It is now well over a year since the refugees came from Rwanda. Thereare currently about 450000 of them. The original population of this remote and rather inaccessible district of Tanzania was just under 200000. Before April 1994 Ngara was a quiet backwater of typical African rural under-development. Most people were subsistence farmers cultivating exclusively by hand and enduring ordinary day to day poverty with great equanimity.

In the past year or so the district hospital (in which both of us have been working for the past five years), in keeping with government policy, has been obliged to introduce charges for patients. According to the stipulations of structural adjustment Tanzanians can no longer enjoy the luxury of free health care. Our charges are high enough to deter many patients but far too low to realistically run a district hospital. Ngara has been connected to the 20th century and, as its agricultural economy is essentially mediaeval, there are going to be problems.

The events of April 1994 and their aftermath have provided further food for thought, however, and it is surprisingly indigestible. The sudden appearance of several hundreds …