Starting From Scratch

Starting From Scratch: The Long Road to Rebuilding Health Care in Rwanda

KIGALI, RWANDA
By Ravi Jaipaul

How does a country rebuild an entire health care system? In April of 1994, the Rwandan Genocide spared none in a fanatical pursuit of racial purity. Entire hospitals; including Doctors, nurses and patients were killed or driven out of the country in 100 days of madness. When peace resumed, the country was left, among other deficits, without qualified health care workers.

Compounded by growing concerns of post-traumatic stress disorder, malaria and HIV/AIDS as well as reconstructing a nation decimated by war, the country was slow in addressing the concerns of health. Schools and training centers began the process of providing short-term, low-trained and overworked replacements to put a temporary band-aid on the issue. These training centers led to an undereducated and largely inefficient workforce, unable to provide the care the country needed.

Today, sixteen years later, it is easy to dismiss the Rwandan system as still being in disrepair. A World Health Organization report states that Rwanda does not have the minimum health workforce required. Estimates suggest that there are only 400 Doctors and 3,600 nurses and midwives for the largely rural population of nine million in Rwanda. Alberta and British Columbia, in comparison, share a similar population with Rwanda and have over 13,000 Doctors alone.

Infant mortality in the country remains incredibly high, as rural hospitals are crippled from the lack of resources needed to perform life saving operations and interventions. Corruption in administration continues to plague the health community, with regular investigations and firings occurring based on the grounds of financial mismanagement.

However, progress has been made on many fronts. In the national budget, health has increased to 12%, up from 4.2% in 1996. Millions of dollars in international aid is earmarked each year for global initiatives, such as eliminating malaria and prevention of HIV/AIDS. This has led to a promise of increased salaries for nurses in Rwanda; in hopes to combat the ‘brain-drain’ that continually sees professionals leave for more prosperous opportunities elsewhere. There is also a drive to use innovation to solve the accessibility issues for rural patients. Last month, the Minister of Health pledged 2500 mobile phones to Community Based Health Workers, hoping to connect patients, health care workers and communication of care through technology.

In 1996, the government introduced “Vision 2020,” a plan which aims to improve human resources for health professionals, restructure and prioritize the health budget and improve on current health statistics. As a result, 50 inadequate training centers were closed down and the Kigali Health Institute was created to train nurses and technicians for the health center in a centralized, standardized post-secondary setting.

Welcomed into the role of Nursing Lecturer at the Institute, I have first-hand witnessed the successes and struggles that exist within the educational and health care system. A lack of local staff and under-funding continue to hamper the ambitious developments of the Institute. With the new mandate in Rwanda for all institutions to teach in English, the students are struggling to master a new language, leaving a difficult language barrier for teachers to bridge. The new development of a four year Nursing program is still in it’s infancy, requiring more time to be recognized by the government as an official program and designation. At the same, Rwanda’s first Nursing degree students graduate this November, lending hopes to starting the first Masters in Nursing program next year. This would be an opportunity to retain locally trained and taught professionals.

Despite the enormous complexity that exists in reconstructing a health care system from almost nothing, there is a determination and drive by the health professionals in the country to improve the system in Rwanda. This drive, coupled with government and international initiatives has led to new hope for universal and qualified health care for all Rwandans.

Ravi Jaipaul is a University of Alberta Graduate on a six month internship in Rwanda teaching at the Kigali Health Institute through a partnership with Saint Francis Xavier University, the Coady Institute and the Canadian International Development Agency.

Two Hours Traffic

Movement is the most dangerous part of my day.  It is also the most exhilarating. Often, we take the experience of going somewhere for granted, hopping into our cars or getting on the bus with nary a thought as to the beauty that exists in the act.  Beautiful in the fact that there are rules, laws and order. It’s easy to take movement for granted, until you are forced to engage yourself in the infrastructure of Rwanda.

