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#202 - 🌍 Global Neo Pod - Starting a Neonatal-Perinatal Medicine Fellowship in Rwanda

Hello Friends 👋

In this episode, Dr. Nkuranga and Dr. Hadfield discuss their journey into neonatology and their current roles in Rwanda's healthcare system. They also discuss the development of the Neonatal-Perinatal Fellowship Program in Rwanda and the collaborations and stakeholder involvement that were required to establish the program. They also share their experiences of living and working in Rwanda, as well as the challenges of balancing work and family. The conversations concludes with advice for individuals in leadership positions and an invitation for collaboration


Short Bio: Dr. John Baptist Nkuranga is a Senior Pediatrician/Neonatologist, Senior Lecturer at the University of Rwanda and global health specialist with expertise in areas of Neonatal and Child health. He is currently, the Director of Medical Services and Director of Maternal, Child and Women’s Health (MCWH) in King Faisal Hospital, Rwanda, a national referral and teaching hospital. He has 12 years progressive career in clinical, public and child health, and held various leadership positions in Rwanda’s healthcare system. In addition, Dr Nkuranga is a member of various national and international technical working groups (TWG) on maternal, neonatal and child health as well as senior neonatal mentor, mentoring teams in lower level district hospital neonatal units. He is also affiliated to various regional and International professional associations including currently being the Treasurer of the African Neonatal Association (ANA) and a member of the African Neonatal Network (ANN). Nkuranga’s passion lies in translating evidence into practices that meaningful improve neonatal and child health.

Short Bio: Dr. Brandon Reed Hadfield is a neonatologist currently serving in Rwanda.  Dr. Hadfield’s career has been one committed to service and included a tenure in the United States Navy, where he served as the sole pediatrician and medical director of the Newborn Nursery at the U.S. Naval Hospital, Rota, Spain. During his time in the Navy, Dr. Hadfield provided exemplary care to military families, serving as the sole pediatrician and consultant for the naval base with a population of over 2500 children. Currently, Dr. Hadfield works at the Rwanda Military Hospital and King Faisal Hospital in Kigali,Rwanda.  In these roles , Dr Hadfield oversees critical neonatal care and is part of the team that is spearheading the initiation of a national Neonatal-Perinatal Medicine fellowship program.

X: @neobhad


The transcript of today's episode can be found below 👇

Shelly-Ann Dakarai (00:00.898)

Hello everyone. Welcome to another episode of the Global Neonatal Podcast. Today I'm so excited to have Dr. John-Batiste Nkuranga and Dr. Brandon Reed Hatfield as our guests today. Dr. John-Batiste Naranga is a senior pediatrician and neonatologist and a senior lecturer at the University of Rwanda. He is currently the director of medical services and the director of maternal, child and women's health at the King Faisal Hospital in Rwanda and National Referral and Teaching Hospital. 

Dr. Brandon Reed Hatfield is a neonatologist who previously served in the United States Navy, where he served as a staff pediatrician and the medical director of the newborn nursery. Currently, Dr. Hadfield works at the Rwanda Military Hospital and the King Faisal Hospital in Kigali, Rwanda. He's also part of a team that is initiating a national neonatal medicine fellowship program.

​​Shelly-Ann Dakarai (00:01.389)

Well, Brandon and John, welcome to the podcast. We're excited to have you here.

Brandon Hadfield (00:07.2)

It's great to be here. Thank you so much.

John Baptist Nkuranga (00:10.346)

Yeah, so I have to be with you. Thank you.

Shelly-Ann Dakarai (00:15.609)

So let's jump right in. A lot of times we like to start with trying to, you know, talk about how you got into neonatology. I know for both of you, you were pediatricians for a few years before deciding to pursue neonatology. So can you talk to us a little bit about what led to that decision to move on and do more training in neonatal care? Perhaps John, we can start with you.

John Baptist Nkuranga (00:37.419)

Right, well, it's a wrong journey. That's a difficult question, but

John Baptist Nkuranga (00:45.086)

I would say that right from the medical school, by the time I was in my final year of medical school, I had a clear option where my interests were in pursuing medical career or profession. And that was either I had to do pediatrics or I had to move on and do public health. Whatever reason I had.

clearly delineated the lines to go. After rotating in your clinical rotations, the surgical and the surgical, then you figure out where you feel your heart is. The same, so the same applies to choosing neonatal medicine is that once I did my residence program in pediatrics, then I rotated it different, pediatrics specialties.

Whatever reason that I don't know, I got more interested in.

newborn care, unfortunately one of the conflicts and sometimes annoying, but at the end of the day, that's where I felt and I did my thesis in unit intensive care unit. Since then, I have decided that if I'm to do any subspecialty, it has to be in a newborn care medicine. Now, why did that? I don't know, I think it just came natural.

Shelly-Ann Dakarai (02:16.693)

Yeah, sometimes we can't explain what draws us to these little babies. Brandon, what about you?

Brandon Hadfield (02:23.636)

So for me, my interest in pediatrics in general, stemmed from a childhood pediatrician. I had terrible earaches as a child and one pediatrician fixed them. And so then I wanted to be a pediatrician and that's from a very young age, probably eight or 10 when I wanted to be a pediatrician. And then within my pediatrics residency training, I was always drawn to take care of the very critical child children.

You know, I used to think learning that you would draw closer to a family by taking care of them for 20 years, you know, as their child grew. And in my, in residency, I realized that when your child is near death and then overcomes that, or unfortunately sometimes does not, you are closer to those families than you will ever be with the child you see for 20 minutes once a year.

