Surgeon builds sustainable kidney transplant program in Rwanda


Jeffrey Punch has his weeklong trips to Rwanda down to an efficient science.

The professor of surgery in the Medical School brings just one bag, a carry-on typically packed with a week’s worth of underwear, socks and shirts, a jacket, three pairs of pants, a shaving kit and surgical loupes. The pants are worn twice each to save on packing space. He also brings a mini pharmacy in case travel-related illness strikes.

It’s not a lot, but it’s enough, and it’s best to keep things simple for ease of repeating. That’s how he approaches the kidney transplant program he’s helping to start there: Teach a few, use existing resources, help many.

A photo of surgeon Jeffrey Punch
Jeffrey Punch, professor of surgery in the Medical School, has helped launch kidney transplant programs in both Ethiopia and Rwanda. (Photo by Paul Trombley, Michigan Medicine Department of Surgery)

The road to Rwanda starts in Ethiopia

Punch, a transplant surgeon at University of Michigan Health, started his work in Africa through his church, doing mission trips to Kenya. The trips were quick in-and-out visits that did not involve direct patient care. Punch’s group provided local youth with basic medical education, such as CPR and sexual education, that was not typically covered in primary and secondary school curriculums.

What was sustained was the connection to the country. The people and the setting got him hooked on Africa.

Along came a Michigan trainee and chance to do something that didn’t just feel good but could do lasting good. It would also fit his skill set as a transplant surgeon.

Senait Fisseha hailed from Ethiopia and obtained her medical and law degrees in the United States. She then trained as a resident in obstetrics and gynecology at Michigan Medicine and secured a grant from the Susan Thompson Buffett Foundation to address women’s health issues in her home country.

As Fisseha worked on programs within her own specialty, she learned the prime minister wanted to start a kidney transplant program to tackle a growing and expensive chronic kidney disease problem — a paradox of the expanded Ethiopian life expectancy.

Different and more chronic conditions can plague a population as it ages overall, and Ethiopia was no exception. Conditions like kidney disease were competing with tropical diseases as drivers of morbidity and mortality and the government was sending people abroad for treatment and transplants at great expense.

Supplies weren’t enough. The country needed trained specialists to manage the problem at home, and they needed to learn at home for the program to succeed.

Fisseha tapped Punch through help from Tim Johnson, then the chair of the obstetrics and gynecology department. Johnson also had done extensive work in Africa with the goal of education and training of specialists in their home country, rather than the traditional model of showing up on mission trips, doing operations, and then leaving.

Punch and others partnered with St. Paul’s Hospital Millennium Medical College in Ethiopia’s capital city of Addis Ababa, making numerous trips starting in 2013 and training four surgeons. The process taught Punch about navigating an unfamiliar bureaucracy, a different culture and different approaches to care.

The Ethiopia program took six years to stand up and is now self-sustaining, though not immune from disruption: The COVID-19 pandemic and a civil war have both periodically paused the program.

A photo of multiple surgeons performing a kidney transplant
Jeffrey Punch, third from left, works with a trainee on a kidney transplant as other team members and students observe. At the head of the table observing are, at left, Lloyd Brown, a transplant surgeon from Rush University, and, at right, Sabin Nsanzimana, Rwanda’s minister of health. (Photo courtesy of Michigan Medicine)

Same need, different country

Fisseha’s work later took her to Rwanda, where the same kidney disease problem existed. Having essentially finished his work in Ethiopia, Punch followed, this time partnering with more health-care providers to stand up a program based at King Faisal Hospital in the capital city of Kigali. He arrived in Rwanda in 2022 and has been returning every six weeks since May 2023.

In addition to his carry-on, Punch usually travels with a nephrologist and a social worker. The nephrologist helps manage patients’ physical condition. The social worker helps ensure conditions outside of the body are conducive to a successful transplant — for example, that potential organ recipients have adequate support at home and a clean, safe place to sleep and recover.

That part can be tricky to get right. Potential recipients, understandably eager for a new kidney, aren’t always up front about their home conditions, and the team needs to balance the risk with the reward.

“They’ll claim to have a place to sleep, and it turns out they do, but the place they sleep is on a mattress with two other people,” Punch said. “And then what if there’s only a dirt floor? Is that OK? Can a transplant patient live there? We don’t really know.”

Punch learned from the Ethiopia experience to scale down the training. Instead of training four surgeons, as he did in Ethiopia, he planned to train two to stand the program up quicker. As it turned out, one of the surgeons broke her ankle partway through training, so another was recruited. In the end, three people will be trained.

Making a difference

The impact so far on people in Rwanda has been profound. As of May 1, the program had delivered 28 new kidneys to people who desperately needed them. In every case, a Rwandan surgeon did the transplant with Punch teaching them how.

Punch said he hopes that by the end of 2025 the trainees will be able to carry on independently and Punch will lessen the frequency of his visits and eventually stop coming altogether.

He reflected on friends with different careers who have cool hobbies, like racing or restoring cars. Sometimes that seems enticing, but then he remembers the reward of coming home after giving four people new kidneys; of stepping out of the operating room and looking out over the green Rwandan mountainside, home of so much pain and now so many miracles.

“Transplant’s so magical. Surgeons can often cure someone of cancer. But it’s not like you take someone that’s miserable and make them feel well the next day. As weird as it sounds, patients that need an operation for a cancer often have a better quality of life than patients with kidney failure on dialysis. The effect of a living donor transplant can usually be felt by the patient immediately. They often feel dramatically better literally the next day, and the patients are extremely grateful.” Punch said.

And then there are the donors, who undergo surgery they don’t need to improve their own health. They’re also grateful for the opportunity to help someone — usually a loved one.

“They are the true heroes. The trust the living donors show is remarkable and makes me feel good about the future for humanity,” Punch said.

A longer version of this story can be found on the Michigan Medicine website.


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