As Dr. Yvan Butera, Rwanda’s Minister of Health, and Edna Adan Ismail, the founder and president of the Edna Adan University & Hospital, came together during the inaugural TIME100 Africa Summit to talk about improving healthcare for African communities, one thing was made abundantly clear: “The wellbeing of people is central to the wellbeing of a country,” Butera said.
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00:00 Edna and Ivar, thank you so much for joining me for this really important conversation.
00:06 Our conversation is going to be focusing on the importance of creating awareness when
00:10 it comes to mental health and the overall well-being, but also breaking the stigma that
00:15 is around that and of course making sure there's access really for everybody who needs it when
00:22 it comes to care.
00:23 I want to start with you, Ivar, here in Rwanda. The conversation around mental health has
00:31 been really prioritized. Lately we're seeing a lot of campaigns that are speaking to young
00:38 people when it comes to alcohol abuse. The First Lady using her op-eds to speak out.
00:44 The President taking every opportunity that he has when he's giving his state addresses
00:49 to speak to young people. Why is this a priority, especially right now?
00:55 Thank you. It is a priority because I think generally for societies to thrive, they base
01:01 on their people. And the well-being of the people is central to the development of a
01:10 country and the continent in that regard. So for Rwanda, it's no different. We base
01:16 the development of our country on our people and we invest in them. So it's human capital,
01:24 it's education, it's healthcare, it's agriculture, it's access to services. Particularly for
01:30 mental health, we've gone through a journey of building our health system so that we respond
01:36 to all the needs of the population. And we've been seeing a trend recently where alcohol
01:42 use and abuse has been rising. And the detrimental effects of alcohol is well known, be it to
01:49 the body, different organs of the body, but also to the mind and the brain. So there's
01:56 a campaign to do that and to ensure that people can be the best that they can. They can perform
02:04 to their best ability so that they can contribute to the development of themselves, of their
02:09 families, but as well as of their countries and ultimately of a continent. So there's
02:14 a big campaign around that. One is to make people understand the nefest conditions that
02:24 come with alcohol use and abuse. Two is to provide services, to try and understand why
02:31 do actually people use and abuse alcohol. Are there social determinants that lead to
02:36 that? And to try and work with everyone to try and solve those so that people be comfortable
02:44 and not necessarily need alcohol to be able to function. So it's around that and it's
02:51 pioneered as you say by the President of the Republic and the First Lady. And it has become
02:55 a national campaign and it's going well and we are seeing fruits that are starting to
03:01 come out of that. Okay. And Edna, coming to you, you have been a trailblazer, championing
03:09 and campaigning against female genital mutilation. This is something that is a harmful practice
03:17 and I would like to pick your mind on what regions can learn from the kind of work that
03:23 you're doing, but honing in on how it actually transforms their lives and societies when
03:30 there's absence of practices that are harmful like that.
03:34 Well thank you very much. It's great to be in your great country again. And when you
03:42 ask me questions about female genital mutilation, the word itself describes that mutilation
03:49 is something which is harmful. And I'm a midwife by profession. I was going to work, I was
03:56 trained in Europe where I've never seen FGM before. It had been done to me, yes. But when
04:02 I came back to my country, Somaliland, in 1961 and I began to deliver women who had
04:08 been so badly cut up, so badly damaged. And this damage being superimposed on the complications
04:19 of pregnancy itself made me rebel against it. I began to ask myself, why has this woman
04:29 been put through this as a child? Why have we been put through this? And then I learned
04:35 that this was a practice that predates all the known religions. It predates my religion
04:42 Islam. And it's a practice that is condemned by Islam. So if we are practicing Muslims,
04:51 why are we doing this to our children? And that gave me the courage to go after this
04:57 harmful practice in my capacity as a health professional and in my capacity as a citizen
05:04 of this world, as a health practitioner and as a Muslim. So campaigning against it was
05:09 not easy. It's the part of the world, part of the body that you cannot easily speak about.
05:17 But then there comes a time when you have to call a spade a spade. You cannot call it
05:21 anything else. And gradually people began to understand the harmful effects. We concentrated
05:29 on the damage it does to the unborn child at the time of birth. So people could relate
05:37 to this and say, why is this child asphyxiated? Because it was delayed in the part of the
05:45 body that was coming through, that was prevented to allow this child to come through as easily
05:53 as God had created that part of the body. So they could understand it's damaging to
05:58 the mother, it's damaging to the baby. Islam forbids it. All religions are against it.
06:04 So we began to learn from scholars, institutions of learning, institutions of Islam, like Al-Azhar
06:16 in Egypt, the school of theology, the school of Islam. And together we united our forces.