And with that, I was very drawn to the ICU. And then during my time as a general pediatrician, I spent quite, I was debating between PQ and NICU, but during my time as a general pediatrician, I did spend quite a bit of time dealing with neonatal care and it was very challenging for me to, to do the initial resuscitation and send the child on. I wanted to be there and continue to continue that care. So that's kind of how I got to neonatology and the global health is another story, but I think to neonatology, that's how I got to neonatology for sure.

Shelly-Ann Dakarai (03:49.365)

Right, right. And so just to continue on that, you said you had worked as a general pediatrician for some time, and I know that was in the military. Can you talk a little bit about your role there?

Brandon Hadfield (04:01.408)

Sure. So I was a general pediatrician for the United States Navy. And as such, I was, I was sent to be the pediatrician in Spain. They had a Naval base in Spain and I was the only pediatrician there with others. Three family practice doctors and nurse practitioners. But basically I was the consultant and ended up filling a, a role on many different levels. So I would direct to the newborn nursery. I ran a developmental clinic.

I consulted with the school, you know, there was a lot of different things and that really pushed me, even though the U S military was a very fully resource setting and it wasn't a lower middle income type setting, it really pushed me to see the full aspects of global health and to see that, that I wanted to be working in a setting that wasn't just in the highest resource setting in the U S for my entire career. And so that, that was.

That was pivotal for me and really helped me to continue to see the world. We lived in Europe, we traveled all over Europe and the idea that the world is a much bigger place than the small town where I grew up or even the ICU with all the fully resource settings in the US.

John Baptist Nkuranga (05:12.718)

Thanks for watching!

Shelly-Ann Dakarai (05:15.469)

Right, so you did general pediatrics, worked in the military, then went on to do fellowship. So how did you end up in Rwanda? Because your fellowship was in the US. So tell us about the path that led you to Rwanda.

Brandon Hadfield (05:29.108)

So I always say it's about who you know, and that's really how I got to Rwanda. But ultimately as I was figuring out where my next job would be, and I was interviewing different places, I had thought along and hard about wanting to work overseas and in my mind it would be, it was nearly impossible for me to find a great position where I would be doing actual NICU level care in a lower middle income country. That was the dream job.

but I thought it was difficult to find. And I envisioned myself, I had kind of consigned myself to do some of the...

Very crucial and important work, but not the high level of neonatal care in a global setting, but then to continue my NICU type stuff. And so I was going to do, I was going to live a dual life. That had been my vision. And I had a conversation with one of the people I was interviewing, her name's Charlotte Rent out of Duke, who then connected me to another, another neonatologist named Misrach, who's at Johns Hopkins. And she connected me with Jean Battiste about the opportunity as they were getting ready to start this

And it seemed like the perfect opportunity. From there, things just kind of fell into place. So that's the short story of a long journey of how I got here to Rwanda.

Shelly-Ann Dakarai (06:47.117)

Right, okay, yes, it's funny how life takes us in these paths. Talking to one person leads to another, and then next thing you know, you're doing the job you wanna do across the world. So, Jean-Baptiste, that brings us to a good point in, given some context, can you tell us a little bit about Rwanda for those who may not know much about Rwanda?

John Baptist Nkuranga (07:10.518)

Thank you for the question.

It's quite an interesting, but a complex question now. I'm imagining where to start. First of all is that, for those who don't know Rwanda, it's one of the smallest countries, I think, on the continent, especially among the landlocked countries. So it sits in the, just in the middle of African continent, just between the Central African region and the East African region. So I'm talking about Uganda in the north.

Tanzania in the east, talking about Burundi in the south, and Democratic Republic of Congo in the vast part of the west. So it's just nested in between there. It's quite densely populated. We have about 13 million people. That is quite condensed. That small.

John Baptist Nkuranga (08:13.046)

piece of land. But over the years, it is especially now I'm droning to the health care system, since I think I have to mention that it also has unique history that it about 30 years ago in 1994, it had terrible history of going through.

and a genocide where things were turned back. People died and others left out of the country. And then, in the later half of 1994, the war ended and since then we started what is referred to as rebuilding the country. It's that most dramatic human history. Since then, the country has completely transformed

what it was, a non-existent, almost disappeared country in its state and context that a human being can understand to now one of the fair, organized, and managed countries.

One of the remarkable improvements that happened actually, it's in the health sector. It has a fairly well-established healthcare system that starts built from bottom up, that's from the health centers, by the work of health workers, to health posts, then the health centers, and goes up to district hospital, to the different hospitals, the way our healthcare system is built. And so doing that,

John Baptist Nkuranga (09:56.854)

Rwanda is one of the few countries that managed to achieve what we used to call a millennium developmental goals, especially in maternal and child health indicators. And it still struggles and hopes to meet some of those with sustainable developmental goals in 2013. So the child mortality and neonatal mortality drop significantly during that span of time. I mean more than two-thirds of mortality dropping to where we are now.

see where birth where we need to be, but at least we are around 19 to 20 babies dying per a thousand live births. So that is quite still high, but quite significant compared to other African countries, especially African countries that did not go through what we went through 30 years ago. So it's things fair ago, well coordinated.

nice to say but generally that is where we know we are known that's one of the cleanest countries in Africa home to

one of the few endangered species of gorillas. So many people for the tourists, they just come, they hear about visiting gorillas, they come to Rwanda. Those are the few, but it's an interesting country and we are an interesting population. It's always hard to make comparison. Every society and community has unique things. We also have our own unique way of life style and just that some people like and others depending on the people's preference. Yeah.

go on and on but I think yes that's what we can say about Rwanda. Thank you.

