Rwanda Trains a New Generation of Cancer Nurses

With his warm, friendly smile, Jean Bosco Bigirimana is winning over a roomful of eager listeners with a presentation on the groundbreaking cancer care work he and his colleagues are doing in Rwanda.

“When I began nursing, we thought that cancer meant death or suffering,” says the 28-year-old oncology nurse. “But with education and access to improved treatment we found this not to be true. People can live for a long time if they are diagnosed early. Even those at the end stage can live free of pain and the quality of life can be improved.”

After the presentation, he greets new acquaintances with a warm embrace—the type many Americans would reserve for an old friend. He follows one hug with, “What is your name again?” and smiles at the response. “Ahhh, that is good,” he says, as if the proffered name is itself intrinsically blessed or fitting.

Bigirimana’s personality has played no small part in his success as oncology coordinator for Inshuti Mu Buzima, Partners In Health’s sister organization in Rwanda. His colleagues describe him as a rising star in Rwanda’s rapidly advancing field of cancer care, citing his clinical skill as a nurse on the ward and his talent as a trainer and in the classroom. 

Bigirimana’s role is a highly demanding amalgamation of clinician, trainer, patient counselor, public health educator, and nursing advocate. His tasks include coordinating cancer care in the three districts of Rwanda where IMB works; calling patients to inform them of test results; scheduling patients; educating patients on different topics related to cancer; and mixing and administering chemotherapy.

This deceptively short list belies the complexity of Bigirimana’s daily work. Patient education, for instance, takes on a new meaning when the patient has never heard of cancer—or believes the illness is caused by witchcraft or is punishment for a past wrongdoing.

Nor are misconceptions confined to patients. Chemotherapy drugs are inherently dangerous to both the patient and the administrator. Without proper protective equipment, those mixing and administering the drugs may expose themselves to serious harm—sterility or even cancer in the most extreme examples. Convincing his fellow nurses that cancer can be treated safely sometimes proves challenging.

These partners have replaced the case-by-case approach with national protocols and a national training program together with a formal cancer care program at Butaro Hospital with hopes of bringing trained cancer care nurses and doctors to every corner of Rwanda.

“Rwanda has a lot of talent, a lot of dedicated, patriotic citizens. They just don’t have a lot of skilled personnel when it comes to cancer,” says Dr. Neo Tapela, IMB’s director of noncommunicable diseases.

To address this skills gap, a coalition of partners—including the Rwanda Ministry of Health, the Rwanda Biomedical Center, Partners In Health, the Dana-Farber Cancer Institute, and Brigham and Women’s Hospital—formed to implement a multiyear training effort. The initiative is also generously funded by GlaxoSmithKline.

“PIH has been supporting cancer care in Rwanda since 2006,” Tapela says. “In the beginning, it was on a small scale, case-by-case, and it followed the same principle PIH has for all patients. Cancer patients started showing up—and you can’t say we don’t provide cancer care—so my predecessors figured out how to diagnose and how to get the medicines.”

Today, these partners have replaced the case-by-case approach with national protocols and a national training program together with a formal cancer care program at Butaro Hospital with hopes of bringing trained cancer care nurses and doctors to every corner of Rwanda.

A major component of this effort is the national Baseline Cancer Care Training for doctors and nurses, which launched in March 2012. Tapela—who holds positions at Brigham and Women’s Hospital, the Rwanda Ministry of Health, and IMB—describes the one-week course as intense and participatory, “with lots of role plays, ‘Jeopardy,’ and visits to the Butaro Cancer Center of Excellence to see cancer care live.”

Under the direction of trainers, including Bigirimana, participants gain foundational knowledge on questions such as, what is cancer? What is the epidemiology of cancer right now? What are the main cancers seen in Rwanda? Which cancers are treatment priorities of the Rwandan government? And what are the treatment options, including palliative care? The trainers are Rwandans, as well as medical oncologists, surgical oncologists, and oncology nurses from Dana-Farber Cancer Institute led by Dr. Lawrence N. Shulman, the Institute’s director for Global Cancer Medicine and PIH’s senior oncology advisor.

Bigirimana examines Jeanette, who is being screened for cancer after the discovery of breast and abdominal masses in her body. Photo: Aubrey Davis / Partners In Health

“A lot of that is to lay the theoretical foundation because nobody [in Rwanda]—not nurses, not doctors—gets enough exposure to cancer in the standard curriculum right now in nursing and medical school,” Tapela says. There is a paucity of trained oncology physicians and nurses in Rwanda, and collaborators from Dana-Farber and the other Harvard hospitals have filled that gap.

While these collaborators have provided world-class expertise, Tapela and her colleague Celia Reddick, a PIH curriculum and training specialist, and other IMB team members helped adjust the curriculum to reflect the needs of course participants, as well as the clinical realities of delivering cancer care in a resource-limited setting. For instance, many participants in the training are A1 nurses, who have the equivalent of two years professional training following secondary school.

Each course consists of about 30 doctors and 30 nurses. To date, three groups of students from facilities throughout Rwanda have cycled through the course. But the purpose of the course isn’t simply to impart knowledge to the attendees; it’s also to identify and train expert trainers, Tapela says. True to PIH philosophy, the program’s end goal is to build a cadre of skilled Rwandan trainers who can then pass along knowledge to their colleagues.

The approach is working. The majority of trainers for the first course were foreigners, but in the most recent session, nine of the 12 trainers were Rwandan.

The Baseline Cancer Care Training is just a beginning. The Rwanda Ministry of Health envisions an ongoing package of trainings, including three-month-long rotations for Rwandan post-graduate physicians and specialty nurses at Butaro Cancer Center of Excellence, a PIH-supported national specialty facility for cancer care.

Rwanda still faces many challenges when it comes to effectively treating cancer on a national scale—for example, adding oncology curriculum content to the pre-service training clinicians receive and ensuring that trained clinicians have access to the necessary drug supplies—but Tapela is optimistic.

“There is definitely a motivation, individually, to do more—you can see this with Jean Bosco—and nationally that is what the government is doing. The government has sent three Rwandans to train as pathologists in South Africa and Kenya. They’re also sponsoring a couple of doctors to train in cancer specialty services …. [They are] actively trying to build capacity so that important services are provided—and by skilled Rwandans.”

In the end, it is dedicated Rwandans such as Bigirimana who are poised to shape their country into a model for developing nations around the world. “I see him being a leader nationally. He definitely has the skills and the heart for it,” Tapela says.