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Expanding laboratory services in the Land of a Thousand Hills

From the December ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Trahern Jones

The room was filled with Auto-Tuned voices singing in Kinyarwandan, the sound tinny as it poured through a lab technician's cell phone. I placed a freshly stained and dried slide on my microscope stage, drew the nearby curtain to gain a semblance of darkness, and put my brow against the eyepieces. I could see nothing. It was like looking up at a night sky on a moonless and cloudy night. The fingers of my left hand were slippery with immersion oil; I wiped them on my jeans and fiddled with the fine focus. At first, there was a distant, green haze. Then, turning the knob once, and twice more, the sky filled with glittering, green stars: hundreds of mycobacteria, fluorescing brightly. This sputum smear was strongly positive—the 21-year-old student who coughed it up that morning had a floridly contagious case of tuberculosis.

At first there's a sense of exhilaration—of catching the culprit red-handed—upon seeing a pathogen from a patient sample under a microscope. But then comes the worry: Was I in the room when this smear was made? I imagined the millions of aerosolized bacteria floating in the air each time a sputum cup is opened and closed, and wondered: What if there was a problem with my N95 mask at the time? Or what if I ran into this person on the hospital campus earlier that day? Maybe I shook his hand just after he coughed into it—maybe I touched my face, my nose or my lips just a little bit later?

Photo courtesy of Andrew Norgan, left, and Trahern...

Photo courtesy of Andrew Norgan, left, and Trahern Jones.



I tried to put the worries out of my head. The lab technician on the other side of the curtain turned up the music on his cell phone, and the Kinyarwandan voices drowned out the sound of my pen scratching on the pages of my lab notebook.

This was Kibogora Hospital on the western edge of Rwanda, just five minutes' walk from Lake Kivu, one of the great lakes of Africa. Abutting the hospital are the terrace-cultivated slopes of Rwanda, densely foliated with banana trees and manioc plants; on the other shore loom the deep green volcanoes of the Democratic Republic of Congo. In the evening, the songs of fishermen waft up from the pirogues paddling across the inlets and glimmering water. Pied crows, wearing their distinctive black-and-white plumage (for which we nicknamed them “Tuxedo Birds”) swoop overhead and line the power lines. Rwanda is often called The Land of a Thousand Hills and the reason is abundantly clear: Wherever you look, misty slopes swell and fall off into the horizon, and each is overlain with a patchwork of villages and farms, stitched with dirt and mud roads.

Andrew Norgan and I came here in July 2011 for three weeks to expand the Kibogora Hospital laboratory's TB diagnostic services—specifically, to introduce fluorescent microscopy—as an independent research and volunteer project under supervision by Dr. Roshini Abraham at the Mayo Clinic. We soon discovered the area's muddy roads were a tenuous connection between Kibogora and the outside world. Traversing the rural routes from the international airport in the capital of Kigali to the hospital's secluded spot can take six or seven hours by four-wheel drive, perhaps more when the rains turn the road into a muddy bog. The drive itself is always eventful; between punctuating cries of “muzungu” (“traveler” or colloquially “white person”) shouted by children on the hillsides, the visitor is bound to see one or two road accidents—one of the leading causes of death in the country. The long journey necessitates a stop for a snack or two, and although sampling a roadside vendor's wares may put one at risk of catching a stomach bug, we could hardly resist. We savored the brochettes sold throughout the countryside—goat meat on a stick, well salted and dripping with fat.

Our project's goal was to introduce fluorescence microscopy to Kibogora Hospital's laboratory. Most of the country's hospitals use the Ziehl-Neelsen technique to diagnose tuberculosis from a patient sputum sample. Although it's cheap, rugged and only requires a simple light microscope, the century-old technique lacks in sensitivity, and many cases of TB in Rwanda probably go undiagnosed by laboratories that use it. Fluorescence microscopy is more sensitive but requires a more expensive microscope, and the price lies far outside the budget of most rural African hospitals. Fortuitously, we were able to obtain an LED ParaLens microscope attachment—a user-friendly, cheap and rugged fluorescence system that attaches to any standard light microscope.