Shelly-Ann Dakarai (11:47.245)

Yeah, no, thank you for that overview. That was very extensive and it gives a good context. So thank you so much. I know you talked about how your Indianate mortality is still pretty high, but you've made a lot of strides. And so there is a paper, a recent paper, I think it's a year or two ago, I think by Dr. Lon and colleagues, and it talks about how many years that countries take to get to...

certain numbers in their mortality and then the work that has to happen after that, it's sometimes even more because now you're talking about that the critical care aspect of trying to improve care. So it's, Rwand has made great strides and so and that's great to know and you guys continue to work to improve things. So that kind of brings us to ask it a little bit about your role as a neonatologist there because my understanding is there are only...

three neonatologists for the entire country. So I am sure your role is very different than, you know, a country with more resources where the neonatologist probably primarily has a clinical role. John, can you tell us a little bit about when you came back as a trained neonatologist, kind of what that transition was like for you then, and talk a little bit now about what your day-to-day looks like.

John Baptist Nkuranga (13:04.482)

Right, thank you again. Unfortunately, most of your questions cannot have direct answers. They will draw from different aspects. So you're right, we now have just over three million naturalists, as shameful as it is, a country of 13 million. That is extremely low. But again, it's not unique. There are some countries in Africa that have seen worse of...

despite that we are in this 21st century era. So to answer the question is that when I qualified and came back home, understandably that to do neonatology, you needed to go out of Rwanda.

in most contexts either go to South Africa or go out of the African continent because until recently the subspecial training of fellowship programs in Unitology were nonexistent in the majority of the African countries.

So when I came back, definitely it wasn't as difficult or unexpected because I already knew what was the I had worked in Rwanda all my life. I had done as a pediatrician.

briefly worked in Rwanda for three years after my residence before I went to do the military fellowship. I had the opportunity to be the manager of one of the district or regional hospitals. I knew what was lacking, what was available and the expectations. So coming I definitely had, I knew what to expect and I knew what to do.

John Baptist Nkuranga (14:56.874)

to do that. So I joined my current hospital which is King Fes hospital. They needed a neonatologist because King Fes hospital is one of the privately run government palestetal hospitals and the resources are fairly better than most of the other surrounding hospitals. And so the hospital wanted a neonatologist because we were trying to improve.

and provide speciality care, being one of the national pharaoh hospitals. The move was to establish some speciality care and move away from general patient care, which is left to district hospitals and rather lower-level hospitals, that's how I joined. And my NICU wasn't that big, it's still not big. It's about a 10-bed unit.

Immunities Intensive Care Unit. Definitely we use the pediatric department for non-critical care stable babies to manage them. So meaning the 10 bed is not the only population of newborn or preterm newborns we manage. It's rather the high care, critical care, but we use the other space for pediatrics to manage the non-critical care patients. That's why I started from there.

But again, being one of the second in your natural history had come to Rwanda, my job has been mixed up for doing that. So my day looks like I have days that I do actually do the rounds, look after, discuss patients, treat patients in the NICU. And then after that, I do a lot of admin work.

serve as my hospital's medical director. So that has its own demands and its own back and forth activities that you have to go and end the meetings that are always there. But also, really my role in my hospital and my unit is maybe 50% of what I do in newborn care aspect.

John Baptist Nkuranga (17:14.038)

You sit on almost every technical working group in the country that has to make decisions on newborn care. So I do that. I contribute enormously in revising guidelines, protocols that have to do something with newborn care.

on the Minister of Health's National Technical Working Groups and Steering Committees. So there is a lot of us being involved in those meetings more often to complement that. And lastly, again, I...

do although time is running short but I did quite a lot of mentorship that means visiting lower level health care and supporting the teams that are treating newborns in district hospitals and contributing in some sort to improve the care of newborns in those hospitals that do not have the direction to have me or to have the resources that I have. So it's quite extensive, I don't want to

John Baptist Nkuranga (18:18.628)

there is where somewhere I'm not doing enough to support but again when you are one or two or three then you're expected to do all that you are expected to be here there and that is definitely what you have to do if you are one of the few in a country to do some sort of that.

Lastly, just to give time for that, is now we took on the board's responsibility to say it is never going to be three neonatologists and we are never going to find spaces to train the people we want to train. For example,

My training in Unitarochi is I had to apply by myself, I got an opportunity, I applied, did interview, that's personal initiative. It has nothing to do with the institution to do that. And my colleague would did the same. So it would only depend on a few people and do that as a country.

had set targets, goals to achieve a certain period of time, including the Sustainable Development Goals mandate that requires us. So we had to take on the bold to say, we need to start the way we start and move on to start a local new natural resources program so that we can train our own people, physicians, and hopefully produce an avenue in the tourism to take care of our babies now and in the future. Okay?

Maybe I'll stop there. That's a lot itself.

