medical Society, Inc. in 1997:

Sheffield PJ, Desautels DA. Hyperbaric and hypobaric chamber fires: a 73-year analysis.

Care to see what a modern hyperbaric chamber looks like? Try this coverage of the new facility at Prince of Wales Hospital in Sydney – http://www.youtube.com/watch?v=KJMhYzqhLHc (this replaced the one from the photo above).

Oh, and if you wanted to see a bit more about one of our patient’s today, go and look here to meet Felix. http://www.ohi.org.au/east-africa/2014/11/16/felix/



Rwanda Day 2: Under Way and When Does Developing Become Developed?

It’s happening.

It took a day’s travel, 34 travelling staff and more locals, an afternoon of unpacking, a morning searching for the last drugs and the frantic rebuilding of a cardiopulmonary bypass machine but the surgery isn’ just an abstract idea any more.

By the time this gets out there, the first three operations will be finished.

When you mention an aid trip, most people develop a quick mental picture of what that must mean. Sometimes that’s right. In this case it might be worth mentioning that while there are some particular challenges doing heart surgery on kids in Africa, there’s plenty about being here that is pretty familiar. Not every developing country is quite like what you imagine a developing country to be.

Words that are all too familiar from working in Australia. (Well, the first ones.)

Words that are all too familiar from working in Australia. (Well, the first ones.)

Rebuilding a Health System

The deaths of so many in the genocides left Rwanda with very serious ongoing problems. Less than 5% of the population had access to clean water. There was no banking system and no taxes being collected. AIDS, malaria and tuberculosis came in waves, killing more. Considered a lost cause, aid money was not flowing.

That is not the Rwanda of today. Many steps have been taken to rebuild the country and health has been a central part of that. For a system that had lost vast numbers of health workers that was a big challenge.

Here’s the recent numbers now for a country of around 11 million people:

* Between 2005 to 2011 malaria deaths fell by 87.3%.

* From 2000 to 2010 the maternal mortality ratio fell 59.5%.

* The chance of a child under 5 dying decreased 70.4% between 2000 and 2011. For that to happen, the absolute number of child deaths annually fell by 62.8% (over the same time the population increased by 35.1%).

* A focus on vaccination has led to greater than 93% coverage for the 9 vaccines in the schedule (including 93.2% coverage for all three doses of the HPV vaccine among eligible girls by 2011 – at the same time, the USA had less than one quarter covered).

While Rwanda has problems to deal with, it’s a stunning example of what investment in health can deliver for people. I look at those stats and I’m a little embarrassed by what passes for discussion about health back where I’m from.

Rwanda focussed serious efforts. Some would say cash counts, but it’s not entirely about that. The amount of money spent per person per year on health by the government is around $56 (US). Some would argue the focus on public health initiatives is partly due to the prominence of women in the rebuilding process. Few would say it’s not impressive.

So if it’s so great, are we just here for a holiday?

Big Cases for Little Kids

It turns out that cardiac surgery is not as simple as getting a toenail removed. Even when it’s a patient blue from low circulating oxygen getting a toenail removed. Getting a cardiac surgery program running requires people who have had quite a lot of training doing operations that aren’t entirely that easy plus ways to look after the kids before and after the surgery.

It’s also very cost and labour intensive. So given the choice between getting 93% of people vaccinated and investing large amounts of money in setting up a new surgical program, I’d choose the vaccination.

It turns out that teams need a certain amount of expertise and experience. In the UK, the guidance is that you need to be doing more than 400 major kids’ cardiac operations per year amongst 4 surgeons to continue with a paediatric cardiac surgery service. There’s debate about numbers like that but we probably can’t claim we’ve set up a franchise for east Africa.

So one day, we’d hope to put ourselves out of work, when the local health system has the luxury of making cardiac surgery a priority. The anaesthetists, surgeons, bypass specialists and nurses spending time with us will hopefully get bored by our presence soon enough and get on with it all alone.

Then we can get onto other debates, like whether to tempt fate in the slightly green swimming pool (actually there’s not much debate on that one). Or which music should be on the speakers in down times (if any of the team is reading, seriously no more John Farnham).

For now, we have to be here.

The business room where sometimes they play songs about business socks once it's all done.

The business room where sometimes they play songs about business socks once it’s all done.


Most of the stats in here come from this review in the BMJ

There’s some interesting stuff in here from the NEJM.

And that UK guidance can be found in their review.

And don’t forget the other updates from Open Heart International at www.ohi.org.au