I LIVE IN Rwanda, a beautiful East African country also called the Land of a Thousand Hills. We have a saying here: “When you are well, you belong to yourself, but when you are sick, you belong to your family.” But my first trip to the United States taught me that culture matters, particularly in the context of end-of-life care.

In a palliative care education and practice course at Harvard Medical School, I learned the principle of patient autonomy — that individuals have the ultimate authority to make decisions about their own health care. Patients are “in control.” But while shadowing my mentor at Massachusetts General Hospital, I noticed photos of family members in patients’ rooms. I remember asking, “Where are the people who are shown in the photographs?” I now know that this may be an attempt to recreate a family or to provide a last chance to reconnect with life, but all the people I saw in the pictures were alive — why were people trying to create an illusion of family when the family exists?

I asked my mentor, “How can we bring back those people from the photos to the room?”

Of course, I came with my bias and an African perspective on end-of-life care. Here, decision-making is based on patient autonomy and community responsibility, because one aspect does not exclude the other. There is synergy between them.

In Rwanda, there are no photos in the patient’s room. Instead, there are people.

Finding my calling

THIS YEAR, RWANDA commemorates 30 years since the genocide against the Tutsi. Some estimates hold that more than 1 million people died in just 100 days. During the genocide, I was living in my birthplace, the Democratic Republic of the Congo, but I witnessed the suffering in its aftermath. Hundreds of thousands of refugees moved to Goma, the Congolese city where my family and I lived, and tremendous chaos, including a cholera outbreak, soon followed. Shortly after the genocide, my family moved to Rwanda, deciding that it actually was safer than Goma. I remember seeing indescribable wounds, dead bodies, and health challenges to which I had never been exposed before. I was 15 years old.

This was profoundly challenging for me and prompted me to question my initial dream of becoming a pilot. I wanted to contribute to the alleviation of such suffering. Circumstances arose where my father’s business faced challenges, prompting him to suggest that I pursue medical school — it was locally accessible, and the Rwandan government provided scholarships to those who succeeded on the entry exam — with the option to reconsider once our financial situation improved. Flight school would have required me to move to Kenya or Uganda, and tuition fees and life expenses would have been less affordable than medical school. Reflecting on the proverb, “Many are the plans in a person’s heart, but it is the Lord’s purpose that prevails,” I came to understand that not attending flight school was part of God’s perfect plan for my life’s calling.

When I entered medical school, my aim was to become a surgeon. Since most of the cases I saw in hospitals and during medical school were surgery cases, I viewed surgery as an opportunity to contribute to the rebuilding of our country. After graduating, I was assigned to a district hospital as part of the Ministry of Health’s initiative to bolster the public health system. We were working to repair wounds, perform orthopedic surgeries, and attend to the physical consequences of the genocide. There, I encountered Rafiki, a 24-year-old diagnosed with advanced liver cancer. His harrowing ordeal compelled me to question my purpose.

Rafiki’s suffering was unlike anything I had encountered before. Despite his immense pain, I hesitated to prescribe morphine, fearing myths surrounding its use, such as the idea that morphine hastens death. Instead, he was only receiving weak opioids. Even when his mother desperately pleaded with me, kneeling before me, begging for something to ease her son’s pain and allow him to rest peacefully, I felt powerless.

Rafiki’s agonizing death in such horrific conditions became the catalyst for a profound shift in my perspective. What was the point of dedicating years to medicine if I couldn’t alleviate suffering at the end of life? Where was the humanity in witnessing people endure agony without intervention? It forced me to reconsider my path in life, though I wasn’t yet certain of the direction it would take.

During that time, Rwanda’s Ministry of Health arranged its first palliative care training. I attended with the intention of gaining insight into the suffering experienced by patients and their families. However, by the end of the two-week program, I realized that the focus had shifted from them to me. It was during this training that I began to comprehend my own experiences of suffering, leading to a deeper understanding of myself.

That marked the pivotal moment in my professional journey when I made the decision to shift my focus from surgery to becoming a palliative care physician. It felt like navigating from an abyss of suffering to an ocean of opportunities.

At the time, most people in Rwanda did not know that palliative care — an approach to improve the physical, psychological, and social quality of life for families and patients facing life-limiting illnesses — even existed. To many, particularly my colleagues, palliative care was often seen as — to use the language of the Apostle Paul in 2 Corinthians 2:16 — a “savor of death unto death,” given that these patients were already considered hopeless. However, for the patients and their families, I was a “savor of life unto life” amid the encroaching darkness. My presence offered a rekindling of hope when all seemed lost.

As my passion for palliative care deepened, it transformed into my true calling — a vessel through which I could serve the vulnerable, restore dignity, and uphold the principles of humanity.

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