Hundreds of people gather in an open-air courtyard at University Central Hospital in Kigali, Rwanda. Men in suits, women in flowered dresses, even prisoners in pink and orange gowns are waiting to find out if they will receive medical care. Some have no visible signs of injury. Others arrived on crutches, with arms in slings, or with catheters protruding from their clothing. Several have swollen, broken limbs: injuries that should have been mended long ago but were neglected because of the country’s long surgical-ward backlog, or simply poverty.

Emmanuel Mugatyawe, 36, sits on the ground as a friend fills out his yellow admissions form. He has been waiting two months for an operation to repair a broken leg – now infected – that he sustained when a car plowed into his motorbike.

“These are not routine cases; there are very few fresh injuries,” says Shashank Karvekar, an orthopedic surgeon and member of the Rotary Club of Solapur, India, after he and his Rwandan colleague Joel Bikoroti examine several dozen patients, scheduling many for surgery. Over the next eight days, a team of 18 specialized doctors (12 of whom are Rotarians) will perform surgeries on 268 Rwandan patients, including procedures in orthopedics and urology. The trip, initiated by District 3080 (India) and hosted by District 9150 (Central Africa), is funded by The Rotary Foundation with support from the Rwandan government. It’s the fourth medical mission to Rwanda that the two districts have organized since 2012. This time, among the volunteers is K.R. Ravindran, the first sitting RI president to take part in the mission.

A few buildings down on the University Central Hospital’s campus (referred to as CHUK), Rajendra Saboo, 1991-92 Rotary International president, is busy coordinating the last-minute logistics of the mission. The 82-year-old from Chandigarh, India, has done this many times. After finishing a post-presidential term on the Board of Trustees, Saboo and his wife, Usha, began to look for ways to participate in the type of hands-on service they had long encouraged of their fellow Rotarians.

They wanted to help India, a country that often receives outside assistance, make a stronger global contribution. It didn’t take long for Saboo to focus on medicine. He found that many local doctors had trained or worked in limited-resource settings similar to what they would find in Africa. “Our doctors are medically very strong,” Saboo explains. “And because India also does not have infrastructure of the highest level, they’ve learned how to innovate.”

Saboo’s first mission, to Uganda, took place in 1998 and focused on cataract surgeries and corrective operations to help disabled polio survivors. Organized with Rajiv Pradhan, a pathologist and past governor of District 3130, it consisted of doctors from Saboo’s district (3080) and Pradhan’s.

Today, Saboo recalls the mission as a life-altering experience – one so successful that the two soon arranged a trip to Ethiopia. That visit marked the start of an 18-year partnership that has brought more than three dozen surgical missions to 12 African countries, as well as Cambodia and six of India’s least developed states. Over time, the missions have increased in frequency to four per year, while adding specialties such as plastic surgery, urology, and gynecology. Saboo has been on almost every trip. “Raja Saboo is absolutely full of energy,” says Pradhan. “He’s constantly thinking of new ways to support medical missions. Even at this age, he’s working 12 hours a day.”

Rwanda, a compact central African country with mountainous topography that often draws comparisons to Switzerland, is perhaps best-known for its darkest moment: the slaughter of up to a million citizens, mostly members of the Tutsi minority, in the 1994 genocide. Twenty-two years later, it’s one of the fastest-growing economies in Africa. Kigali, its capital, is among the tidiest cities on the continent. Since 1994, life expectancy has more than doubled in Rwanda while maternal and child mortality rates have fallen.

Rwanda still faces public health challenges, however. Access to surgery is among them. According to The Lancet, an estimated 5 billion people, including nine out of 10 residents of lower- and middle-income countries, do not have access to “safe, affordable surgical and anesthesia care when needed.” In these countries, the British medical journal notes, 143 million additional surgical procedures are needed every year. Although most Rwandans are covered by national health insurance, which gives them access to low-cost care, many people living in rural areas cannot afford to get to a public health facility. Moreover, surgery is only available in five of the country’s public hospitals, and many patients must wait to be referred from local health centers or district-level facilities.

