Building Local Expertise: MCW Faculty Join Multi-Institutional Collaborative Partnership to Train Gastroenterologists in Rwanda

Dr. Kulwinder Dua (right) teaching live advanced GI endoscopy procedures at the University Teaching Hospitals in Rwanda.

Two years ago, Kulwinder Dua, MD, DMSc, received a message from Hanna Aberra, MD, PhD, the director of the Gastroenterology & Hepatology (GI) program at the University of Rwanda. Dr. Dua mentored Dr. Aberra as a visiting professor during her fellowship training at Saint Paul Hospital and the University of Addis Ababa in Ethiopia in 2013. Now she wanted to establish a similar program for GI fellows in Rwanda.

“That's how it all started,” explains Dr. Dua. “I went over there and was very impressed with the setup they have and that they were also in the process of getting Ministry of Education approval to start the GI fellowship program.” As part of that process, the Rwanda Ministry of Education looks at who is going to teach the fellows in the program and what capabilities the local faculty have to meet those educational needs. Because there had not previously been a GI fellowship program in Rwanda, there was a lack of qualified gastroenterologists and hepatologists local to the area to provide the appropriate training. That’s where Dr. Dua’s background and expertise come in.

Dr. Dua is a professor of medicine and pediatrics in the Division of Gastroenterology and Hepatology at the Medical College of Wisconsin (MCW), where he has practiced gastroenterology for over 30 years. His primary interest is in advanced interventional endoscopy. He is also the chair of the World Endoscopy Organization Outreach Committee, which aims to provide endoscopy access, training and collaborative research in developing countries and underserved areas of the African, Middle Eastern, South American and Southeast Asian regions. Through this committee, as well as in partnership with MCW’s Office of Global Health, Dr. Dua has provided GI education in Ecuador, Ethiopia, India, Nigeria and Sudan, among others. He now adds Rwanda to that list.

Dr Kulwinder Dua (center) with Dr. Kia Saeian (left) and Dr. Hanna Aberra (right), Director of the Rwanda GI Fellowship Program at the University King Faisal Hospital, Kigali, Rwanda.

Partnership with the Ministry of Health of Rwanda

To formalize an agreement, Dr. Dua worked with the Ministry of Health of Rwanda and the MCW Office of Global Health, whose mission is to reduce global health inequities through local and global multi-institutional collaborative partnerships. Together, they were able to facilitate the signing of a Memorandum of Understanding (MOU) between MCW and the Ministry of Health of Rwanda that allows for an MCW faculty member to travel to Rwanda up to one week per month to help train their fellows alongside local faculty.

A few months later, the GI fellowship program at the University of Rwanda was approved. Now four fellows are currently training in advanced endoscopy procedures under the guidance of Dr. Dua, who continues to visit Rwanda regularly under the MOU. To provide a comprehensive training in gastroenterology, other GI faculty from the MCW Division of Gastroenterology and Hepatology also have traveled or will be travelling to Rwanda: Kia Saeian, MD, MSc (Hepatology); Daniel Stein, MD (Inflammatory Bowel Disease); and Francis Edeani, MD (GI Motility).

In addition to the hands-on procedure training that the fellows receive on site in Rwanda, they also attend regular didactic seminars from Dr. Dua and his colleagues via Zoom. They have even had the opportunity to access MCW’s GI fellow lectures on Wednesday mornings, further strengthening their link to the MCW community.

A Focus on Patient Outcomes

To graduate from the fellowship, trainees also are required to complete a research project in their area of interest, adding yet another facet to the mentorship that Dr. Dua and other MCW faculty provide through the program, going beyond skill-based training and tying into the research pillar of MCW’s mission. For example, Dr. Dua is currently working with a fellow on epidemiological research related to ERCP, a complex endoscopic procedure, looking at regional patterns and patient outcomes. Another fellow is working with Dr. Saeian on a project related to the treatment of liver cirrhosis with bands, where Rwanda provides the unique opportunity to study and compare patient outcomes in a region where lack of resources often limits the banding treatments that liver cirrhosis patients can receive.