Shelly-Ann Dakarai (19:57.517)

No, thank you. Thank you for answering those questions. Thanks for that perspective. And there are so many places that don't actually even have neonatologists. And just listening to what you do, it's a lot every day. And so it's certainly inspiring. And to see where Rwanda has come from too, I know you said it's sad that you only have three, but the amount of work that has been done is pretty impressive too. So I just wanted to celebrate that as well. So you...

briefly talked a little bit about the fellowship, which I do want to get into for a little while, but one of the things that I also wanted to ask that you kind of brought up was that mentorship of other outlying NICUs. Can you tell us a little bit more about what that looks like? So there are outlying hospitals that care for newborns and what that role looks like and how that mentorship looks.

John Baptist Nkuranga (20:51.21)

Right, thank you. So we do, as I mentioned, our healthcare, it follows the structure of the healthcare system and we have about six layers of care from the community to national tertiary referral hospital where I am now. So there are a number of layers in between.

And in so doing, we struggled, that's maybe about five or ten years ago. We had tough discussion on what mode of newborn care unit that we needed to do that will respond to the national demand. For example, what I mean is that some countries have regionalized systems. For example,

at level one or level two, I am able to do this and this and this, and then I will refer to level three or level four. Some countries are organized like that. So we had just to make whether to regionalize and make sure that we use the resources appropriately, meaning I can better create those levels and equip better the few referral hospitals make you to be able to take care of the more sicker babies. And then the lower level.

or relatively equipped in the way they are. Unfortunately, the Rwandan context become a bit difficult in a sense that we did not have other social support at the referral hospital that can support families. So what do I mean? If a family has, unfortunately has a preterm baby.

and they go to the hospital. The hospital will get a for the newborn baby, but do not have the whole resources to support the whole family. Food, water, drinks, accommodation where they sleep. Definitely the mother will sleep in the hospital, but the other surrounding support will not be there, so we don't have that.

John Baptist Nkuranga (22:54.322)

facility. And the same applies if you refer a baby from a district hospital to a referral hospital far away from the baby's home. Still that mother when he goes to the referral hospital will not get those social economic support in the referral hospital. It becomes extremely difficult for the family that was left 100 kilometers away to be able to support this mother who came

John Baptist Nkuranga (23:25.079)

is more decentralized model. Each district hospital has

and NICU looks after certain set of preterm babies. All district hospitals have that mandate to do that. So that at least the minimum care that can be provided should be provided closer to where the family can get support until the government or the country will get enough resources to do what in other developed countries do. If you recall there is what

John Baptist Nkuranga (23:59.74)

families can go there, get food, get all the support. We do not have that yet. I dream of a day when that will be possible, but we are not yet there. So with that context, that's how the mentorship came in. So that people who are trained, it's mainly done by pediatricians who are relatively better and have the experience to look after babies and newborns that support district hospitals. So the way it is done is that

We have at least overall about three days in a month, it's a little, where a pediatrician or a neonatologist, I use pediatrician because this time, a neonatologist one or two, three cannot go to all those hospitals. We have 42 district hospitals. So, all neonatologists, all I do, for example, in my situation, which is similar to the other, you visit the NICU, the neonatal unit.

You do all the clinical work that you do in any other hospital. You do the round. You teach in the afternoon. So you teach nurses, you teach doctors, and build their skills and capacity to anticipate and be able to manage. So you're all number one.

is to transfer the skills and knowledge. It's not to treat one or two babies or 20 babies before the level, rather to transfer the knowledge and skills to the team. And then continuously follow the map. So every pediatrician perhaps falls in that hospital for the whole year. He goes there three days in a month, then another month, schedules that into the activities. But mentorship is more than that.

So you need to transfer knowledge and skills. You need to talk about organization of the unit, how do you organize a unit to better cater for the very sick and the un-sick and all that. You need to do advocacy and make sure that, try to advocate to make sure that the unit has the basic minimum required in terms of equipment, in terms of supplies, in terms of consumables that needs to improve the care of the newborns there.

John Baptist Nkuranga (26:11.672)

quality improvement activities. So it's another interesting, sometimes challenging, sometimes annoying, sometimes rewarding experience when you support these hospitals. But so far, they have been, the Minister of Health and its partners have maintained that noble activity back and forth. And fairly, it has been part of the things that have contributed over a long period to the reduction of the unit of mortality.

Of course, as you said, we are now moving into more tough difficult because to reduce further the mortality, we are talking about making them more sick, they're more preterm surviving so that you can go build and that really requires a little bit more complex understanding in terms of skills and knowledge but also more complex in terms of equipment and supportive system that you have

John Baptist Nkuranga (27:13.288)

And the fellowship is part of moving into that direction, it's part of moving the bar a little bit higher so that we can try to see if we can push the needle further or, yeah, thank you.

Shelly-Ann Dakarai (27:30.457)

Thank you so much for that detail. I wanted to ask because I'm sure that some of our listeners who may be in similar situations might enjoy listening to that and kind of getting ideas and maybe inspiration of the ways that your mentorship program works, because I know there are other countries and other situations that do that as well, and everybody does it a little bit differently. So I like hearing the details and how you do yours. So thank you so much.

So I know we've talked a lot about the fellowship, it keeps popping up. So I think now is a good time for us to talk a little bit about that. So I know that's gonna be starting in April and by the time that this year's the fellowship program should have started. So maybe Brandon, can you tell us a little bit about the fellowship program and how you, your role in it and how it all got started, your role and what you guys hope for it?

Brandon Hadfield (28:28.904)

So, thank you. I will speak to this. I will tell you that I am far from taking credit for this fellowship. As you might imagine, starting a fellowship from the ground up involves a lot of both local and other support systems. So by the time I came on, the fellowship planning was already in place. So I won't speak a ton to that, but was already in place. And as an outsider coming in,

of Rwanda. So the idea and the goal of Rwanda is to have a neonatologist in 10 years to have a neonatologist at each one of these district hospitals. The vision is fantastic.