The first day we set up the system and began teaching the laboratory staff how to use it, we were already catching positive sputum samples. The night sky in our microscope eyepiece filled up with bright, green stars of fluorescing mycobacteria. That night, under a real night sky filled with equatorial constellations, we toasted the new system with orange and lime Fanta. As a cool wind blew from the hilltop and carried the sound of distant voices speaking French and Kinyarwandan, it was clear why one might choose to live and work in so remote a place.

On that very spot where we sat celebrating, missionary Frank Adamson arrived with his wife in the early 1940s. They built their mission here, just a little north from where the roads dive into the forests of the Congo, on the south end of Lake Kivu. It included a health post and an orphanage to serve the local villages of farmers and fishermen. The need for health care, however, was greater than the Adamsons could provide, and the post expanded its staff of nurses continuously until 1963, when Kibogora's first doctor, Esther Kuhn, arrived.

The sixties were revolutionary for the area, as the post grew from a mere dispensary to a full-fledged hospital, particularly when surgery was introduced under Dr. Al Snyder in 1967 and 1968. Yet the patients' needs were even greater, and only grew as the area's population increased: Long lines of injured farmers, women in labor, and coughing kids incessantly pushed the hospital to expand its services. More buildings, more equipment, and more doctors were the pattern from then on.

The country's genocide in 1994 abruptly disrupted this work. Hospital staff members who could not flee the carnage were lost to the “genocidaires.” Invaluable equipment was looted. But Kibogora Hospital's recovery after 1994 is a testament to the dedication of loyal Rwandan staff and expatriate health professionals. Much was saved and salvaged, and now the hospital's services and campus have grown even larger than before the tragedy.

Every morning, afternoon and evening during our visit, a motley fleet of four-wheel-drive ambulances came rumbling up and down the dirt road leading to the front gate of the hospital. They carried the injured and infirm to the “Service des Urgences,” where a dedicated crew of 65 nurses and 12 Rwandan and Congolese doctors provides some of the best care found in western Rwanda. The hospital boasts more than 260 beds, divided into surgical, medical, pediatric, and obstetric wards, along with separate beds for isolation patients (those with TB and infectious diarrhea), as well as a special malnutrition unit for children. Kibagora Hospital also stands as one of the few teaching hospitals in Rwanda. The facility is currently preparing to open its own university of health sciences, and is poised to open the doors to its first nursing class in early 2012.

In the past, many Rwandans only spoke Kinyarwandan and French, but English has now been added as one of Rwanda's official languages. This is likewise true for Kibogora's hospital: Its two permanent expatriate nurses, Sheila Etherington and Julie Yerger, hail from the United Kingdom and the U.S., respectively, and much of the national medical staff speaks English fluently. The hospital is always looking for dedicated foreign medical professionals to spend some time teaching and working alongside its staff. Although specialists in surgery and obstetrics are in high demand at the moment, all specialists, and especially potential educators for the nursing school, are invited to visit Kibogora.

Our time at Kibogora was eye-opening, educational and fun. The drive back to the airport was bittersweet; after stopping briefly at Nyungwe National Park to view wild troops of chimpanzees, we continued to the chaotic East African metropolis of Kigali. We climbed aboard our flight, and within hours, stood nodding sleepily in the comparatively hyper-modern Brussels International Airport. We had left the constellations of stars in an equatorial sky, and the faint, singing voices of fishermen paddling their pirogues on the great lakes of Africa. But they would never leave us—and neither would the quiet promise, one day, to return.

Trahern Jones is a third-year medical student at Mayo Medical School in Rochester, Minn. He would like to thank Andrew Norgan for both his collaboration in Rwanda and his suggestions for this article.

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