The Kanye-West Mobile

The people’s choice for transport is the Matutu, a converted mini-van with  added benches for increased human capacity. To add  interest to your day, people watch or feel a little more a part of Africa, I hop a Matutu. African Mama’s load into the bus, chattering and laughing with animated conversation while balancing their young ones on their laps or over their shoulders. Professors and students cram in side by side and exchange formal pleasantries. Clubbing girls, adorned with big sunglasses  and large amounts of chewing gum apathetically enter and mumble for the driver to turn the music up.   Fares are handled by the Conductor, who carries a wad of bills and hops out at random, unmarked bus stops or street corners, enticing passengers through use of a gentle shoving, to choose THIS minibus, as opposed to the dozens of others. Granted, there are subtle differences, if one is picky. Those with a flair for the artistic have transformed their caverns of steel and rust as moving tributes to favorite T.V. shows, Rap Artists and Sports Teams; from Kanye West and Sean Paul to Manchester United and Prison Break. Costing a pittance (180 RWF, $0.30) for a lengthy twenty minute ride downtown (it’s stops ever 1-5 meters for more passengers), the Matutu is the economical and integrated way to move around Kigali.

I never fully understood the allure of motorcycles until I first sat on a Moto-Taxi. Like farming and tending your crops connects you to the land, riding one of these Japanese Mini-Bikes connects you to the thrill of movement. You feel the repercussions of speed; as air whistles through your clothes during the jerky accelerations, dust and exhaust pitches up at you on the dusty roads and the constant hum of the street life permeates the government-mandated helmet (safety first) perched atop your head. The degree of separation between you and the world is lessened on a Moto, enabling you to chat with others at long red-lights, or for the driver to give slow moving pedestrians a well-intentioned comment as they whiz by, millimeters away from danger. It’s the connectedness, openness and the sheer joy of Moto’s that draws you in.

My first Moto ride was on the third night in Kigali. Slightly drizzling, and completely on the opposite side of town, we were only able to direct the Moto to our neighborhood (Nyamirambo), not knowing where we lived. It was like getting into a taxi in Edmonton and only knowing you lived in St. Albert. Charles, my Moto-driver, however spoke English and we chatted amiably the whole way.

“What is your name?” He asked over the roar of the engine and splatter of the rain around us. I replied, yelling over the noise. “HEAVY???” he screamed in response, beside himself in laughter as he pointed at the compressed shocks over his front tire as we whizzed down a busy thoroughfare. “YOU SURE ARE!!!” he chided, as he convulsed in obvious joy over what he thought my name was.

After 42 minutes (what should have taken 15), three phone calls to friends and two stops to ask for directions, we ended up miraculously at our guest house. We paid our then disgruntled taxi-drivers and, still pumped off the high of riding a motorbike for that long, pledged our allegiance to the two-wheeled creatures.

Now, we are veterans of the Moto circuit, making friends through simple Kinyarwandan banter, and an obviously display of manners (upholding the stereotypical Canadian attitude of "please" and "thank you's"). For the seven minute ride to work in the morning, we have stopped the arduous process of haggling for the local fare (paying $0.87 instead of $0.70, gasp!), instead appreciating the subtlety that an extra 100 Rwandan Francs could mean to the driver.

Moto Like A Rock Star

 As I hopped onto a Moto recently, I greeted the driver and began to say, “Nyamirambo” when he cut me off by kick starting the engine, drowning me out. As I began to buckle the helmet tightly, he looked back with a knowing smile and said, “Merez Station (a block away from home).” We laughed and I yelled to him as he shoulder checked and gunned the engine, kicking up thick, black-smoke from the tailpipe as we swerved and wobbled out into the mid-afternoon rush hour traffic,

“Tugende, Inshuti!” (Let’s Go, My Friend!) 

Nyamirambo --> (NYR)

"You live here?" My colleague asked, pointing up at the two story faded-orange building I was standing outside of. "Isn't this area," he said, leaning in and looking around, "a little dangerous?"

I stopped rolling up my sleeve, and watched to see if his face betrayed his words and showed any signs of untruthfulness. It did not;  his eyebrows were genuinely raised in surprise as he shook my hand and proceeded on down the street.It took me a moment, frozen in our busy intersection to digest what he had said. You see, my colleague is from the Congo. The man from the Democratic Republic of Congo asked if where we live is dangerous. The Congo. C O N G O.

View from our deck: Menacing

This wasn't the first time I have heard concern over the area, but in that moment I gained a deeper love for the misunderstood side of town we live in.