And I hope that we can get there. The goal is to train three fellows in every year. Between our initial goal was three and the Minister of Health has asked us to push that to six. So I don't think we'll get to six this year, but in the coming years we'll get to six. And that's a two-year fellowship program. So these fellows will be pediatricians. So they have finished their pediatric residency training and then they will join the fellowship. The fellows will rotate among the three different hospitals

a neonatologist, one public hospital called Seah Shuka, which is just C-H-U-K, that's in the French pronunciation, which I just butchered, I'm sorry. And then there's the King Faisal Hospital and then the Rwandan Military Hospital, which is where I'm at. And so the fellows will rotate through each of these hospitals.

And it's a two-year fellowship with a significant amount of time spent in an overseas, in like several months in their second year to get kind of a more, to get that appreciation as well with rotations being done in India and then a short observorship done in Canada or the U.S.

Brandon Hadfield (30:25.18)

So that's kind of the model for the fellowship. Um, and I, again, I defer a lot to John, as far as the background, everything that picked up. The other thing I will say is we have been fortunate enough to have the support of the Vermont Oxford network. Um, and the group there. And so the, as part of that fellowship, um, we will have the plan is to have eight times a year for two weeks. There's a group that will come from usually a group of two that will come from the U S to help with training.

online lecture support.

And so the first group should be coming in the end of April to do like a NICU and fellow bootcamp, the same type thing you might have in the U.S. And it's looking like, I was just having some conversation this week, it's looking like that's going to be a neonatologist and in the U.S. what we call neonatal transport nurse. So a multidisciplinary to the transport nurse with capabilities that does a lot of things. But we really push that multidisciplinary approach as they kind of come over to train. So it's not just the neonatologist who come to train, but the nurses and practitioners

in the future we'll have some respiratory therapists probably coming as well.

Shelly-Ann Dakarai (31:33.081)

Thanks. So John, could you tell us a little bit about the history behind it? I know you mentioned that as a country and the government realizing that there's a need for more personnel, this was decided to do a fellowship, but I'm sure there were so many steps that needed to go to get to where you guys are. Can you speak to a little bit about how you were able to get all those stakeholders together to come up with a plan and then all of the

collaboration that goes into it. I know it's an open-ended question, but I'm intrigued in learning about it. I know in some places, we had somebody from Zambia and they did a postgraduate diploma, so she talked about how that was set up. So I am intrigued to hear about how you were able to get this fellowship from thinking and concept to now implementation.

John Baptist Nkuranga (32:32.342)

try to see how I summarize it for the interest of time and for the listeners to never get bored. So first of all, I felt when I traveled to do my fellowship in Canada, I already had questions.

why is it going to be like developing this subspecialty? It's almost impossible. It's by chance that you get an opportunity to go and train and there is no system that will train people so how will this grow up? And when I came back, I still had the same question but I did not have where it is going to go, where to start from to do that. Fortunately...

A year after it came, there was a very big meeting. And again, this was a meeting where the president of the country had a meeting with all doctors.

And one of the things he challenged was that we are not doing enough to produce more specialized doctors. And he was concerned that the country was sending a lot of budget to treat people outside of the country because the law in Rwanda mandates that if a person has a condition, that condition is treated, the government should support that person to be treated wherever it's treatable.

breaking the rule and you do that so the government was spending enough money to send people outside fortunately that's usually done in my hospital what we call national referral board so national referral board is a team that is designated and mandated by my current hospital that manages that.

John Baptist Nkuranga (34:33.558)

to say if somebody is sick and there is more than three doctors says this condition can't be treated, it's treatable for this person to regain significant quality of life, then those people sign and then the board sends a recommendation to the government that the government has to pay and support that person to go with that treatment. So the meeting with the president that he spent time on and saying one of the things we are doing,

John Baptist Nkuranga (35:03.472)

We have to find out how to train more specialized people, how to invest into that, and then make sure that the government can carve into the fellows going outside our, fellows mainly majority, we send them to India, South Africa, and a few other European countries. And so that's where it started, and that started a movement. Fortunately, when the government says, when the president says, he says, so it's go back, one year you come back and ask,

what did we discuss and what did we achieve. So it's a whole, quite a level of accountability if you don't do, and to do that. And so the commission was set up to start some speciality programs across. So that was an opportunity for me. Now, who had a dream to say how could this happen? And so I just push it now, I approach the right people and say...

How is it possible? Can we also look into the newborn care unit given the mortality that has not changed in March and yet we need to change it? I will be honest initially The ministry put effort in those areas where we send people outside that's cardiac conditions renal transplant and renal treatment

cancers, so those were major where we sent majority of the people outside and so for the ministers said we have to start with this. So bringing in an early related, it's not always straightforward, but anyway there was an opportunity. Unfortunately as the things changed first we had got a new CEO who happens to be

to originally from Ethiopia. And when we discussed with him between how does that fit the new natural assets, I was in the group.

John Baptist Nkuranga (36:50.578)

There is a collaboration with the US. They have set up some similar training program in Ethiopia. So you would rather talk to them and start making connections and see if they would be interested to support. And that's how VON came in and that's how our colleague from the US, from John Hopkins, Dr. Misilak came. So we wrote to Misilak and we asked, we supported her to come to have an assessment, to have a look

at Rwanda and tell us if it's possible. Mrs. Rakem visited some hospitals, I spent with her about three days, and then she struggled back, which was where she said, when we started this program in Ethiopia, they were far behind where you are now, so you have the basics to start the program. And that is the ball started rolling. And we went into now developing curriculum.

