University of Cincinnati and Rwanda build capacity in cardiology

Virtual training and exchange are the heart of an initiative for sustainable cardiology fellowships

In Rwanda, fewer than half a dozen cardiologists provide specialized care for 13.5 million people. Until recently, Rwandan physicians have had to leave their country in order to pursue the necessary years of advanced training for the medical subspecialty.

In 2019, the University of Cincinnati Rwanda Initiative partnered with the country’s national university and teaching hospitals to provide that training through a virtual program and faculty exchange. Now their collaboration has become part of the Rwandan government’s strategic launch of fellowships in 12 crucial internal medicine subspecialties to improve healthcare access and outcomes in the country.

The first two cardiology fellows, Dr. Olivier Niyigena and Dr. Bienvenu Muvunyi, visited the University of Cincinnati College of Medicine in January and February 2024 for an 8-week rotation in the Division of Cardiovascular Health and Disease.

UC Rwanda Initiative

In 2016, Dr. Hanan Kerr, an associate professor of clinical medicine at UC, joined a large team of volunteer U.S. medical staff that traveled to Rwanda to provide cardiovascular care in three intense weeks of surgical and post-op treatment. She saw firsthand the country’s critical shortage of doctors in her field and found her interest drawn to the education side of the problem.

“There was no subspecialty training on the ground. And that's what everybody really wanted. They appreciated the surgery, and they appreciated the care, but they wanted training,” she said.

Kerr made a solo return visit in 2018 to learn more from the medical faculty, residents and students at the national University of Rwanda and the country’s four teaching hospitals.

She worked closely with Dr. Gloria Mukeshimana at King Faisal Hospital and the University Teaching Hospital of Kigali (CHUK). Mukeshimana is Rwanda’s first female cardiologist and the only one then in a faculty role in cardiology in the hospital system, a responsibility that staggered Kerr.

In comparison to Rwanda, the U.S. had 16,870 cardiologists (2022 data), for a per capita ratio under 1:20,000.

They appreciated the surgery, and they appreciated the care, but they wanted training.

Hanan Kerr UC College of Medicine

Niyigena, who met Kerr in 2018 while he was a third-year resident in internal medicine at the University Teaching Hospital of Butare (CHUB), describes the kind of mentorship she offered as “a huge need” for young doctors like himself and Muvunyi.

“People are not trained, and the few cardiologists that were there were not able to give much in terms of teaching because of the burden of the work that they had,” he said.

“Our patients were sent to India, to Kenya, to get quality subspecialty medical care,” said Muvunyi. Most could not afford that option, and local physicians often lacked access or training to offer them more than general medical management for cardiovascular diseases, he said.

Like most of his peers, Muvunyi had little hope of continuing into advanced training after he finished his residency in 2018 and went to work in a district hospital. The financial and personal costs to pursue a fellowship in South Africa, Kenya or Egypt were prohibitive.

Kerr, Meshesha and Muvunyi sit at a banquet table

UC’s Hanan Kerr with Amha Meshesha and Bienvenu Muvunyi at the 2022 government launch of Rwandan medical fellowships | Photo provided

Once back at UC with closer contacts on the ground in Rwanda and a clearer picture of the problem’s scope, Kerr founded the University of Cincinnati Rwanda Initiative with a group of faculty colleagues.

In collaboration with the Rwandan Ministry of Health, the University of Rwanda, the University Teaching Hospitals of Kigali and Butare, King Faisal Hospital and other stakeholders, their goal was to support ongoing efforts to build a self-sustaining cardiology program that will train the next generation of doctors in Rwanda.

Virtual training

A UC team planned to travel to Rwanda in 2020 to provide in-person training and proctorship and to develop the partnership. But they had to cancel the trip because of the COVID pandemic.

“So we started a virtual program of education for the residents,” Kerr said.

“We started slowly, working with the chief residents at the time and building a core curriculum, initially,” said Dr. David Pratt. Then a cardiology fellow and now an assistant professor of clinical medicine in the Cardiovascular Health and Disease Division, Pratt led the virtual initiative on the UC side.

