Where Does the Money Come From?

I would like to chat for a minute about where countries like Rwanda get the money to do things like install Electronic Medical Record systems. Are the governments taking this money from food programs, or from building schools in rural villages? No, not really. The answer was interesting to me, and thus, I think it might be interesting to other western world taxpayers. Ready? It largely comes from us. For example, the three biggest donors of the money for the Rwandan EMR system are the CDC, a Washington, DC-based organization called PEPFAR (which stands for the President’s Emergency Program Funding AIDS Relief (or something like that)), and the Global Fund. Why do they do this? Why isn’t the CDC spending that money on, say, H1N1 prevention here in our own country? I asked a new friend from the World Health Organization for his thoughts, and here’s what he said. Firstly, the CDC and these other guys have long since been made aware that global health figures prominently in the state of American health (and the health of other countries; I’m just using the US as an example). Epidemics – such as swine flu – that don’t start in the US will likely make it across our borders and affect us too. Therefore, it makes sense for the best monitoring to be available in places where epidemics are more likely to start – places where health is poorer in general. Secondly, the AIDS epidemic has taken a toll on the whole world. Period. And it has got to stop. Just because you don’t see someone with AIDS in your backyard doesn’t mean the disease hasn’t indirectly impacted you. Think about how much potential productivity and economic contribution has been destroyed in African nations because of AIDS. Think about how much more global GDP will be someday when Africa is the next China – a new consumer and producer market. This will not happen if AIDS continues to devastate the market. So, they give money to direct relief, as well as to supporting structures that they think can help improve the quality of care overall.

I am not saying one way or another if I agree with this assessment, but I figured I’d throw it out there for you to ponder. So go ahead, ponder.

Electronic Medical Records in Africa

I have to talk a little bit about what I came to Rwanda to do, and some of the lessons I learned. My trip started out with a week-long conference at the posh Kigali Serena Hotel, where I worked with the World Health Organization and governments of several central and western African nations including Rwanda, crafting policy and architecture guidelines for eHealth. Us Americans are naturally amazed by this – if we in the United States can’t figure out how to effectively deploy electronic medical record systems, how can Rwanda? Nigeria? Ethiopia? Tanzania? But the really cool thing is how unencumbered they all are – they are open books ready to do this stuff right. They have the opportunity to avoid the ridiculous issues we have here, like bureaucratic IT contractors who convince complicated hospital networks to let them send in 200 people to bumble around with computers and write lengthy processes for two years, only to be left with a system that meets nobody’s real needs. (Sorry, that was kind of a lengthy, bumbling example!) And they have a mission – a mission in addition to the goals of practice efficiency and streamlining of patient care (they want that, too). But this other mission is to really track and properly treat HIV/AIDS and Tuberculosis patients. I didn’t know this until recently, but if you are on Anti-Retrovirals for AIDS or on the TB treatment program (I don’t know what that’s called), you absolutely MUST take your meds according to your treatment plan. They are not nearly as effective otherwise. And can you imagine how hard it would be to track patients and their individual plans, track their test results, track whether they’ve picked up their meds at the pharmacy, track their scheduled weekly treatment appointments, track who’s paying for all of this, without a good computer system? So many people slip through the cracks. These Sub-Saharan African governments seem to really get how devastating these diseases have been to their economies, and they want so badly to control them, reign them in, and ease population suffering as much as possible. How can you re-instill economic activity and growth with a large percentage of your population too sick to work? (By the way, I can just hear some of you skeptics and realists reacting and telling me all about the corrupt government officials who funnel money away from important care and treatment programs. I am sure that also happens – I’m not a total idealist – I’m just telling you that I saw a really refreshing other side to that picture. I saw representatives from Ministries of Health across this region really dedicating themselves to technologies that they believe can help their countries.) Overall, I think it’s exciting. I think soon in Rwanda, you will be able to walk into these little one- or two-room village health clinics with dust on the floor and people lined up outside, and you will see a computer in the corner, with power and internet (um, at least sometimes). And I think it’ll be really beneficial. Doctors or nurses will be able to access recommended treatment plans for patients of a specific diagnosis. Community Health Workers who help administer drugs can enter and track commonly seen side-effects – which is especially important for new drugs being introduced to this market. Patients can go to the district hospital for emergency care, and the clinicians there will be able to quickly access their basic health summary to understand who they’re treating – whether it’s an AIDS patient, for example, or access a list of their allergies or adverse reactions to drugs. Yes, there are a lot of other problems in Africa – violence in the Congo, potential famine in Kenya, etc. – but it is cool to see that there are also steps being taken in many Ministries to build infrastructure that will help their countries move forward.

