Sara Hogan, MD
Sara Hogan, MD
Dermatology · Washington, DC

UGHE Butaro Dermatology Clinic

June 14th
Butaro Health Center, Butaro, Rwanda

Project Description

Since 2020, I have served remotely as global co-lead to establish a dermatology clinic at Butaro District Hospital (BDH) and develop the dermatology clerkship curriculum for medical students at the University of Global Health Equity (UGHE) in northern Rwanda. This involved nearly two years of informational interviews and inroads with UGHE faculty, Rwanda Ministry of Health officials, and BDH administration and physicians, and curriculum writing. I was awarded a 2022-23 American Academy of Dermatology Skin Care in Developing Countries grant ($2500) and used all of the funding to sponsor a local dermatologist, who I mentor and who serves as local lead for our clinic. When we opened the BDH dermatology clinic in fall 2022, we introduced dermatologic care to a population of about 380,000 in the Butaro province and neighboring regions. Prior to this, there was no dermatologist in the region. The clinic has now served 450 patients, which continues to gain buy-in from local community workers, and also serves as a teaching site for UGHE medical students, who will go on to serve as GPs throughout Rwanda's district hospitals. Our first cohort of students and visiting faculty was in spring 2023, however, I was unable to travel as I had recently given birth to my first child. Still, I participated in as many virtual teaching sessions and Zoom meetings as possible. It was a success in many regards (all of our medical students passed with an average of 86%, on par with other UGHE specialty clerkships) and we identified numerous areas for improvement for future cohorts and clinic workflow. This spring 2024 marks my first trip to Rwanda in person, with my now-toddler in tow. I am able to take an extended trip as I recently left my private practice position and working part-time as teaching faculty with the GW Department of Dermatology. My goal is to continue capacity building so this dermatology initiative, in the next few years, is run entirely by Rwandans for Rwandans.

Population Served

The primary population served by our project is the people of northern Rwanda, specifically the Burera district, which encompasses a geographic area of 645 km2 and population of 380,000 people. Prior to the establishment of our dermatology clinic at Butaro District Hospital, Northern providence residents had to travel more than 4 hours to Kigali, the capital city, to see a dermatologist. Like many sub-Saharan African countries, in Rwanda there is less than one dermatologist for every 1 million people. Patients from the neighboring districts of Musanze and Gicumbi are a secondary target populations. They are being reached through an education program we developed for community health workers, who play a vital role in the Rwandan healthcare system. Other target communities include hospital general practitioners and medical staff interns, for whom we have provided two CME sessions on proper use to topical steroids, common skin conditions, and when to refer to dermatology.

The medical students of UGHE also benefit from this project. There are 108 students enrolled – mostly from Rwanda, with few from the East African region. It is a 6.5-year long program with a strong emphasis on equity and social medicine and combines medical education with a masters in Global Health Delivery. After completion of their medical studies, UGHE graduates spent two years working as general practitioners in one of Rwanda's 42 district hospitals. Last year, we had 30 UGHE medical students participate in the clerkship. This year we have 36 students. The exposure of UGHE students to dermatology is a key first step in the process to address the longstanding shortage of dermatologists in Rwanda, especially as the first dermatology residency program in Kigali was started in 2023. We train UGHE students to diagnose and treat common dermatologic conditions, and recognize when to refer to a dermatologist at a referral center.

Expected Impact

The expected impact is improved access to dermatologic care in northern Rwanda. A secondary, and exciting, impact, is a research agenda that I developed along with my local dermatology colleague. Until now, there have been only two studies published on dermatologic disease in Rwanda--most recently in 1980. We are collecting data on the prevalence of dermatologic conditions and the burden of skin disease among our patients to better quantify our patient's needs. The UGHE curriculum I developed is also a living document, constantly evolving to reflect the dermatologic needs of our patients, and reflect the formularies available in Rwanda's district hospitals. We have been mindful to only use textbooks and visual learning aids that show dermatologic skin conditions in deeper skin tone/darker skin color. The unfortunate reality is that the images are limited in number. It one of my to future goals to create a textbook to aid in the training of east Africa's future dermatologists.

Trip Photos & Recap

In a country of over 13 million people, Rwanda has only 11 dermatologists. There were previously no dermatologists in Rwanda's Northern Province, which has a population of 1.2 million, and where the University of Global Health Equity is located. UGHE provides medical training to Central-East Africa's future physician leaders, who also receive graduate training in the delivery of health services in limited resource settings. After graduation, our students spend 2 years working as GPs at one of Rwanda's 42 district hospitals.

With grant funding, my UGHE dermatology clerkship co-director Dr. Jean Bosco Ndagijimina (a Kigali-based Rwandan dermatologist) and I established a dermatology clinic at Butaro District Hospital in December 2022. Held twice monthly during non-clerkship months, and daily during our 9-week clerkship, the clinic is rapidly growing in patient volume and serves as our primary training site. Our patients travel many hours to be seen at our clinic, often by foot. The dermatologic cases we treat are often complex with advanced presentation of disease. Treatment plans are formed around available formulary drugs and patients' ability to afford medication.

At the end of the clerkship, we aim to for our students to feel confident in diagnosing and treating common dermatologic conditions and to recognize early when to refer a patient to a dermatologist.

Much remains to be done, as we continue capacity building, expand of clinic services and complete research initiatives. I am proud of our work, the care we give and in admiration of our patients and students.