Gastrointestinal endoscopy in Rwanda – The 5th Rwandan Endoscopy Week 2022

All over the world many patients are suffering from conditions requiring gastrointestinal endoscopy. But endoscopy facilities in many African countries are rare, as is the case in Rwanda, with about 2.5 million inhabitants. This leads to high numbers of late consultations, if any, to prolonging of suffering, and to undertreatment of diseases. In the case of gastrointestinal malignancies, this results in advanced disease and high mortality rates. For long periods, gastrointestinal endoscopies in Rwanda were performed only occasionally. The need for far more endoscopy facilities and expertise is evident. At this moment the number of gastroenterologists and internists with some expertise in gastroenterology and endoscopy is very limited, and less than 30 doctors perform endoscopies at various locations.

Establishing and sustaining an endoscopy service

In 2015, within the University Teaching Hospital of Kigali (Centre Hospitalier et Universitaire de Kigali – CHUK), the Department of Gastroenterology and Hepatology was established including an endoscopy unit to provide specialized consultations for patients with gastrointestinal conditions. In 2017, Rwandan health professionals interested in gastroenterology, and hepatology founded the Rwandan Endoscopy Society (RSE). This was done with the support of international and local partners, especially the King Faisal University Hospital in Kigali.

In the same year, the RSE, in collaboration with GI-specialists from Dartmouth Hitchcock Medical Center (Hanover, New Jersey, USA) and Brigham & Women’s Hospital (Boston, USA) and later also with partners from Australia, the Netherlands, and the World Endoscopy Organization (WEO), launched the first Rwandan Endoscopy Week. This proved a great success and stimulated a now yearly recurring academic and clinical event. The clinical activities throughout this week are conducted at seven hospitals countrywide, including public, private, urban and rural facilities, with increasing numbers of endoscopies. Endoscopy, alongside Helicobacter pylori identification and eradication, aids in GI cancer prevention and diagnosis. This microorganism is highly prevalent in Rwanda. About 85% of the procedures performed are gastroscopies. The teaching program includes lectures and hands-on training for fellows, residents, general practitioners, and endoscopy unit nurses. In addition, biomedical engineers from the US assess the functional status of and repair the endoscopy equipment available in the country, if necessary. During the recent 5th Rwandan Endoscopy week from 24 October to 4 November, 2022, over 900 upper, lower, and advanced GI endoscopies were performed. GI awareness and endoscopies are on the rise.

In 2020, the US non-governmental organization GI Rising (cooperation between Dartmouth and Brigham & Women’s) was founded to further GI education and care in Rwanda. This resulted in Rwanda’s first post-graduate GI training program, a self-sustaining fellowship in gastroenterology and hepatology. Two university hospitals in Kigali have jointly been recognized in 2021 by the World Endoscopy Organization as centres of a formal 2-year fellowship training program in GI endoscopy: CHUK and King Faisal University Hospital. This program is open not only to Rwandans but to medical doctors from other African regions as well.

Challenges

Despite all these favourable developments within a very short period of time, the lack of endoscopic equipment, coupled with a lack of training and expertise in therapeutic endoscopy, hinders specialized gastrointestinal care. The equipment is often donated, namely used endoscopes from abroad, and maintenance of this equipment is a challenge. Also, consumables such as balloon dilators, varices band ligators, and biopsy forceps are in short supply.

The value of exposure to GI practice and training in high-income countries cannot be overestimated. Such global health experience enables the trainee from a low- and middle-income country (LMIC) to acquire a deeper understanding of the entire spectrum of GI disease including cultural differences (for example in risk factors). In addition, the trainee will experience GI care at the highest level and may be able develop a similar framework at home in a bilateral long-term collaboration with the host institute in the HIC, in which leadership skills should also be strengthened. This training and exposure may reduce inequities in global health care. Some residency training programs and medical schools in HICs have developed global health electives for that purpose, but the number of fellowships is limited. Another challenge is the (permanent) scheduling of such electives in educational programs.

In conclusion, in the field of endoscopy in Rwanda, considerable progress has been made in terms of training in GI endoscopy and patient care; sustaining and further developing this initiative are important challenges for the future.