Nyamirambo, our neighborhood,  is the bustling Muslim district of Kigali; a bounding pulse of the city of Kigali. Two towering mosques mark the entering and the passing of our neighborhood, and our house lies directly in between the two.  This leaves us vulnerable to the morning calls to prayer, the never-closing bars, the stray-dog discussions  at 4 am, and the constant hum of the chatter and traffic that never ceases. 'Rambo even has a Town Crier. One man, obviously chosen for the sheer-unpleasant quality to his voice, arms himself with a loudspeaker, and at random intervals (day or night, sun, rain, whatever) plants himself on the corner of every intersection and yells in rhythmic Kinyarwandan (Ubanda-Grenada-Lugunda-Uganda).

2020: Closing in a Decade

The newly paved Avenue de la Justice is the thoroughfare for all happenings of the neighborhood. Streets are lined with creatively thought out names such as "Human Lover Boutique" and "2020" (obviously the new 2012). Pass by these shops, and hear old-fashioned sewing machines constantly "whirring" as mannequins are dressed with the freshly minted wares. Others are seen scrubbing second hand shoes (donations from Canada and Europe), returning them to their former glory, where they are sold for a profit.  A fifty foot tall television screen randomly plays a Kobe Bryant highlight reel on repeat. Women carrying fruit baskets weave their way up and down the Avenue, miraculously balancing their wares with dignity and skill while balancing their babies who are wrapped around their backs, sleeping comfortably in their mother's makeshift-baby-backpack. Children sprint up and down the shoulder of the road playing and laughing in their school uniforms after school while devout Muslims bee-line for the Mosque, heads down and deep in thought. The indiscriminate smells of the neighborhood punctuate and captivate the air, wafting faint trickles of the day's menu (is that goat?) and open-fire stoves. Moto Taxi drivers line up outside the Great Wall of China Supermarket, chatting about whose bike is cleaner, faster and most dangerous.

The First Wave is Free

Stay a little longer, and you see destitute poverty reach it's dark claws into the neighborhood. The rest of Kigali has been purged of the beggars and street vendors that punctuate so many majority world cities, and Nyamirambo has become a collecting ground for everyone not rich enough to belong elsewhere. Dull-eyed children carry  trademark yellow Jerry cans to the local watering hole to be filled. Women breast feed malnourished children while plead with their eyes for some change with their free hand. A man, amputated at the hip, uses flip-flops as hand shoes as he trudges his way down the street. Drugs, prostitution and theft lurk behind the shadows of day.

Kigali is like a bad actor; pretending to be something that it is not. Few neighborhoods offer the realism and awakening of the real situation that Nyamirambo does. It forces you to confront questions of charity, of ethics, of power and privilege. Of how where you were born determines a large portion of how your life will be lived. With 80% of Rwanda living in the rural populations, our neighborhood is a truer representative of the state of the country.

It's what makes living here matter though; the chaotic, urban sprawl, the misunderstood neighborhood characters and community that we are becoming a part of, the poverty and privilege. It's all here in the beautifully bold and vivid streets of Nyamirambo. 

This. Is. Genocide.

"400,000 people are dead. 2 million are displaced. The numbers... well, they are numbing.... If we let the numbers hinder us, we can be crushed under the hopelessness they represent. ” -WFD Speech

I knew the words well, I wrote the speech. I had spent two years with the Walk for Darfur, speaking from an activist standpoint on the Genocide in Darfur to thousands of students across Alberta.  I had never given the words a second thought, until now. They echoed through my mind, almost with a twinge of innocence, as I wandered through a Rwandan countryside Genocide Memorial. For two days the numbers of Genocide crushed me, utterly and completely. The numbers numbed me to the soul.

From room to room, the tour went from terrible to horrifying as our guide started in a room full of adult corpses. These remnants of the 1994 Rwandan Genocide were preserved in grisly fashion layed out on wooden racks, bones unnaturally gleaming white. The smell of mass decay and hell wouldn't leave my nostrils for days. The final room of children and infants was too much to bare. Nausea and waves of dry heaving were swallowed back down as I forced myself to enter. Even in death, their innocence was their trademark. Kids and infants killed for no other reason than being born. It was then I noticed my chest heaving, my breathing became audible like that of an angry animals, my muscles flexed, as if ready to fight, my eyes focused forward with intensity. My soul was shaking with the failure of humanity.