Mzungu in Heels, Part I

I’ll use my first entry for the tale behind my blog’s name, “Mzungu in Heels”. It starts with a rather amusing conversation that I had with my Partners in Health colleague and new friend, Dave, on our way out to Rwinkwavu, Rwanda. (Rwinkwavu, by the way, is a rural district or province in – I think – eastern Rwanda. The reason I’m not sure is that Google Maps can’t seem to find it, and since I don’t really know other methods besides Google and my Blackberry to find where things are, I’ll have to settle with my best guess.) So, Dave is one of the very few Mzungus (pan-African term for “white people”) living amongst the villagers in “Rwink” (pronounced as if it had a silent “w”, which I feel a certain affinity towards, having lived with a silent “w” in my own name for 28 years). As we drove down the hillside on the curvy red-clay road into the valley where Rwink is situated, our shiny 4WD SUV attracted the attention of some of the villagers. They ran out to the car, waving and pointing. I didn’t know how to feel or react – were they hoping for money? Food? Dave sighed. “Yeah, it gets a little old, you know? Never being able to go anywhere without attracting attention.” I looked at him questioningly. He continued, “it’s like that game you used to play when you were little – the punch buggy game. You know, when you got to smack your brother and sister if you spotted the punch buggy first. Well in this case, we’re the punch buggies.” What a fabulous analogy, huh? Within only a few hours of hanging out in Rwink, I began to understand what he meant. Of course we wanted to chat and joke with the village kids, but sometimes when all they wanted to do was run after you, laughing and pointing, it could get a little frustrating. So when finding myself walking around with a fellow Mzungu and being overwhelmed by the “punch buggy” feeling, a source of a good laugh was of course to punch my colleagues on the shoulder and say quietly “Mzungu ________!” But how to fill in the blank? We couldn’t use colors. I mean, “Mzungu white” is basically redundant, “Mzungu green” only happens when you’ve accidentally drunk the unpasteurized milk, “Mzungu black” is like an oxymoron … So we were left with descriptions of however we were dressed: “Mzungu in plaid!”, “Mzungu in shorts!”, and of course, “Mzungu in heels!”

So, you may now be thinking, who in their right mind would bring high heels to central Sub-Saharan Africa? OK, I admit while staying out at the hospital in rural Rwink I left my heels in the suitcase and subjected my sneakers and rubber-soled ballet flats to becoming balls of red clay dust. But in Kigali, heels were actually rather apropos. Kigali is the capital city of Rwanda, and is shockingly clean, safe, and businesslike. It’s like the entire city is in the midst of an unspoken rebellion against what the western world would naturally think of them after the horrific mid-1990s genocides – like they are so determined to be exactly the opposite of the violent, disorganized image that their relatively recent history suggests. They take pride in their beautiful city – one day a month is a day of service, and all residents join in cleaning up their neighborhoods. As a result, there is seriously no litter on the streets lined with healthy vegetation, and there are sidewalks and paths nicer than a lot of streets in Boston. It really is picturesque. Rwanda, c’est le pays de mille collines – Rwanda is known as the land of a thousand hills. Kigali is set on a few rolling hills and deep-set valleys that glow red and green during the day and twinkle with tiny white lights from the city’s inner neighborhoods at night. Yes, electricity – pretty darn constant – throughout the city. There is even a weekend salsa-dancing scene!