Dr. Cyprien Shyirambere meets patients near the brink of death at the Butaro Cancer Center of Excellence in northern Rwanda. They and their families may have no idea why they’re sick; they just want a cure.
Shyirambere often helps them reach one. The pediatrician began working with Inshuti Mu Buzima, as Partners In Health is known in Rwanda, three years ago as the center’s oncology program associate director and has seen how basic services can save lives.
For World Cancer Day, Partners In Health spoke with Shyirambere about why he chose to study medicine, how cancer care has changed in his home country, and what challenges he faces treating the disease in one of the most remote regions of the world. This interview has been edited and condensed.
What inspired you to become a doctor?
I saw the scarcity of clinicians in the country, because people were not willing to do medicine. They wanted to do a quick program like information technology or finance in order to make money.
If you look in World Health Organization literature, you will see that Rwanda was one of the countries where the health workforce was significantly short. I wanted to train in medicine and give my contribution, so that Rwandan people could have more access to health care.
After completing my training, I was doing my rotation in different departments. While in pediatrics, I saw that children actually need more attention because they die so quickly if there’s no one to provide basic things, such as IV fluids and antibiotics. When they do get special attention, they show quick recovery. That is especially what inspired me to go into pediatrics.
What got you interested in oncology specifically?
It was not an easy decision. When you are training, you are told that cancer cannot be cured in poor places like Rwanda. Then I heard that there was a program in Rwanda where PIH was treating cancer.
I said, "Well, it’s time for Rwanda also to start something." So that’s how I joined the Cancer Center of Excellence in Rwanda.
What did cancer care look like in Rwanda when you started?
Before the Butaro Ambulatory Cancer Center opened in 2012, there was not much in the country. Chemotherapy was not available in public facilities. There is still no radiotherapy. Only a few people with financial means could afford cancer care in a private hospital in Kigali, the capital of Rwanda, or go abroad to places like India or China.
The majority of Rwandans had no access to cancer care. It was a death sentence in Rwanda. Telling someone, "You have cancer," was equal to saying, "You are going to die."
How has that changed since the Butaro center opened?
Now, people know that if you have cancer, you can get treatment—and not just in Butaro, but also in other referral hospitals.
We have had around 6,000 patients in five years. That’s around 1,200 every year. The top four cancers we see are women with breast cancer or cervical cancer, and children with acute lymphoblastic leukemia or Wilm’s tumor, which is a cancer of the kidney. There are also cancers of the blood, such as Hodgkin and non-Hodgkin lymphoma.
Shyirambere helps Wilson Ngamije* back into his jacket after a quick exam. Ngamije is at Butaro District Hospital to receive chemotherapy for Hodgkin lymphoma.
What stands out about cancer care at Butaro?
What makes our cancer center unique is the collaboration with other cancer centers in the United States. There is no oncologist here in Butaro. We have a physician. We have general nurses who have received training in oncology. And we have protocols that have been endorsed by the government—all of which we use to treat cancer. Academic cancer centers in the U.S. give us leadership mostly, and sometimes staff come here to give us on-site mentorship.
We believe that cancer can be treated without all the oncology facilities, but with people who are committed and with a strong health system. That’s what makes our cancer center unique—that motivation, that collaboration, that commitment.
As people become aware of the cancer center, the number of patients have increased from around Rwanda and outside the country. Almost 10 percent of the patients we see come from a neighboring country, mainly Burundi and Congo.
What are some of the challenges you face?
We see patients who arrive in late stages of cancer, and this impacts their prognosis. And of course, there are limitations in the capacity of our staff, in terms of training.
We also lack resources. This is basically a district hospital, so we don’t have all the facilities around us. We don’t have an intensive care unit or a CT scan machine, which is mandatory for staging cancer. We don’t have any radiotherapy machine in the country, so we refer our patients to Nairobi, Kenya, and it’s very expensive.
Another challenge is the social-economic situation of our patients. We need to subsidize their transport and their food, and this is becoming a burden to the hospital.
How are you meeting these challenges?
Increasing awareness in the community is one strategy we use to decrease the number of people who come with late presentation [of their cancer]. We work together with the Rwandan minister of health to increase awareness in the population for early detection. We use media, community health workers, and all means of communications so that people know that cancer exists, that it can be treated, and that some can be cured.
There is a plan to expand the facility so that we can serve more people. But of course, this goes with funding, so we have to identify more funds to continue to support these patients. We are hoping that in three years, one of our referral hospitals in Kigali will have a facility with two radiotherapy machines.
Most of our patients are poor. They get chemotherapy free of charge, so I want to continue to ensure their access to treatment and work on a plan to bring radiotherapy to the country.
LISTEN: What lessons have you learned in doing this work?
Do you have a story about a particular patient you’d like to share?
I have a lot of my patients in my heart, but there’s one patient I will always remember. He’s a 9-year-old boy named Kachonga. He came to see us from the Congo with his mother. For almost three years, the child had been going to different hospitals in the Congo and Burundi. He was treated incorrectly for tuberculosis for almost eight months.
Then Kachonga and his mother heard that there is a cancer center in Rwanda. They came and discovered that he had Hodgkin lymphoma. The child was treated for six months with chemotherapy, and now he’s back to school and doing very well.
When I see Kachonga for follow-ups, and I compare how he is now to when he came to see me, I feel very happy. He’s doing well.
What is it about Kachonga that made an impression on you?
Kachonga was very sick. His mother had almost no hope. But Kachonga himself still had hope that he would be cured. He was standing strong, despite being really sick.
LISTEN: What do you want people to know about cancer—both how it’s treated in Rwanda and on a global level?
*Name has been changed