It's a process, we identified a team that's especially, we took over the VON collaboration because VON has a pool of neonatologists interested that can support and so we test teaming together writing up the curriculum according to the national requirements. And yeah, so we took it up, got to the process, the annoying process of approvals and reviewing and all that task work

John Baptist Nkuranga (38:17.04)

We are done with the curriculum and we define what we need at the curriculum. At least we define that every way a pharaoh will be treated and will be trained and rotating, there must be a neonatologist to mentor them. And that's how we had to look for someone like Dr. Brandon to say, we need another neonatologist from outside, who is a full-time, surprisingly, for whatever reason thinks the way they fall apart, we get to do that.

John Baptist Nkuranga (38:46.76)

in the US and is open. I said, are you serious or are you joking? He said, yes. My thinking was that we have to look for somebody from the region, the African context, because we did not expect that an American train will come to be paid whatever one that was able to pay. I felt that was almost impossible, so do that. But yes, so we got all that. We got branded, we are set. We have built infrastructure.

We got the support we needed from the government and from partners. We have almost anything we need to start, to accept and start the program in April. So this last week we had the final...

Ministry of Education because the only ministry what we call High Education Council is the one that approves any training program credentialing it and do that so they had their last physical visit of the sites last week, I think the program is approved We're waiting for the fellows there. They have applied, yet to receive those are applied and they do the selection and recruitment but we are happy to do. We have the support in terms of

in terms of political will, in terms of resources. We actually have basic resources to run the program for the next three to five years. I don't know what will happen after that, but the whole goal is that it will be sustainable in one or the other. Maybe I stop there and take up the other question.

Shelly-Ann Dakarai (40:23.625)

Wow, thank you so much for that background. It's quite a lot of work and quite impressive and very amazing all that has gone into getting this off the ground. And again, shows the power of partnerships and being prepared when the opportunity presents to speaking up and saying, why don't we do this? So very, very inspiring work, Dr. John.

So Brandon, John kind of alluded to this, that he was surprised that you would come over there. And talk to us a little bit about the fact that you and your family are living in Rwanda and what that experience has been like for your family. You were in the military, so they've lived other places before. So just tell us a little bit about that transition and how you and your family are doing.

Brandon Hadfield (41:14.452)

That's great. Um, and I guess I will say, um, a little bit of background. I was a, in a unique position because I was graduating fellowship and because I was in the military, I had no debt. So many us physicians are strapped with a significant amount of medical school and training debt because I was in the military and I had just finished my commitment with the military, I was debt free. And so because of that, it put me in a unique position to be able to come. Unhindered and just come. But the, uh, I think that was.

the biggest hindrance and I think the other thing that put me in a unique position is because I had done general pizza I wasn't deep into an educational career so that's the other question is how someone could come deep into an educational career.

And for me, the biggest thing I will tell you is I have a wonderful and supportive wife, Erin, who has long since always wanted to be adventurous. But she understands that my position through training and even in Spain is the only pediatrician meant that I was always going to be on the man. And while my family is the most important thing, many times my time is not allocated to my family first, the priority of my time goes other places. And so that was the biggest. And so, um, it was interesting. People always ask me, how did you.

tell your kids you were moving to Africa. And so we did, we told them they were moving to Africa, but it was, it was to them, oh, it's like we're going back to Spain again. So we lived in Spain and it was an adventure and moving to Africa was the same. It was an adventure and it is an adventure. Um, the, I was, we made the decision to move here, but I will tell you, I was pleasantly surprised with the cleanliness and the safety that is here in Rwanda.

You know, you say you're moved out and that's always as an outsider coming in. But the safety that is here and I could tell stories all about that, which is not for this podcast, but the safety and the cleanliness that is here made us feel very comfortable. We are very happy. And while John jokes about, well, I don't make near the money that I could make in the U S I'm happy and my family is happy. And to me, that's the most important thing. And making money is not what I decided I wanted to do. Anyone who works in global.

Brandon Hadfield (43:23.05)

health will tell you that you have to realize that you're going to make much less money especially when you come from the US system or that the reimbursement for positions is significant you know it's and so but my ability to come here and to be happy to have I have plenty and I have paid plenty to for my needs and

the family came and we are adapting. As I'm sitting here talking to you today, my children are in a swim meet with us. That's with all a bunch of unwanted schools and so absolutely the adaptation has been good.

and it does not come without its challenges, but it's been a great experience for our family. There is a significant expatriate community here with a lot of the NGOs and different things, and so we have that kind of connection as well.

Shelly-Ann Dakarai (44:16.669)

I see. And John, can you talk a little bit about how you balance it all? You are quite busy with all of your different roles. Brandon told us, you know, he's happy here and kind of what keeps him going. Can you tell us how you manage to keep going?

John Baptist Nkuranga (44:38.752)

Yes, it comes with a cost. I annoy many people the way.

John Baptist Nkuranga (44:47.118)

example is that Brandon being an American background, he writes a lot and we do write less. And he sends emails, he expects me to respond to it in the most fastest time possible. I take all my time to get back to him. And that's not, generally speaking, truth is that you

tend to think that you balance and you end up imbalancing everything. I think the whole idea is that there is a whole expectations if there is a guideline that is being worked on, you expect you to give them feedback and sometimes genuinely the team that is managing babies is not a still young team. We also need to really...

be there and support.