Wexler is presenting to a small group in a conference room from a slide reading, “Anterior MI ECG changes: Anterior (V1-6) q waves and/or Loss of precordial R waves: ‘Poor R wave progression’”

UC’s Laura Wexler leads a cardiology lecture during a visit to Rwanda, 2023 | Photo provided

Invited speakers offered twice-monthly lectures on core cardiovascular topics. The lectures were synchronous and interactive and were recorded for anyone unable to attend live.

“It spurred interest in a career in cardiology for several of the residents, which we’re very proud of, and it's only grown from there,” said Pratt.

The program now covers 30-40 key topics in cardiology each year, regularly attracting 25-30 residents and junior fellows weekly for lectures and interactive case presentations, which are highly rated as valuable by the participants. Lecturers now come from beyond UC and Cincinnati Children’s Hospital Medical Center, including Dartmouth University, Duke University, Ohio State University, the Mercy Health system in Cincinnati and the Cleveland Clinic. Dr. Blair Suter, who holds faculty appointments at both UC and OSU, now runs the virtual program.

Muvunyi and Niyigena credit the virtual program with filling a gap for them before the national establishment of subspecialty fellowships in 2022.

“That's how people like me—being two years away from a teaching hospital [studying] cardiology, I started to refresh again,” said Muvunyi. “So that when we started in the fellowship, everyone was on the same page in terms of baseline residency training in cardiology.”

“Before these presentations, people were fearing cardiology, thinking that cardiology was very complicated, it was very complex,” Niyigena said. “The presentations have improved our knowledge and confidence, and we have come to get rid of the fear.”

Fellowship launched

UC became an instrumental partner in the subsequent development of a cardiology fellowship in Rwanda, one of the first four programs (cardiology, nephrology, gastroenterology and endocrinology) launched in the second decade of a national initiative by the Rwandan Ministry of Health to build the country’s medical capacity.

Alt-text: Meshesha and Hattemer pose together; Hattemer is wearing surgical scrubs and a white UC lab jacket. There is medical equipment in the room beside them.

Amha Meshesha with Charles Hattemer, chief of UC's Division of Cardiovascular Health and Disease, 2021 | Photo provided

Dr. Amha Meshesha, an attending physician from Ethiopia at King Faisal Hospital (who was himself only two years out of cardiology fellowship) and Mukeshimana built the fellowship curriculum with the support of faculty in UC’s cardiovascular division.

Despite the ongoing COVID pandemic, Meshesha visited UC in 2021 to strengthen the relationship and become familiar with the resources the division can offer the fellows to enlarge their education.

After the approval of the curriculum by Rwanda’s Higher Education Council, Niyigena and Muvunyi were selected as fellows in a highly competitive national process. At a May 2022 event to celebrate the launch of four new fellowship programs, the country’s first lady urged the selection of additional candidates, so Dr. Léandre Nsanzumuhire and Dr. Kubwayo Alain Prince joined the first cardiology cohort.  

Bilateral exchange

With the loosening of COVID restrictions, more exchanges have followed Kerr’s and Meshesha’s visits  as the relationship between the U.S. and Rwandan medical colleges has grown closer.

Attari and Meshesha, gowned and gloved, stand over a person draped for surgery; Attari’s hand is poised over the surgical field where Meshesha is working

Attari assists Meshesha in the first Rwanda procedure to implant a bi-ventricular AICD to restore normal heart rhythm, 2021 | Photo provided

In 2022, with a substantial grant from Medtronic, Dr. Mehran Attari, an electrophysiologist from Mercy Health and member of the UC Rwanda Initiative, led an “EP week” at King Faisal Hospital. Electrophysiology is the branch of cardiology that focuses on the electrical systems regulating the heart’s rhythm. Attari offered lectures, attended rounds and proctored procedures in the hospital’s hospitals catheterization lab.

Kerr herself returned to Rwanda on a Fulbright grant in spring 2022 to get feedback, evaluate the virtual program’s success and familiarize herself with ongoing training needs.

UC’s Dr. Laura Wexler and Dr. Jack Rubinstein traveled to Rwanda in 2023, as did Dr. Jeff Dixson, a cardiologist who practices in Alaska, and Dr. Rebecca Laird, who now practices in Colorado. Their visits came during a period of crisis. Meshesha had returned to Ethiopia, and Mukeshimana had left Rwanda for further training.

