University of Cincinnati and Rwanda build capacity in cardiology

In 2019, the University of Cincinnati Rwanda Initiative partnered with the country’s national university and teaching hospitals to provide that training through a virtual program and faculty exchange. Now their collaboration has become part of the Rwandan government’s strategic launch of fellowships in 12 crucial internal medicine subspecialties to improve healthcare access and outcomes in the country.

The first two cardiology fellows, Dr. Olivier Niyigena and Dr. Bienvenu Muvunyi, visited the University of Cincinnati College of Medicine in January and February 2024 for an 8-week rotation in the Division of Cardiovascular Health and Disease.

In 2016, Dr. Hanan Kerr, an associate professor of clinical medicine at UC, joined a large team of volunteer U.S. medical staff that traveled to Rwanda to provide cardiovascular care in three intense weeks of surgical and post-op treatment. She saw firsthand the country’s critical shortage of doctors in her field and found her interest drawn to the education side of the problem.

“There was no subspecialty training on the ground. And that's what everybody really wanted. They appreciated the surgery, and they appreciated the care, but they wanted training,” she said.

Kerr made a solo return visit in 2018 to learn more from the medical faculty, residents and students at the national University of Rwanda and the country’s four teaching hospitals.

She worked closely with Dr. Gloria Mukeshimana at King Faisal Hospital and the University Teaching Hospital of Kigali (CHUK). Mukeshimana is Rwanda’s first female cardiologist and the only one then in a faculty role in cardiology in the hospital system, a responsibility that staggered Kerr.

In comparison to Rwanda, the U.S. had 16,870 cardiologists (2022 data), for a per capita ratio under 1:20,000.

Niyigena, who met Kerr in 2018 while he was a third-year resident in internal medicine at the University Teaching Hospital of Butare (CHUB), describes the kind of mentorship she offered as “a huge need” for young doctors like himself and Muvunyi.

“People are not trained, and the few cardiologists that were there were not able to give much in terms of teaching because of the burden of the work that they had,” he said.

“Our patients were sent to India, to Kenya, to get quality subspecialty medical care,” said Muvunyi. Most could not afford that option, and local physicians often lacked access or training to offer them more than general medical management for cardiovascular diseases, he said.

Like most of his peers, Muvunyi had little hope of continuing into advanced training after he finished his residency in 2018 and went to work in a district hospital. The financial and personal costs to pursue a fellowship in South Africa, Kenya or Egypt were prohibitive.

Once back at UC with closer contacts on the ground in Rwanda and a clearer picture of the problem’s scope, Kerr founded the University of Cincinnati Rwanda Initiative with a group of faculty colleagues.

In collaboration with the Rwandan Ministry of Health, the University of Rwanda, the University Teaching Hospitals of Kigali and Butare, King Faisal Hospital and other stakeholders, their goal was to support ongoing efforts to build a self-sustaining cardiology program that will train the next generation of doctors in Rwanda.

A UC team planned to travel to Rwanda in 2020 to provide in-person training and proctorship and to develop the partnership. But they had to cancel the trip because of the COVID pandemic.

“So we started a virtual program of education for the residents,” Kerr said.

“We started slowly, working with the chief residents at the time and building a core curriculum, initially,” said Dr. David Pratt. Then a cardiology fellow and now an assistant professor of clinical medicine in the Cardiovascular Health and Disease Division, Pratt led the virtual initiative on the UC side.

UC became an instrumental partner in the subsequent development of a cardiology fellowship in Rwanda, one of the first four programs (cardiology, nephrology, gastroenterology and endocrinology) launched in the second decade of a national initiative by the Rwandan Ministry of Health to build the country’s medical capacity.

With the loosening of COVID restrictions, more exchanges have followed Kerr’s and Meshesha’s visits  as the relationship between the U.S. and Rwandan medical colleges has grown closer.