Dr. Dua recruited Dr. Saeian to undertake the fellowship training related to the subspecialty of hepatology, which is the study and treatment of disease affecting the liver. Dr. Saeian is a hepatologist with more than 20 years of experience specializing in diseases of the liver. His expertise is crucial in preparing fellows to address the high rates of hepatitis B and C in the region. Fatty liver disease is also rising because of Rwanda’s adoption of the Western diet, and alcoholic liver disease and cirrhosis are prevalent.

“That's where a lot of our work comes in,” explains Dr. Saeian. In addition to training fellows, their Ministry of Health provides short-term medical licensure for MCW faculty to provide clinical services not currently available while in Rwanda, such as interventional endoscopies and advanced pediatric endoscopy services. Dr. Saeian sees the partnership with the MCW Department of Medicine, Division of Gastroenterology and Hepatology as “more of a sustained, repeated presence, to develop the local expertise being able to provide these services.”

Striving for Autonomy in the Region

Right: Dr. Kulwinder Dua (right), Professor of Medicine, Medical College of Wisconsin, and Chair of the World Endoscopy Organization (WEO) Outreach Committee awarding the WEO Center of Training plaque to the Rwanda Minister of Health, Dr. Daniel Ngamije.

This long-term commitment with the end goal of regional self-sustainability is at the heart of Dr. Dua’s vision for the fellowship program.  “They ask me, ‘What is your end point over here?’” Dr. Dua remarks. “And basically, my answer is that my end point is the day when you don't need me, and I have to stop coming.”

While the program is still in its initial stages, there are promising signs that Dr. Dua’s goal is within reach. The four fellows currently in the program have already committed to stay and work in Rwanda upon graduating, which will improve the capacity for gastroenterology care and training in the region. Based on the training being provided through the MOU with MCW, two university hospitals in Kigali, Rwanda, were recently recognized as World Endoscopy Organization Centers of Training, a high-profile distinction that acknowledges the excellent quality of endoscopic education being provided and positions the program to be a destination where people from other countries in Africa can come to be trained as gastroenterologists.

“Getting this center up and running, getting it recognized as a Center of Training, will eventually lead to many gastroenterologists in the region who will get trained and then go out to their own country and do something similar,” explains Dr. Dua. “And this is how it multiplies.”

Dr. Dua’s enthusiasm is evident, both for the fellowship program itself as well as the opportunities it brings for growth and making connections. While discussing the program, he shares his excitement about a graduated fellow who was able to use his connections to the program to facilitate Rwanda joining the Liver Cirrhosis Consortium of Africa. He talks about his plans to expand the program to include MCW faculty from other GI subspecialties. And he has already received a request from the Rwandan Ministry of Health to explore whether the same process can be started for a nephrology fellowship program.

Fostering Connection

In a brief time, Dr. Dua cultivated a program whose ripple effect is already far-reaching. Yet despite the many moving parts, he also has cultivated genuine and lasting relationships with his trainees. “They sometimes send me pictures of what they did and how successful they were from the training they received. I get video clips sent to me from a proud faculty who did a complex case without me,” he shares, clearly proud of his trainees’ accomplishments. “So that is very gratifying to see.”

It's not surprising that Dr. Dua’s strength in relationship building and facilitating connections has contributed to the success of this program. After all, the opportunity to pursue the project came to him through a former mentee. It’s a testament to the power of personal connection and the large impact that a small group of individuals can make. The partnership between MCW, the Rwandan Ministry of Health and the University of Rwanda joins a growing number of international collaborative partnerships, and is a shining example of the embodiment of MCW’s missions of community engagement, education, patient care, and research on a global scale.

To learn more about other MCW faculty collaborations in Rwanda that are addressing cancer burdens, housing insecurity, mental health, and surgical services, contact the MCW Office of Global Health.