Rubinstein points out an image on a laptop to two other people who are masked and gloved and wearing scrubs; the setting appears to be in a hospital, and other electronic equipment is visible

UC’s Jack Rubinstein, center, examining a transesophageal echocardiogram with medical team in Rwanda, 2023 | Photo provided

“Only four of us stayed, and all the burden of cardiology for 13 million was on our shoulders. We were seeing patients, educating patients and also retaining patients for interventions. And our patients, we need to speak to them in the local language that they understand. When you tell the patient he will undergo an MRI, he doesn't know what that is. You become like a relative to the patient,” said Muvunyi. “And you're a treating physician. So all these pressures were on us in making decisions.”

The visiting physicians assisted with both teaching and patient care to support the cardiology program until new faculty could be recruited.

Kerr said, “I remember getting a text from Olivier. I asked him, how was the rotation [with the U.S cardiologists there]? You know what he said to me?

"‘Cardiology is sweet again.’”

Rwanda fellows at UC

Now the first two cardiology fellows have had their own opportunity to participate in the exchange with UC. They have just completed an eight-week rotation in Cincinnati at the Division of Cardiovascular Health and Disease in the College of Medicine's Department of Internal Medicine.

It was an experience designed to give them intense exposure to a volume of cases they don’t often see at home. It has also given them direct familiarity with technologies and care strategies they knew at best only in theory.

Their rotation included time in several UC labs devoted to cardiac imaging and testing, as well as in the electrophysiology clinic, the catheterization lab and the heart failure program. Muvunyi and Niyigena also joined rounds in the cardiovascular ICU.

Seeing some procedures in high numbers at UC was a clear benefit, the fellows said.   

Muvunyi and Niyigena, gloved and gowned and wearing UC Health badges, sit at a table and examine a heart, which Muvunyi is tipping to the side; surgical instruments are on the table, as well as bloody gauze

Muvunyi and Niyigena work on their first heart dissection during their UC rotation, 2024 | Photo provided

“We can have a case in Kigali of stress today and spend another week without another case,” Muvunyi said. “Here we can get around eight cases per day. Today we had to read seven SPECT tests, nuclear [imaging] tests. And these tests, they are not even available in the region.”

Rwanda is seeing an increase in ischemic heart disease that is more typically diagnosed in the US.

“All these patients, when they go outside [the country] and bring back their reports, sometimes we may not [have been] knowledgeable to read them and interpret them. But here we’re seeing them on a regular basis. At the end of our attachment here, we will have that knowledge.” 

“I think the most wonderful thing for me is to see a new thing that I was only reading in the books,” Niyigena added. He cited the EKOS implant (which uses a combination of drugs and ultrasound to dissolve clots that may cause sudden blockages in the bloodstream) and the WATCHMAN device (which helps prevent blood clots forming in the heart without the use of blood thinners).

“That was new to us. We don't know that this technology exists,” he said.

The two plan to take home strategies they can adopt immediately to improve the care they can offer. One example is stress echocardiogram testing, where ultrasound imaging is added to the electrical testing (ECG/EKG) performed to examine a patient’s heart under stress, typically from treadmill exercise. Combining the tests to assess the heart’s response to high demand offers more complete diagnostic information than stress EKGs and resting echocardiograms alone.

“We’re not doing stress echo back home. When you read about it, when it is in theory, you think this is something that is complicated. But we see that we can improve our stress tests in terms of that, in terms of making it complete,” Niyigena said.

Equipment for both tests is available at King Faisal Hospital, but the treadmill is on one floor and the echocardiography machine is on another. Creating a protocol to pair them routinely when needed will make a significant difference in diagnostic accuracy.

Paying it forward

Harris, Niyigena and Muvunyi sit in front of a monitor; Harris is turned toward the other two and is gesturing as he speaks.

UC’s Dr. David Harris discusses an MRI image with Niyigena and Muvunyi during their UC rotation, 2024 | Photo provided

Muvunyi and Niyigena say the support they have felt during their UC exchange is something else they hope to take home with them.

“Here, a fellow can call an attending [senior physician] any time for opinion, for advice," Muvunyi said. "The fellows have a platform to go see the patient, do what they think, but also they have at the end of the day that small time to discuss with the attending about their findings.”