Aside from a minority of patients who can afford private care, complex cases wind up at one of two public hospitals in Kigali: CHUK and Rwanda Military Hospital, which also hosted doctors from the mission. A persistent shortage of surgeons means there’s typically a long waiting list. According to Faustin Ntirenganya, who heads the department of surgery at CHUK, the hospital employs just 10 surgeons and three anesthesiologists – a staffing shortage that, at times, means a backlog of up to 1,000 cases. Despite a growing number of surgical residents at Rwanda’s national university, the lure of better-paying jobs abroad makes holding on to specialists difficult, Ntirenganya says. “Our biggest challenge is numbers,” he says. “Our limited team cannot handle the needs of the whole population.”

The Rotary mission helps meet the high demand. In four trips to Rwanda, Saboo’s teams have conducted nearly 900 surgeries. For some patients, the mission represents a final chance. Michel Bizimungu, who had been out of work since rupturing a patellar tendon playing soccer last October, was told his case could be handled only at Rwanda’s top private hospital, at a price far beyond his means as a cleaner. Then his case was referred to Asit Chidgupkar, an orthopedic surgeon and member of the Rotary Club of Solapur. Although Chidgupkar had never encountered this specific injury, and CHUK lacked some needed equipment, including biodegradable screws and suture anchors, Chidgupkar devised a plan. The next day, in a four-hour procedure involving three separate incisions, he repaired Bizimungu’s knee. Chidgupkar called the procedure an “absolute improvisation.” (He later presented the case at an orthopedic conference in India, and he keeps in touch with Bizimungu, who updates him periodically on his recovery.) “It’s one of my most memorable cases,” he says.

The mission also provides training. Mission doctors teach cutting-edge surgical techniques to local physicians, medical students, and residents. During surgery, the visiting doctors demonstrate techniques and learn from host country doctors. Bosco Mugabo, a fourth-year resident in surgery at the University of Rwanda who assisted Chidgupkar with Bizimungu’s operation, says the opportunity was invaluable. “There are some tricks and hints that you don’t learn from school,” he says. “You learn them from a specific surgeon.”

With this in mind, Saboo worked with local health authorities to slightly modify the Rwanda mission. At a dinner in Kigali, he announced plans to invite 10 Rwandan doctors to India for three-month stints of training there – part of an effort to boost local capacity in a more sustainable manner. The next mission to Rwanda will also be smaller and focus more on teaching two in-demand specialties: reconstructive urology and anesthesiology. In addition, 20 Rwandan children will undergo open-heart surgery in Saboo’s home city of Chandigarh. With travel funds from the Rwandan Ministry of Health, 30 Rwandan children have already received such operations there. According to Emmanuel Rusingiza, one of only two pediatric cardiologists in Rwanda, the country’s high rate of rheumatic heart disease, which generally results from untreated cases of strep throat, means the country has a waiting list of more than 150 children. “A big number of them are passing away,” he says. “It’s a very hard situation.”

As the mission in Kigali winds down, Saboo is already looking forward to the next one. With more Indian districts interested in sending doctors, and African districts interested in hosting them, he expects the number of trips to increase, even if his own attendance becomes less frequent.

Many mission participants, both first-timers and veterans, say they plan to return, though it sometimes entails a significant personal and professional sacrifice. Karvekar, whose own son underwent heart surgery in India just days before he traveled to Kigali, is one of them. “I’d wanted to go on one of these trips for a while,” he says, noting that the mission was his longest absence from his family’s private clinic, where he’s the only orthopedic surgeon on staff. “There were a lot of challenging cases, but fortunately we were able to do them well and, I think, give the patients a good result.”

“It is totally a labor of love,” adds Saboo, speaking for himself as well as the team of doctors. “When they come here, there’s no compensation. They come purely because they want to extend their services to humanity beyond their own borders.”