One of my most annoying, especially with the ministry and the other support teams that work, that has to work with you, is that they would expect that they sent an email and you tell them, look, I check emails from 5pm, don't expect that my day is to sit and look emails. No, my day is to run around the hospital. It's around 5pm if I'm not on call that I will sit and look an email and try to make sense and respond to that.

But nonetheless, to be honest, you get busy. You truly sometimes get and think a lot to people. You cannot respond to all this and you feel you're getting overwhelmed. But at the end of the day, as I think as the brother, I think he always gets to that. Definitely there is a part of one way to come and give back.

John Baptist Nkuranga (46:47.71)

and definitely learn from that experience, try the best work within that experience. But I can tell you, even myself, who trained in Canada for three years, sometimes it got difficult. How do you work without X, without Y? Do that. So what I need to say is that those things sort of puts you in an uncomfortable position sometimes and wondering.

But at the end of the day, I think all of us as human beings, if there is a bigger picture behind it...

you can't continue to be inspired and moving forward. So my job is really not to perfect anything. It's just to keep going and to keep trying to do my best to prioritize and say, Brandon needs these emails, maybe needs urgent response, or maybe those who write right, I have to be in the hospital and finish whatever I do. I will get back to the emails and all that. So it's quite daunting, but it's an enjoyable.

and it makes you grow, whether you like it or not. You don't become the same person. The way you think, the way you connect and do that is totally different. Did I answer your question? I'm not so sure that I did. The only thing I need to do for somebody listening is that...

Shelly-Ann Dakarai (48:08.583)

Yes, you did.

John Baptist Nkuranga (48:09.906)

Sometimes, yes, sometimes what you do requires more time that you will not get. And perhaps sometimes more skill set that you never acquired in the process. And all you need is to adapt and make sure that things continue moving, not in the pace you want, not in the pace you are expected of by the external people, but at least you keep moving. And when you look back, you see that there is a step, a step you're making along the way. Yeah, thank you.

Shelly-Ann Dakarai (48:42.849)

Thank you so much for sharing that and that perspective. I was going to ask, but you did answer that in that I was going to ask, you know, how any advice that you have for persons who might be kind of thrown into leadership positions, you know, both you and Brandon were like fresh out of PhD training and then became directors and had various responsibilities. And then you do fellowship training and then you are in, you know, other leadership positions.

You know, you're not necessarily following a path where you started and then you had a mentor who told you how to do the job and then you were thrust into kind of leadership type positions. But I think you gave us some good advice there where you talked about, John, just focusing on what you have to do and just focusing on progress and not necessarily perfection and that helping to keep you going on the hard days. So I don't know if you have anything else to add to that, Brandon.

John Baptist Nkuranga (49:38.915)

Maybe Brandon for his says.

Brandon Hadfield (49:39.249)

I will say that John sells himself short many times. He did.

John Baptist Nkuranga (49:45.25)

Yeah, sorry, before Brandon says, I just wanted to say that for anybody listening and anybody willing, actually there are many people out there who are willing to help, but you would never know until you ask or until you start something. I can tell you, my strongest lesson with this fellowship is that how many people out there that are willing, for example,

Brandon Hadfield (49:45.524)

Go ahead.

John Baptist Nkuranga (50:12.642)

making it up, I'm just serious. The people that have worked on the curriculums, you said they take time to do that. Sometimes the ministry tells you, we have a deadline to send this, and then you send them, and say, we have never paid them anything.

Just we all we do, for example, in the Rwandan context, the ministry does says, OK, we need to have a workshop to review this curriculum, document, to make sure that all we do is the logistical support. We'll pay you air ticket, we'll pay you the hotel where you're in Rwanda and local transport. But we need your time. We need your expertise. Can you give it away for that? And it's not easy to get people from the US, from the TARF. US is very well known.

the toughest working conditions as a medical person in the way they do. So I wanted to say that, yes, as daunting and challenging it may feel, but there are always people willing to help and I'm ready to do that. So I just wanted to add to that. Thank you.

Shelly-Ann Dakarai (51:23.021)

Thanks, John.

Brandon Hadfield (51:23.525)


And I will say that John sells himself short. And one thing that having been, and because John is very successful in what he does. And I, like John says, sometimes do get frustrated with John because I know he's so busy and I can't ever find him because he's always doing so much because you tell me you're starting a neonatal fellowship and also the medical director of a major hospital of the largest hospital and the largest tertiary hospital in the country, you can only imagine what that does, but what he does, which I have

He sets time, so he tells me every evening he has a time where he reviews emails. So he does that every day and that's his time for his emails. But he also is very good at recognizing the priority. He said we're going to set a meeting, we're going to have these meetings regularly, and then we're going to do it. He called me one day and said we need to have a meeting tomorrow, it's important, more important than anything you do because it's going to help the fellowship start. And so we just have the meeting and so I'm setting those priorities.

And so that's to speak a little bit about what John does and how much he's able to accomplish. As I have been here, you asked about the being drawn into leadership and I think what he said is true. Even though you don't have clear mentors and a clear pathway, there is so many people willing to help. Since I have been here,

in Rwanda. My role has been twofold, one to help the fellowship start, but two to start a NICU, to help a NICU which has been running with pediatricians to figure out how to upgrade it and how to fix it in the absence of funds. But I have many, many people who have willing and reach out and help me and support. I have mentors in the U.S. who are willing and able to help.