We left the class, and the guide pointed to the other classrooms that lay in long houses that were scattered throughout the hillside. Like a nightmare where you run as fast as you can, but can't escape the evil, the guide said we could visit the other houses... but they were all the same. Homes of bodies. There were more than I dared to count.  As if reading my mind, the guide explained there were “over 50,000 are buried in these hills.” The tour ended with the guide saying,

“This. Is. Genocide. This. Is. Genocide. This. Is. Genocide.”

Each time he said it, he sounded a little more lost, as if replaying the madness of it in his mind.

I was too sad to cry, too shocked to feel hurt. Watching humanity at its absolute-lowest point was despicable. Inspiration, Faith and Hope, the ingredients I had grown up with had been replaced with Death, Decay and Darkness.

Two days later, we went to the Kigali Memorial Centre. In progressive stages, the exhibition walks you through the causes and precursors of genocide, the days of the massacre and the aftermath. Whole families, whole congregations, whole communities disappeared forever. Rwanda was dead. The most disturbing part came on the final part of the tour, entitled “The Missing Future.” Here, life sized photos of children in the massacre included plaques that described the kids. Keri, a 7 year old boy, had his last words written as, “Mom, where is it safe to run to?” Underneath, in quiet font, it said he was killed by machete. Amielle, who liked soccer and laughing, was shot to death after saying the words, “Don’t worry, UNAMIR will help us.” It went on and on like this...

The exhibit ended in a hallway filled with pictures, put up by family or friends of the victims. It was here I lost it, staring into the smiling eyes of hundreds of innocent children. The room had benches where people had gathered to rest. My legs buckled on the closest one, and I buried my head in my hands. I dug the heels of my hands into my eye-sockets, unsure if I was trying to brand the terrible images to memory forever, or force them out altogether. I cried uncontrollably on the bench, hands shaking and tears flowing like sharp daggers from my eyes. I have no idea how long I sat there and when my own crying had subsided, I realized that others were crying too. Everyone else in the narrow hallway, spread on black benches, were filling the audible silence of the kids absence with our sadness. We were crying together but each person was lost in their own personal hell. When the tears subsided,  I stood and watched a proud lady, dressed in all-black, clutching at a crinkled photograph of a smiling young boy. We shared a look before I left.

Everything you ever sense, in touch, feeling or thought has an effect on you that is greater than zero. Some things, like a dog trotting by you on the street, or the steady hum of traffic out the window, have such an infinitely small effect that you can’t detect them. Other things, like heartbreak and happiness, effect your life in such a way that it changes it forever. The look we shared will stay with me forever.

As we held eyes, I saw in them the horror and pain and despair I felt I had in mine. But as I held her gaze for a moment longer, I saw something I never expected to see... hope. An, absolute, quiet, determined hope existed. And it has to, for us to move forward. For Rwanda to move forward. The people of Rwanda have shown an incredible resilience, drawing on strength and hope from the very core of what it is to be human. The country bears an incredible burden and responsibility to it's citizens, preaching reconciliation and forgiveness. Every small victory is a reason for celebration, every step forward a triumph. There is a lot of healing to do still, yes, but much has been done since 1994. Rwanda is peaceful, Rwanda is changing, Rwanda is alive again.  
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Like we said in the speech those years ago, if all we were to do was focus on the numbers, the chaos and disregard for human life, no one would ever act. We would simply be numbed into submission, too overwhelmed and defeated to do anything about it. In the longhouse, surrounded by the horrors of the Genocide, I was flooded with a wave of quiet, forceful resolution.

It was in that moment that I was changed. I no longer felt comfortable, safe, inspired, hopeful... free. In these  seconds of weightlessness and uncertainty we define ourselves, and distinguish between right and wrong, good and evil. We choose in those trying moments what it is we will fight for, what it is that we will live for... what it is that we are here for.

In the weeks that have passed since Memorial, I have found my way past the sadness that exists, and instead have focused on finding the light that exists within, the resilience and strength found inside. By finding our own hope, we can bring our energy, our passion and our experiences to help a situation or to empower a community, assist a family or even a person. It may not make a difference to the world, but it could make the world of difference to one person. And that difference alone could mean the distinction of having hope and losing it completely. That difference could mean life and death.

