Rwanda 20 years on: investing in life

Summary

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Introduction

In 1994, the genocide against the Tutsis led to the deaths of 1 million people in Rwanda (nearly 20% of the population at the time), as well as the displacement of millions more. During the 100 days after Easter, 1994, a bitter post-colonial divide linked to eugenic constructs of race rooted in a previous century—but grimly familiar to those who remember the crimes of the Nazis—tore the country apart. Whether survivor, perpetrator, or member of the diaspora, no Rwandan emerged unaffected. Much of the rest of the world stood idly by.

The health effects of the genocide lasted long after the physical violence stopped that July. An estimated 250 000 women had been raped, and thus did HIV become a weapon of war.¹ One of the 20th century's largest cholera epidemics exploded in refugee camps along Rwanda's western border.² Fewer than one in four children were fully vaccinated against measles and polio in 1994.³ Rwanda's under-5 mortality rate that year was the highest in the world; life expectancy at birth would remain the lowest anywhere through the next few years.4, 5 Tuberculosis control programmes, weak before the genocide, were in complete disarray; for years afterwards, many patients received only intermittent therapy.⁶ Moreover, most health workers had either been killed or fled the country; many who remained had been complicit in the genocide, and trust in physicians and nurses was frayed.⁷ Destruction of health facilities and the collapse of supply chains for drugs and consumables handicapped the country for years. Capacity to respond to the new crisis of mental health trauma was as strapped as capacity to respond to the trauma usually attended by surgical teams: Rwanda boasted neither psychiatrists nor trauma surgeons.

Some assume that such awful circumstances led to a tardy but emphatic humanitarian response. Such assumptions are wrong. Many were ready to write Rwanda off as a lost cause. In 1995, Rwandans received about US$0·50 each in foreign assistance for health, the least of any country in Africa.⁸ Some development experts even advised withholding primary care services from children to stave off population growth and prevent what they called a “Malthusian abyss”.9, 10 From the outside, it appeared that for years to come, Rwanda would be vulnerable to the donor community's shifting whims and divergent prescriptions.

Progress was halting in the years immediately after the end of the genocide.¹¹ In 1998, the new government launched a consultative process to create a national development plan, which led to a document called Vision 2020.¹² The idea was to move from the disaster of the mid-1990s towards becoming a middle-income country by 2020. The plan invokes the principles of inclusive, people-centred development and social cohesion. Central to this vision was health equity. Prosperity would not be possible without substantial investments in public health and health-care delivery; recovery from the horrors of 1994 would not be possible without provision of some of the services long monopolised by those who controlled the ship of state. The Rwandan Constitution of 2003 formalised the inalienable right to health;¹³ by contrast with the decades of violence culminating in the 1994 genocide against the Tutsi, the decision now was to invest in life.