Brandon Hadfield (53:08.58)

And so I think knowing that you're not alone. And I think the, the important thing, which is often said is that knowing and learning people and learning how to interact with people and

Because once they realize that the care that you have, then they will care what you have to say. But first you have to have that relationship with them and be able to do it. As I have done this both in Spain and here, it's important to have that respect of the culture and understand that you have to, and I don't pretend to know Rwandan culture. I've been here such a short time, so the amount of culture I know is very little, but respecting and knowing that culture of

setting your work in, knowing how to achieve what you hope to achieve within those goals. But even here I will very often say, this is what I want to do medically in the NICU, but I want to make sure it's culturally appropriate, so I'll go talk to the pediatrician and then we'll talk about it and figure out the cultural way to get something done and the best way to, within that culture, succeed.

And so I think that answers your question about the leadership roles. You often grow into your leadership role, recognizing your limitations and reaching out for help.

Shelly-Ann Dakarai (54:28.953)

Thank you, such words of wisdom from the both of you. And so we are getting to the end of our time together and I appreciate the time you took to do this. I know how busy you both are and I am sure our listeners have enjoyed the conversation and have learned quite a bit from the strides that Rwanda has made. So if anyone would like to reach out and connect with both of you to collaborate or just to say hello.

How can they do so? What's the best way for folks to connect with you?

Brandon Hadfield (55:04.776)

So for me, email's probably the best way. They'll show post it in the show notes, but my email is my last name, Hadfield, and I'm actually still associated with my US email, so it's hadfield at U-T-H-S-C-S-A dot B-D-U. I will also put my WhatsApp number. I'm happy to take WhatsApp number. I'll give that to Shailya so people can communicate with me via WhatsApp as well. But email's probably the easiest and best way to do that.

John Baptist Nkuranga (55:24.786)


Shelly-Ann Dakarai (55:33.07)


John Baptist Nkuranga (55:34.338)

Yeah, I think it's more or less the same. I agree with Brandon. Email or WhatsApp.

Shelly-Ann Dakarai (55:37.413)

All right.

John Baptist Nkuranga (55:43.846)

I always know good things. WhatsApp is helpful because you can easily remind people, I can already everybody's busy, seated here. These days, no one does one thing that you have so much demand that request. So even if I invite you for a meeting, if possible, it's very kind to say, hey, do you remember that we have agreed on a meeting? This is it. So WhatsApp has made it easy to do that kind of quick

respond to an email or to respond to that meeting and so they work very well. And maybe something we did not say before we do that is that again, I don't want in this podcast to talk positively or praise each other, but I just wanted to say that the role of Plandon in myself,

Definitely as you get into other things, many things, including social, we did not talk about social. Rwanda is an extensively socially connected society. You have family, you have that, and they take ads of conflict, they take the weekends as well. But, and so is my colleague.

was not able to join the third in your natural history. But at least with the coming of Brandon, I think it would be difficult. If it was a tip, cause he's now the pushing behind.

whatever we are doing. So we have at least somebody to make sure that somebody picks up the pieces, puts them together and pushes us to look at the pieces. And it's a privilege. So I'm not sure how others that may be able to start programs like that, but I can completely sleep and understand that brand new work.

John Baptist Nkuranga (57:35.938)

do the schedule of something, x, y, and you feel relaxed that there is at least somebody at the centre who has, I mean, maybe who has the culture or direction to look into and keep you on track whether you like it or not. And that's very positive, that's very important where we are now, especially now that we are talking about.

the actual implementing phase. The other one was always preparatory, but now we're talking about a pharaoh's starting, pharaoh's rotations, pharaoh's evaluation, pharaoh's appraisal, a pharaoh's growth, program evaluation and credentialing. All that is going to be tough and practical, and I'm not worried at all. The fact that we are with Brandon and we'll keep check on that so that we can all move forward.

Shelly-Ann Dakarai (58:32.261)

Great, so sounds like a great partnership.

Brandon Hadfield (58:35.728)

And Shailene, can I add as you're talking about the context, I had a conversation with Ms. Rack yesterday and I asked her, because people reach out to me all the time, individuals say, how can I help? I would say there's two opportunities for people who want to help with this fellowship development. Number one is coming on these two week visits. So we're scheduling them out for a year, for the first year.

Shelly-Ann Dakarai (58:39.672)


Brandon Hadfield (58:58.224)

You can reach out to me and I can connect you with the right people. And then the second one is being willing to give a guest lecture. So all of the same topics that neonatology fellows in the US or other countries would get, we have those same lectures and we have about a third to half of them which are given by guest lectures. So if you feel free if you want to reach out to me as well and we can start to make those connections. I expect I'll get many emails and that's okay. I'll respond to them and I love to keep the connections. And so that help would be much appreciated.

Shelly-Ann Dakarai (59:29.765)

Sounds good. Well, happy to give a platform for connecting people to help with this very important and impactful initiative that's happening in Rwanda. Well, thank you both for being here. I appreciate the time and I hope that folks reach out if they would like to join and collaborate in some way. And to everyone else, we'll see you again next episode.

Brandon Hadfield (01:00:00.68)

Thank you, bye bye.

John Baptist Nkuranga (01:00:02.05)

Thank you. Thank you, Shelly . Bye. And thank you for hosting us.


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