06:24 And today we have been able to reduce the incidence of female genital mutilation in
06:30 my country, Somaliland, to about two-thirds of what it was. It's not a victory, but it's
06:38 a progress towards victory. And it takes a world, it takes all of us together to fight
06:46 it. And I appreciate governments and also the United Nations, a world health organization
06:54 that I served with honor and dignity for many years, UNICEF and others, to have laws and
07:00 resolutions that condemn the practice. So it's together, it's all of us together against
07:06 something which is harmful to the health and welfare of our babies and of our women. So
07:11 thank you for asking me this question. Please go after it. Please spread the word, because
07:17 it happens in my continent, Africa. It happens in great countries in Africa. And we don't
07:23 need to have that. We don't need to damage our children. We have to fight bigger battles,
07:28 hunger, ignorance. We need to fight disease. We need to fight malaria. We need to fight
07:33 tuberculosis. We need to fight COVID. We have bigger battles to fight. And when our children
07:42 have survived childbirth, to catch them again at age six or seven, catch our little girls
07:49 and mutilate them only to damage their body, to damage their unborn children at the time
07:58 of childbirth is wrong. And we must not do it. We must stop it. And we hope that governments
08:05 and legislators will join us in this battle. Fathers will join us in this battle to protect
08:12 their little daughters. Grandparents will join us. Islamic scholars will join us in
08:18 this battle. And anybody who has that responsibility of leading societies and communities will
08:26 join this battle. Girls must be protected. Our children need to be protected. Our mothers
08:33 need to be protected. Our communities need to be protected, for goodness sakes. We have
08:38 many battles. Let's fight them together.
08:41 Girls, mothers, children must be protected.
08:45 They must be protected.
08:46 Indeed. Indeed. Eva, I want to come to you. When it comes to protecting the vulnerable,
08:55 protecting those that need it the most, one of the things that is needed is a task force
09:00 that is sufficient. Now, the World Health Organization forecasts that there will be
09:05 a shortfall. Let's talk about East Africa alone, of about 6 million health care givers.
09:11 Now, in Rwanda here in 2019, the University of Global Health, Equity was launched, and
09:19 they're doing an incredible job. They're trying to train leaders. They're trying to train
09:23 health care givers. A lot is being done. But can you talk to us about the critical importance
09:31 of having that sufficient task force there, ready to give care for the betterment of the
09:37 community, but also access to care for all?
09:40 Absolutely. Africa faces a critical shortage of health care workers generally. The data
09:45 shows us that in Africa you have one skilled health care worker per 1,000 people, and the
09:51 standards generally are about four to five skilled health care workers per 1,000 people.
09:56 I think only about three countries have achieved that on the continent. So we understand the
10:02 needs of health care workers, especially now. The journey we've gone through, maybe in Rwanda,
10:07 to just give a few examples, in the last 15 years we were able to reduce maternal mortality
10:12 by three quarters, infant mortality by two thirds. But right now we're at a crossroads
10:18 where we need to do tough things, and you need people to do that. As a result of that,
10:24 we've embarked with different universities, you've named one of those, on a reform called
10:30 4x4. It means quadrupling the number of health care workers in the next four years, especially
10:37 where we have the critical shortages, like midwives. We need a lot of midwives, like
10:43 Enda has talked about, to really drive not only maternal care, but also child care. They
10:50 really play a big role in that regard. But we also need doctors, you need anesthetists,
10:55 you need nurses, et cetera. So training is really important, and we're embarking on that.
11:01 But the second thing is, how do you train a lot of people in a short time? How can you
11:06 leverage technology to do that? We were just discussing with colleagues here, and we saw
11:12 good data that shows a physician stationed here in Kigali that can provide training,
11:18 as well as care, to remote villages in the northern part of the country. And the data
11:23 is excellent. The outcomes are about 97% of success rates in providing services, especially
11:29 sexual and reproductive health services. So we're looking at how we can scale this type
11:33 of training, so that you train a lot of people with the few numbers of skilled professors
11:40 that you have, using their time to be able to leverage technology to do that. But also,
11:45 infrastructure is one key component. We are looking at how-- and I think this is a move
11:49 generally that's happening in Africa-- how do you use your hospitals to become training
11:54 sites for the communities, and for the physicians and nurses that live around there? With that,
12:00 you're doing education. Two, you're providing care, so you're tackling issues. And three,
12:06 generally you see development of that community as a result of investment that come along
12:10 that. So the issue that you're raising is extremely important. We'll struggle to achieve
12:18 a lot of health gains that we see, especially with the rise of competing diseases. So generally,
12:24 Africa had gone through a phase where infectious disease were the main issue-- so HIV, TB,
12:30 malaria, et cetera. But now we are seeing a rise of non-communicable diseases, which
12:34 is a little bit more complex-- diabetes, hypertension, cancer. And the way to do it is to tackle
12:40 that is through preventive care. And to do prevention, you need a mass network of health
12:47 care workers. Here in Rwanda and in other countries, we have a large network of community
12:51 health workers. These are people that are voted by the community, trained in their communities,
12:57 and provide preventive as well as curative care. So we have about 56,000 here in the
13:02 country, and they serve as a massive workforce. Right now, we're going-- a reform to train
13:09 them and to adapt them to provide some of the critical needs that we see in the community.