By using these hands, this mind and this heart, I want to use my skills as a nurse to bring light and hope to the darkest situations in the world; from refugee camps to natural disaster zones.  I joined nursing with this very intention, but only now am I starting to understand the scope of the situation. Only now can I admit it with grim resolution. I'm signing up for hell, I'm sure, but will relentlessly be looking for hope. As long as it exists, even if just from inside of us, inside of one person, it is reason to believe in humanity.

That humanity is something worth helping, worth fighting for and worth dedicating yourself to.  That humanity can be better than it is.I believe that this world we live in can be full of darkness, but if you only look for that, you miss out on the light. I believe this is why I am here; to help kick at the darkness till it bleeds daylight.
"When the end of poverty arrives, as it can and should in our own generation, it will be citizens in a million communities in rich and poor countries alike, rather than a handful of political leaders, who will have turned the tide. The fight for the end of poverty is a fight that all of us must join in our own way. We have exciting times ahead, and no time to lose." -Jeffrey Sachs

The Kigali Health Institute

You arrive in a city as a stranger; eyes wide and seeing the world differently, as if never having lived a day on it. You arrive as a spectator; aloof, apart and unconnected. If you want to stay, if you want to survive, however, you have to put aside the notion that you are not involved. Eventually, you have to submit to the will of a city, to its history, to its present, to its pulse, and put yourself, heart and soul, without hesitation to the whims of the new world. To make it count, you have to get involved...

It starts at the Kigali Health Institute (KHI), which lies in the heart of Kigali, and trains the future of Rwandan health professionals. In the middle of the institution lies the Nursing Office, where I type from now.

KHI: Making Nice Signs Since 1997

“You don’t choose nursing,” explained Ibrim, a fourth year student accompanying me on the bumpy bus ride out to the only psychiatric hospital in East Africa, “Nursing chooses you.” He began to give me a crash course on the health care system in Rwanda. The country joined the East African Community in 2007, whose goal is to increase trade and cooperation for the region. Like all other East African Communities, Rwanda needed to become English speaking, which is the third official language. Rural populations, which compose the majority of the population, still only speak Kinyarwandan, placing far more importance on escaping destitute poverty than learning second languages.

The New Bus No One Can Drive

As such, the majority of professors in Nursing here are from East African countries with developed health care systems (also English speaking). Together, we are given the task to create a recognizable, respectable Rwandan Nursing training program. With contracts ranging from six months (like mine) to two years, we hope to train and transfer our jobs over to Rwandans, creating a sustainable and long-term workforce.

The goal is noble, but riddled with problems:

1. Rwanda does not have a Masters in Nursing program, which causes nurses to leave the country to get their Masters. Usually, they do not return.

2. The recently introduced (as in 2009) 4 year Nursing Degree Program has yet to be recognized by the Minister of Health (Who need 4 years of school to be a nurse, anyway???) .

3. Kigali has more Non-Governmental Organizations (NGO's) than a lunch buffet has types of potatoes. With their various Western-mandates, NGO's offer Rwandan nurses double and triple the salary of government paid workers, leaving most city hospitals incredibly understaffed.

It is nearing the end of the semester, so part of my daily routine involves preparing an Adult Medical Surgical and a Health Assessment course to teach. As much as being a professor is a dream come true, I was quickly shaken to my senses that it will bring far more personal gain than help out the institution. Anyone could teach these courses. The internship was like putting a band-aid over a fracture.

To address this concern, I gathered the staff and we identified the greatest problem for the Nursing Department; consistency. Here, every time a teacher delivers a course, they invent it themselves, using a broad, vague curriculum to guide them. The content changes on a whim, the assignments are arbitrary, and the tests range from Kindergarden-esque to PhD impossible.

To help with this, together with my friend Adi (thank you, thank you, thank you) from Edmonton, we are creating an online database for all future teachers to access course information, assignments, tests, hand-drawings, etch-a-sketches... if it was done in a class in the past, it will be here.

As the work picked up it's pace, it was ground to a halt in it's entirety. A sombre memo had been circulated that there was to be an unscheduled two week break due to Genocide Memorial Commemoration.

It was then I decided not only to stay and survive in the city, but thrive in it. To give myself up to the city, to the work, the culture and the people of Rwanda involved seeing the past, witnessing the truth and learning from the ugly mark that history left on this country. I needed to know what happened.

It was time to see Genocide.