Providing palliative care in post-genocide Rwanda

Categories: Opinion.

Today, the 27th January, is the United Nations Holocaust Memorial Day. It is a painful reminder of the 6 million of Jews who died during World War Two.  In the aftermath of this the Genocide Convention was adopted as people said the words ‘never again’.

Sadly, 50 years later in 1994, Rwanda experienced its own genocide against the Tutsi population of the country.

Located in East Africa Rwanda is a small landlocked country with an estimated population of just 11 million. It also has a dark history.

Rwanda has been deeply affected by the1994 genocide. Over 1,000,000 people lost their lives, another 2,000,000 were made refugees and countless people witnessed atrocities.

Inevitably, the health sector was also affected. A large percent of the health professionals were killed and the health infrastructures was all but destroyed.

As a result, the government of Rwanda had 2 main challenges. They needed to both rebuild the country’s infrastructure but also to rebuild the sense of humanity in Rwandan society that was so cruelly taken in the genocide. In one hand the government needed bricks for infrastructure, but in the other hand they needed compassion, justice and forgiveness.

In April, Rwanda will commemorate 20 years since the genocide. This beautiful country that is known as “the land of thousand hills” now marks two decades since the 1994 genocide which claimed the lives of more than a million people and left the country in ruins.

The first decade focused on rebuilding and laying a new foundation for the nation. This included restoring the rule of law, which saw the promulgation of the new Constitution in 2003.

The second decade has been about building on that foundation to firmly set the people and country on the road to prosperity. The health sector faced many of the same challenges as the rest of society. Both patients and health providers have been affected by this indescribable and terrible event.

This is why the development of palliative care in Rwanda is so important.

The WHO defines “Palliative care as an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

The provision of palliative care in post-genocide society has a lot of challenges. To give just one example, we have to work harder to link the discipline to the management of mental health. This is central to improving the quality of life for many patients.

A lot of patients express during counseling that they feel that there is a strong correlation between what happened to them during the genocide and their current situation.   

In a post-genocide society we have to focus on the truly holistic nature of palliative care. This means offering the physical, social, psychological and spiritual support patients need.

In Rwanda, the psychosocial aspects of palliative care must be given great focus as so many were affected by the genocide. If you avoid this reality then you fail to offer effective palliative care.

Equally, the spititual support you offer patients is incredibly important. Too often patients also suffer from a feeling of guilt.

One of my patients once asked, “Why did this situation happen to me? I lost everything during the genocide and now I’m going to loose the only thing I have, my life”.

Many health providers are not ready to hear the stories of patients because they themselves have been affected by the genocide and have their own stories and problems.

As a health professional you feel the weight of an incapacity to help combined with the emotions which you remember from the genocide.

In addition, during national events such as the commemoration of genocide from April to June the situation can seem to feel especially difficult to manage. This is certainly true for those working in palliative care and interacting on a daily basis with death.

During this period the feeling of loneliness can appear among our patients, they often fear to ask for additional service, as they don’t want to be a burden either for their families or for health providers at such a time.

The genocide against the Tutsi population in Rwanda not only saw the death a million of its population, made over 2 million refugees, and made millions of widows and orphans, but it also forced us to look, in retrospect, at what was important in Rwanda’s culture: our humanity. 

Palliative care is the focus on total care that helps us to bring back our humanity. Palliative care helps to treat and heal the wounds left in a post-genocide society.  

The government of Rwanda continues to try and build our society – both the humanity and the infrastructure, but it’s up to us, the Rwandese, to ask ourselves how we can contribute to help to rebuild our country as a nation.

For many patients the disease is less than their feelings about the genocide. A disease can take only their body. But often patients talk about how the genocide can take their sense of identity, values, culture and dignity which can be worse than the loss of a life.

As with the atrocities of the 2nd World War and the holocaust, it will take time for Rwandan society to recover for the consequences of genocide against Tutsi population in 1994.

We will commemorate on the 20th April and remember. But we will also be marking the 20th anniversary of the rebuilding of a nation, of hope, of courage.

About the authors: 

Dr. Christian Ntizimira is a palliative care expert and educator at Kibagabaga Hospital. Magnus Gasana is a psychologist specialist at the Teaching Hospital of Kigali, CHUK

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