13:15 So those are some of the things that are happening in the country, but I think that we need to
13:21 work on to scale on the level of our continent.
13:23 All right. Now I know our time is well spent. We'll soon be getting into our parting shots.
13:29 But before I come to you, Edna, Ivar, Rwanda, when you look at our history, the 1994 genocide
13:39 against the Tutsi, we have a young population right now. Post-genocide trauma is a real
13:46 threat, and we talk about health care. But again, I keep going back to the fact that
13:51 mental health is critical to have all the goals that really Rwanda wants to achieve.
13:57 Is this something that the ministry is prioritizing? And I ask this because mental health care
14:03 is expensive. We have great coverage in terms of medical health care generally, but what
14:10 is being done? Are there intentional steps to address this issue?
14:17 We started by trying to understand what is the conditions, what are the numbers here
14:22 in the country. What we saw is that 20% of Rwandans have at least once suffered from
14:28 a mental health event. That's a big number, right? And there's reasons behind that. So
14:33 we've suffered the 1994 genocide against the Tutsi. What we're seeing, in fact, is that
14:38 there's also transgenerational trauma. There's some research that was done where kids who
14:44 were born to mothers who experienced that also show signs of anxiety, depression, and
14:50 other things. So how do you deal with that now? One is to
14:54 provide services to those people. As a result of that, we have decentralized care to the
15:00 communities, to the lowest level of the community, primary health care level, where we have mental
15:04 health nurses that can provide counseling services, but also curative services. Two
15:11 is to break the stigma around that, in the families especially. There's one thing to
15:16 have access to care. There's the second thing where people actually go and seek care. So
15:21 now we demystify mental health in the communities, a work that is also chaired by the leadership
15:28 of the country, where you break taboos. You discuss these things. You can feel sad. But
15:33 if you feel sad for a long time, there might be an issue around that. You can talk to a
15:36 professional and get help. So we are really investing in mental health, to the level of
15:42 the community, as I said. Or even going further, where the package of community health workers
15:46 now, these people that I talked about, that deal with households, generally 10 households,
15:51 can be equipped with tools to kind of detect these mental health issues as early as possible,
15:57 so that interventions are put in place as early as possible before things get complicated.
16:03 Right. Edna, now still on mental health. There's really like a close link when it comes to
16:11 maternal health. I want to talk about the university that is the Edna Arden University
16:19 that you founded. When it comes to creating progressive programs that are able to meet
16:27 today's needs, what the population needs, this particular issue, linking these two is
16:34 quite critical. Is this an area that you're integrating into the programs that you're
16:39 having now? Yes. Well, of course, before I had the university, I had a hospital. In a
16:48 country, Somaliland, where our health services were totally destroyed. We liberated the country
16:55 in '91 with just 18 midwives for the entire country and 13 medical doctors for a population
17:03 of almost 4.5 million people. And what we needed to do is, yes, you build the facility.
17:14 You train doctors. They take a long time, seven or eight years. You train pharmacists
17:19 and lab technicians. You train nurses. And we focused on human resource development.
17:27 We need to train people. And when we decided that for our population, we needed at least
17:33 1,000 midwives, people thought, Somaliland, a country that's not recognized, is aiming
17:40 to train 1,000 midwives, they're talking through their hat. But we proved them wrong. We have
17:46 over 1,200 trained nurses and midwives in Somaliland today. That's a bigger per capita
17:56 presence of trained health workers than many recognized countries by the United Nations.
18:01 And I can say that because I was formerly UN. But it takes a team. It takes doctors
18:08 and nurses and midwives to work together. It takes a vision and dedication to say, what
18:13 do we need? What can we do with the resources that we have? It's working together. And that
18:20 training today has lowered maternal mortality. Today we have female surgeons who are doing
18:27 brain surgery, who are closing spina bifida, who are fixing birth defects, who are doing
18:35 surgery day and night, who are training other health professionals. And that's where determination
18:41 comes. And it comes with that vision that brings us all together as a team. As I was
18:48 saying a little while ago, you have a football team. You cannot run a team with just goalkeepers.
18:54 You need everybody. You cannot run an air service with just pilots. You need navigators.
19:00 You need flight engineers. You need cabin crew. You need the team together. And that's
19:05 what we did. And my hope, Mr. Minister, and my prayer at 86 years old is that Africa will
19:12 have one million midwives. That's how we will fight maternal mortality. And we can do it.
