2015 marks 21 years since approximately one million people were killed in the genocide against the Tutsi. Over the past week (7-14 April), Rwanda has been commemorating its darkest hour which, for Dr Ntizimira, brings sharply into focus the challenges of providing healthcare in a post-genocide society.
Every year, explains Dr Ntizimira, the memorial week prompts thousands of cases of trauma disorders (crying, convulsion, screaming and loss of consciousness) for which public hospitals are well prepared. But there is also the ongoing struggle that is faced by healthcare providers in the country: caring for patients who survived the genocide and are now living with life limiting illnesses.
Recalling an appointment with a survivor of the genocide in March 2014, Dr Ntizimira emphasises the horror that some patients have lived through: the patient in question, a young woman, was just five when the genocide occurred, and lost all of her family in the atrocity. It is these terrible experiences that present such a multi-dimensional challenge when providing palliative care in Rwanda.
It is arguably the effect that the genocide had on family structures that leads to the greatest challenge: Dr Ntizimira notes that he has never been contacted by a patient directly since working in palliative care in Rwanda; rather it is members of the patient’s family that make appointments and speak with doctors. In this context, it is clear to see the problems that will be faced by survivors who have no family left.
Dr Ntizimira outlines the three main lessons that he has learnt from working in Rwandan palliative care. Firstly, when dealing with survivor patients, recognising the importance of their history and background is crucial: pain management and palliative care will differ for patients with the same diagnosis but different backgrounds. “A patient impacted by a mass traumatic situation,” he writes, “will react differently in their management compared to a patient who has never been affected by these situations.”
Secondly, understanding the psychological condition of a patient is vital. Citing his 2014 article, ‘Providing palliative care in post genocide Rwanda’, Dr Ntizimira explains that “a lot of patients … feel there is a strong correlation between what happened to them during the genocide and their current situation.” Consequently, Dr Ntizimira attempts to deal with patients on a personal level: in practice, this means that he removes his lab coat and uses simple language when explaining a diagnosis; he is determined to show his empathy and compassion for both the patient and their family.
Thirdly, the patient’s family must also be cared for: as Dr Ntizimira explained, the connection between a patient and their family is strong, and it is therefore necessary to provide the family with adequate support. Dr Ntizimira notes that “there is a strong correlation between family psychology behaviour and patient psychological impact, and one can affect the other and vice versa.” He also calls for more research into this particular area so that we can better understand what effects high quality care for families have on patients.
The Rwandan genocide undoubtedly remains an incredibly difficult backdrop against which Dr Ntizimira and his colleagues work: the challenges which they encounter are manifest and possibly unique. But Dr Ntizimira is overwhelmingly enthusiastic about the effect that their work has. “During the genocide, a part of our humanity was lost,” he says. “However, I’m still convinced that the concept of palliative care will bring back this part of humanity lost and will teach us to understand the deep perception of being a ‘human being’.”
Dr Ntizimira is a regular contributor to ehospice. Read his full article on ehospice Africa.
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