The Social Medicine Portal

Addressing HIV & genocide in Rwanda: Work of Dr. Kathryn Anastos & Jon Wallen

On Tuesday, March 10th Dr. Kathryn Anastos and Jon Wallen came to Social Medicine Rounds to discuss their work in Rwanda.   Dr. Anastos’  story illustrates one answer to the question: “What does a social medicine doctor do?”

Dr. Anastos is an Internist who  graduated from the Residency Program in Social Medicine in 1983.  She is currently a Professor at Albert Einstein College of Medicine in the Department of Medicine as well the Department of Epidemiology and Population Health.  She is known for her pioneering work in the study of HIV in women as principal investigator of the  Women’s Interagency HIV Study (WIHS).  Jonathan Wallen is a New York photographer who specializes in architectural and landmark photography.  Since 2003 they have become increasingly involved in work in Africa, some of which they shared last Tuesday.

Mr. Wallen filled the walls of the third floor conference room with pictures from the Tubeho (“To live again”) Project.  Tubeho documents the stories of female victims of the Rwandan genocide and consists of a series of photographs with accompanying stories (see an example at this link).  These were disturbing stories.  The pictures that accompanied them showed both women in the full bloom of life as well as others whose spirits and bodies seemed broken.  Showings of the exhibition have been used to raise funds for the genocide victims as well as to bring attention to the links between gender-based violence and the spread of HIV.

Dr. Anastos framed her work in the context of  Community Oriented Primary Care (COPC).  She shared her initial skepticism, developed from her work in the Bronx, in COPC as a model of care.  Rwanda, however, had changed her point of view.

The couple’s involvement in Rwanda began in 2003.  Dr. Anastos had been contacted by Les Veuves (the Widows) a group of genocide survivors, many of whom were infected with HIV.  They were incensed that they did not have access to treatment while their victimizers – on trial for genocide – were receiving HIV medicines.  Dr. Anastos had worked as an administrator at the Montefiore Medical Group and felt she knew about  building an efficient, comprehensive, high quality primary care practice for a chronic disease.  As she put it, her credibility was as an HIV expert, but her skill was as a manager.   With assistance from the Stephen Lewis Foundation she helped found We-ACTx (Women’s Equity in Access to Care and Treatment) in mid-2004. The goal was to create an HIV treatment program, but this implied first setting up HIV counselling and testing.

One of the lessons of this experience was to ” first, provide the services people ask for, not just those professionals think they need”. This, she felt, was the essence of COPC.  And what people wanted was wanted medical care (to prevent dying and promote health), HIV testing, medical care for their children, food, income, and – a top priority -  education for their children. The local women rejected the idea of going out “into the bush” to provide care.  They wanted it done through existing infrastructure and using local nurses and clinics.  By knitting together multiple small grants an HIV testing program was implemented in September of 2005 and has by now performed over 50,000 tests.  In January of 2006 anti-retroviral care was introduced and there are currently 2,400 people on ART, essentially “everyone who needs it, gets it”.  The program is implemented in coordination with 24 community partners and is staffed by 2 physicians, and 12 nurses.  She feels that the necessary skills to run the program exist locally (“if we left now, the program would continue”) but that the local staff continues to need salary support.

For a beautiful look at the WE-ACTx progam in action, you can see pictures in the linked slideshow.

Because of the focus on meeting people’s expressed needs, several “off mission” programs had been created.  “Just because I think it is not health service related, doesn’t mean we don’t have to find a way to provide it.”  These off mission programs included the provision of food supplements, creation of income generating activities (originally doll making, now bag making, see Ineza), community based education, and a program to help with school fees.More recent activities are a cohort study (requested by the community) and programs to address cervical cancer.  Cervical cancer, an essentially preventable disease is the number one cancer killer in Rwanda.

In considering the successes of their work (and of the COPC model) Dr. Anastos pointed to the strong sense of community in Rwanda.  “There is no cult of the individual. It is always my family, my community, my country.”

posted by Matt Anderson, MD