19:20 We have the resources. And we have proven it, that it works. So while we're training
19:27 doctors and specialists and neurosurgeons, we need them, yes. But babies are being born
19:32 today. They're being born every day to women in villages, up on the mountain, all by herself,
19:39 being delivered by her neighbor, when we could be training health professionals and community
19:44 health workers who could go up the mountain to the mother on the top of that hill and
19:50 giving her professional assistance at the most crucial time of her life, when she's
19:57 giving birth to a new life. So one million midwives for Africa, that's the way to go.
20:05 And we will save our mothers, our mothers who are the pillars of that society, the mothers
20:11 who when she dies will leave us with four or five orphaned kids. Children need their
20:16 mothers. Husbands need their wives. Siblings need their sister. The community needs mothers.
20:25 So let us put our energies together. And we can do it. And if Somaliland can do it, anybody
20:31 can do it. And we have the people in this room to help
20:35 make that possible. Absolutely.
20:37 And on that note, as we wrap up, I want to come to you. This is an area that Randa has
20:42 done incredibly well. We have achieved really dramatic gains when it comes to population
20:49 health but also poverty reduction. I wonder what the future looks like. What does it look
20:56 like for Randa in the next 10 years? I think in general, things are progressing
21:02 well. One figure maybe that can reflect that is in the last 20 years, we've gained a life
21:08 expectancy of 20 years. So in the 2000, it was around 50 years of life expectancy. But
21:13 right now, we are at 70 years of life expectancy. It comes with its own challenges, particularly
21:21 in the health sector, is to revisit what will people need in Randa in 10 years. Our belief
21:29 is that you want to assure that people get care the closest to their homes, really investing
21:36 in community health workers, reforms. How can a community health worker deal with diabetes,
21:41 for instance, and hypertension? They've done extremely well in dealing with malaria. Right
21:46 now in Randa, 70% of cases of malaria are treated by community health workers. We want
21:51 that in the future. 75% of cases of hypertension are treated in our community without necessarily
21:56 needing to travel and going to see a cardiologist. It is possible.
22:00 Two is to invest in specialized care. As much as you invest in primary health care, you
22:05 also need to invest in specialized care. How do you deal with people who have different
22:10 diseases at the same time? So you need care that can combine all that. So we are really
22:15 investing in our tertiary health care. A lot of university teaching hospitals are coming
22:19 up. We started, for instance, in the last two months, we did the first kidney transplant
22:27 in the country. So far, we've done 13. In the last year, we've done 100 open heart surgeries
22:35 for kids that are born with heart defects. So we're investing in this complex care so
22:39 that you make sure that people get services as quickly as possible, especially preventive
22:44 ones. But when there's need to do creative ones, you don't need to send people abroad
22:49 like we're doing right now so that you keep people close to their communities.
22:54 Edna, as we almost come to the end of our time, could you talk to us about the intersection
23:03 between politics and diplomacy? You've had an amazing career, both in politics and in
23:09 health care. You have five hours. I think we might have just about 30 seconds for you
23:17 to help us unpack that and how it can contribute to lasting change. Well, I think if you don't,
23:24 you need a leader. You need politicians who also think about the community and not about
23:30 themselves, not about their political power, not about their individual power, not about
23:36 their next election, but who think about what they can do for the community they serve and
23:45 for whom they have been elected heads of states. I'm so honored and proud that we have President
23:51 Johnson Sirleaf here, who's a living example of what leadership is. It's a balance, balancing
24:03 politics with social services, with community needs, with education, with security, confidence
24:14 building in the community. It's a balance that you just need to find. I'm so blessed
24:20 to have been born into a country that gave me that challenge all the time. I think today
24:27 Somaliland can be an example, like Rwanda is a shining example of what an African leadership
24:33 can do. Somaliland is an example of what necessity makes you do and the art of survival makes
24:41 you do. Learning to do what you can with what you have is an example that Somaliland can
24:49 teach the world because we have survived. We are here. We were left for dead 33 years
24:56 ago and today we are a country that is known for its stability. I'm the only terrorist,
25:02 by the way. I terrorize ignorance. I terrorize disease. I terrorize laziness. I terrorize
25:08 inefficiency. That's what we need to terrorize. As we all should. It's a balance that God
25:17 guides you and you do whatever works for you. You are guided by the love of your people.
25:23 The people you serve need to have that love and that confidence in you to follow your
25:29 guidance, to follow your leadership. Girls and students and children, you're a role model.
25:37 You have to learn to serve as honorably as you can, with as much dignity as you can,
25:45 with as much confidence and determination as you can, and build up the leadership capacities.
25:51 Let them know that they can do it. They've been told so many times they cannot. It's
25:58 time we told them that they can do it and show them what has been done.
26:02 All right. On that note, that extremely inspiring note, we come to the end of our conversation,
26:10 Eva. Thank you so much for the incredible work you're doing and for making the time
26:15 to speak to us today. Thank you so much. You're great.
26:17 [APPLAUSE]