Projects

We are a culture obsessed with projects. Americans (more so than others I have begun to realize) love to have something to do, something to work on, or a task to complete. That is one of the biggest lessons I have learned in my four weeks here at Project San Francisco. Project San Francisco (PSF) is the name encompassing the clinic, lab, training center, and research facility that I am working at here in Kigali. It is based in the center of town and has provided care for men and women infected with or affected by HIV/AIDS since its founding in 1986 by Dr. Susan Allen—the Emory physician who is my boss for the next five months.

Originally a grassroots organization, its presence has grown both here in Rwanda and in the international HIV community. The project is funded by grants from the Centers for Disease Control (CDC), the International AIDS Vaccine Initiative (IAVI) and the President’s Emergency Plan for AIDS Relief (PEPFAR) and has become quite the juggernaut of a research group. PSF promotes couples voluntary counseling and testing (CVCT) for HIV and encourages couples to get tested for and counseled about the virus together with the realization that most African couples infected with HIV are co-habiting men and women. If couples are discordant, meaning one partner is positive and the other is negative, PSF follows these individuals for monitoring of their health, retesting of the negative partner, and reaffirming messages of condom usage in efforts of prevention. And, in the unfortunate incidence of a seroconversion (the HIV negative partner becomes positive), PSF performs complex laboratory tests to monitor the genetic linkage of viral strains and the immunogenic factors involved in transmission. Some of these clients of PSF have been living healthily with HIV for in excess of 25 years and have their blood filtered and studied for the presence of neutralizing antibodies to be used in vaccine development. Its role in vaccine trials and its growing role in family planning are among some of the other tasks that we manage here at the project.

Most remarkably, however, are the training and education efforts we have going on here at PSF. Dr. Allen has secured a significant five-year grant to train every government-run health center in Rwanda how to counsel and test couples for HIV over the next five years. Each week nurses come from their centre de santé (health center) in various regions of Rwanda to PSF here in Kigali for a week of didactic and practical training for CVCT. These objectives, of education and health preservation is at the center of PSF mission.

Above is the view overlooking PSF from the building where my office is located. The building straight ahead holds the only Accredited Laboratory in East Africa outside of Nairobi. The building to the right is the clinic building where the clients of PSF are seen 7 days a week by our nurses and counselors. The second picture above shows the walkway from my office to the clinic building. Below is the office that holds the physician and counselors' offices (including mine) that double as clinic rooms when necessary.

For the past twenty-four years, PSF has been a driving force in HIV research and a life force for many of the people of Rwanda. During Dr. Allen’s visit a few weeks ago I realized just how deeply connected the clinic is to the welfare of the people of Rwanda as she shared her account of the events of the 1994 genocide.

There is universal awareness of the horrific events of 1994 in which hundreds of thousands of Rwandans were killed in tribal civil war. I was keenly aware of this incident when I began researching Rwanda as the setting of my summer project. I continue to think about it daily when I interact with patients and try not to wonder who’s Tutsi, who’s Hutu, and who would wield a machete against his or her neighbor if given the opportunity again. Rwanda is a model of post-war reconstruction driven in part by a highly regimented and intolerant government. The official message of the country is that there are no tribes and that there are only Rwandans, but the grenade attacks in the capital and the genocide prisoners in their distinct pink jumpsuits are a reminder that this government-promoted message is only a thin veneer.

Dr. Allen’s story of being trapped in Zambia during the genocide and trying to reunite with her husband and her 3-year-old son who were in Kigali at the time of the incident was harrowing to say the least. The last sentence she heard on the phone from her husband before seeing him in Kenya two weeks later was “we’re never gonna get out of here alive”. Working with the stoic Rwandan physician who is our project director who suffered unimaginable losses to his family in the genocide is a daily reminder of that same horror. And despite the sadness that colors the history of this country and the culture of veiled mistrust that characterizes its present, Rwandans still march towards the future. Dr. Allen’s dedication to this future is why I am proud to be working here at Project San Francisco. At PSF we worry about the medicine and the numbers, but everyone knows that the staff members who worked here before 1994 survived in large part due to her strength and guidance during the evacuation.

Pictured above is the main entrance and garden beyond the gates of PSF. The garden was created as a memorial to the lives that were lost in the 1994 genocide. The black plaque in the center contains the names of those PSF staff members who were lost in this horrible event.

It is with this history that I come to work on my “project” every day. I have been charged with trying to pilot a training program to teach Rwandan nurses how to provide IUDs and implants (long acting and reversible forms of birth control) to their patients. As one can imagine, after mass murder and civil war, Rwandans are eager to rebuild their families. Unfortunately, with a population growth rate easily surpassing other African countries, an unbelievable population density, and the average Rwandan women having 6 children in her lifetime such fertility is not sustainable. As a result, Dr. Allen feels strongly in helping the government develop infrastructure and policy to try to make birth spacing and family planning the social norm. I am happy to be working with nurses who come for CVCT training to assess their knowledge about these methods and what barriers exist to implementation. As I learn more about the cultural and practical barriers to these methods, I look forward to piloting a training program in two clinics—the Centre de Sante Gitega and the Centre de Sante Muhima.

Above is the office that I share with the other ex-pat interns. Below is the view out of our window and the nest of pelicans that live in the top of the tree by the wall.

These are my goals when I come to PSF every day to work on my discovery project. This “discovery project” is a required five-month research endeavor that is a mandatory component of my medical school curriculum. As many of you know, this opportunity for “discovery” was a huge factor that influenced my decision to pursue my medical degree at Emory. Though I am excited about the work I am doing and get even more thrilled as it starts to take shape every day, I realize that my small project is part of something larger.

The work that I am doing on a daily basis may seem frustratingly tedious at times. But a quick glance out my office window to the courtyard of PSF filled with HIV positive women and their many children reminds me that the details I pursue now are a small step towards a larger vision for a bright future here in Rwanda. Though I am proud of the work I am doing and realize it will be a life changing experience in my personal and professional development, I know that it is insignificant in the grand scheme of what happens at PSF on a daily basis. Since starting my work here I have been embraced by the staff at PSF and taught the cursory phrases of Kinyarwanda. In a medical climate characterized by the maxim “publish or perish” it is nice to be around something that has remained. Project San Francisco has endured hardships that are thankfully unimaginable to most of us and has remained a strong presence in the community that is unwaveringly true to its mission. I am proud to be working for and with these remarkable men and women on a daily basis, and I can’t imagine a better place to spend the five months of my discovery project.

Above is Natalie, one of the general workers at PSF who is also my Kinyarwanda teacher. She doesn't speak French or English, but we communicate rather well. Below is one of the wonderful surprises that accompanies working in Rwanda--the beautiful animals that wander through the garden.