“Only four of us stayed, and all the burden of cardiology for 13 million was on our shoulders. We were seeing patients, educating patients and also retaining patients for interventions. And our patients, we need to speak to them in the local language that they understand. When you tell the patient he will undergo an MRI, he doesn't know what that is. You become like a relative to the patient,” said Muvunyi. “And you're a treating physician. So all these pressures were on us in making decisions.”

The visiting physicians assisted with both teaching and patient care to support the cardiology program until new faculty could be recruited.

Kerr said, “I remember getting a text from Olivier. I asked him, how was the rotation [with the U.S cardiologists there]? You know what he said to me?

"‘Cardiology is sweet again.’”

Now the first two cardiology fellows have had their own opportunity to participate in the exchange with UC. They have just completed an eight-week rotation in Cincinnati at the Division of Cardiovascular Health and Disease in the College of Medicine's Department of Internal Medicine.

It was an experience designed to give them intense exposure to a volume of cases they don’t often see at home. It has also given them direct familiarity with technologies and care strategies they knew at best only in theory.

Their rotation included time in several UC labs devoted to cardiac imaging and testing, as well as in the electrophysiology clinic, the catheterization lab and the heart failure program. Muvunyi and Niyigena also joined rounds in the cardiovascular ICU.

Seeing some procedures in high numbers at UC was a clear benefit, the fellows said.   

The two plan to take home strategies they can adopt immediately to improve the care they can offer. One example is stress echocardiogram testing, where ultrasound imaging is added to the electrical testing (ECG/EKG) performed to examine a patient’s heart under stress, typically from treadmill exercise. Combining the tests to assess the heart’s response to high demand offers more complete diagnostic information than stress EKGs and resting echocardiograms alone.

“We’re not doing stress echo back home. When you read about it, when it is in theory, you think this is something that is complicated. But we see that we can improve our stress tests in terms of that, in terms of making it complete,” Niyigena said.

Equipment for both tests is available at King Faisal Hospital, but the treadmill is on one floor and the echocardiography machine is on another. Creating a protocol to pair them routinely when needed will make a significant difference in diagnostic accuracy.

The virtual UC Rwanda program is now entering its fourth year.

Mukeshimana, one of the fellowship program’s original directors, is expected to return home from her interventional training (training in minimally invasive procedures) abroad, rejoining the current director, Dr. Esubalew Woldeyes, to further expand the cardiology program.

The two additional first-cohort fellows will also come to UC to do an external rotation. Kerr hopes it can be scheduled by the end of this year. In the second cohort, Dr. Emmanuel Bizimana and Dr. Saad Ngoga have begun their fellowships. Four residents in the University of Rwanda’s senior class have now also expressed an interest in studying cardiology.

“Our biggest wish is to have this lasting long,” said Niyigena.

“Sustainability,” Muvunyi agreed. “Because sustainability is a big issue. People get this training, people get this exposure. At the end of the day, it [often] stops, and you say, ‘In my time, I had this and this and this,’ which the next generation would not get." He wants the bilateral partnership to continue and the program to become self-supporting.

Kerr sees the exchange increasing the UC fellows’ interest in global health as well, and hopes that the sense of investment they and faculty and even patients at UC have come to feel in Muvunyi and Niyigena’s training will open up more mainstream opportunities for global study on both sides.

She sees the exchange as offering advantages to UC doctors as well as to Rwandan.

“The cardiologists there are great, like Dr. Gloria, Dr. Amha,” he said of the physicians he has worked with through the UC Rwanda Initiative.

“But you know, to only have a few role models in your entire country and not necessarily know another cardiology fellow in your country—I think that’s now something that isn't quite as big of a problem.

"It’s a big deal to have both peers and role models. And now a ready supply of mentees, too.”

Featured image: Bienvenu Muvunyi, UC’s Hanan Kerr and Olivier Niyigena in the UC College of Medicine | Photo by Natalie Ochmann, UC International