(UC's cardiovascular division has a common reading room where faculty and fellows meet to read nuclear and echo studies.)

Muvunyi described a typical week at home where consulting over critical care decisions takes precedence over daily feedback due to the enormous demands on attending physicians' time.

“You never grow up to the point where you don't need feedback," said Muvunyi. "So this is something that we’ll take back home, to support fellows who are behind us, residents who are behind us. But also in the future when we become attendings, we’ll bring this culture home.”

Long-term impact

The virtual UC Rwanda program is now entering its fourth year.

Mukeshimana, one of the fellowship program’s original directors, is expected to return home from her interventional training (training in minimally invasive procedures) abroad, rejoining the current director, Dr. Esubalew Woldeyes, to further expand the cardiology program.

The two additional first-cohort fellows will also come to UC to do an external rotation. Kerr hopes it can be scheduled by the end of this year. In the second cohort, Dr. Emmanuel Bizimana and Dr. Saad Ngoga have begun their fellowships. Four residents in the University of Rwanda’s senior class have now also expressed an interest in studying cardiology.

Our biggest wish is to have this lasting long.

Olivier Niyigena Cardiology fellow

“Our biggest wish is to have this lasting long,” said Niyigena.

Sustainability,” Muvunyi agreed. “Because sustainability is a big issue. People get this training, people get this exposure. At the end of the day, it [often] stops, and you say, ‘In my time, I had this and this and this,’ which the next generation would not get." He wants the bilateral partnership to continue and the program to become self-supporting.

The three pose in a corridor ; Kerr is wearing a lab coat with her name and UC Health, while Muvunyi and Niyigena wear UC Health badges.

Muvunyi, Kerr and Niyigena in the UC College of Medicine, 2024 | Photo by Natalie Ochmann

Kerr sees the exchange increasing the UC fellows’ interest in global health as well, and hopes that the sense of investment they and faculty and even patients at UC have come to feel in Muvunyi and Niyigena’s training will open up more mainstream opportunities for global study on both sides.

She sees the exchange as offering advantages to UC doctors as well as to Rwandan.

A group of smiling people, including Niyigena and Muvunyi take a selfie in a colorful restaurant

Muvunyi and Niyigena with some of the UC cardiology fellows | Photo provided

“It's bidirectional. These guys are so good at their clinical diagnostic skills, because they don't have a lot of the advanced diagnostic tools that we have here readily available. They've been teaching our fellows skills in echo and mitral valvuloplasty,” she said.

Niyigena added, “We have many rheumatic heart diseases. That is not here. We think that fellows from the U.S. can also benefit from seeing our context.”

Kerr expects as many as 30 cardiology faculty members, most from UC, to travel to Rwanda in the next 12 months.  

She continues to seek funding for the UC Rwanda Initiative to support sustainable programs, scholarships and long-term training exchanges.

Suter thinks that as the virtual program and exchange continue to evolve, multidisciplinary teams could take part in more proctoring visits like the EP week Attari did in 2021.  

“I think that this kind of model, now that we've shown that we're able to do it for a subspecialty medical education from just a grassroots effort and minimal funding, will hopefully expand to other countries where they're looking into developing a medical specialty education."

To only have a few role models in your entire country and not necessarily know another cardiology fellow in your country—it's a big deal to have both peers and role models.

Blair Suter Director of Virtual Education, UC Rwanda Initiative

“The cardiologists there are great, like Dr. Gloria, Dr. Amha,” he said of the physicians he has worked with through the UC Rwanda Initiative.

“But you know, to only have a few role models in your entire country and not necessarily know another cardiology fellow in your country—I think that’s now something that isn't quite as big of a problem.

"It’s a big deal to have both peers and role models. And now a ready supply of mentees, too.”

Make an impact

Cardiovascular Health and Disease is a division of the Department of Internal Medicine in the University of Cincinnati College of Medicine.

As part of the region’s academic medical center, which includes UC Health, Cincinnati VA Hospital, and Cincinnati Children’s Hospital (recently named the #1 pediatric hospital in the country) the College of Medicine advances education, research and practice in 89 specialties.

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Featured image: Bienvenu Muvunyi, UC’s Hanan Kerr and Olivier Niyigena in the UC College of Medicine | Photo by Natalie Ochmann, UC International

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