Left in ruins at the end of the 1994 genocide, Rwanda’s only psychiatric hospital is now seen as a model for the entire African continent. Specialists from Geneva helped to train the staff, who now care for some very disturbed patients.
The Ndera hospital, perched on a hill not far from Kigali’s international airport, seems like a haven of peace. It is surrounded by green spaces and boasts a well-maintained basketball court. A pleasant, relaxing place, it would seem, only a few kilometres from the hustle and bustle of the Rwandan capital.
But as the visit continues, the silence weighs ever more heavily. The patients, with their drawn looks and eyes glazed by the medicines they take, gather in little huddles and stare at the visitor.
“I’ve been working here for 14 years, and have never been the target of aggression,” Jean-Michel Lyamuremye, the hospital’s medical director, assured swissinfo.ch. “What these patients need most is someone who listens to them and understands them, who feels their suffering.”
Region in focus
The area comprising Rwanda, the Democratic Republic of Congo and Burundi is a high priority for Switzerland when it comes to international cooperation and development.
In 2012, the Swiss government supported projects worth CHF38 million in the region, mostly having to do with health and government leadership.
In 2013, the region became one of the core areas for Swiss development policy, with focuses on promoting economic development, vocational training, agriculture and the ecological production of building materials.
The foreign ministry has recognised Rwanda’s “remarkable results” in the areas of health, education and agriculture since its 1994 war and genocide.
However, economic and social progress cannot come at the price of democracy, warned the foreign ministry. In Rwanda, freedom of speech remains under threat and the media cannot operate without restrictions.
The most complex cases
“We deal with some very complicated cases. These people are often suffering from a psychiatric illness, like schizophrenia, combined with serious mental trauma as a result of the 1994 genocide,” Lyamuremye explained.
The World Health Organization (WHO) estimates that nearly a third of the country’s population is still suffering from severe psychological trauma arising from the massacres of Tutsis and moderate Hutus carried out nearly 20 years ago.
“In one way or another everyone was affected by the genocide,” says Lyamuremye. “But people who are well integrated into society, who have work and social contacts, find it easier to overcome this tragedy.”
Ndera also houses drifters expelled from the city by the police as well as disruptive prisoners.
But beyond the hospital compound, how many poor souls are still wandering around, still tormented by the demons of the past? People apparently living normal lives often find it difficult to talk about, failing to find words to express the unspeakable.
But every April, during the official commemorations, the collective trauma returns. The Ndera hospital calls up a large team of carers who travel to the memorial sites to look after the patients on the spot.
“Some people seem to be numbed by the flash-backs. You have to touch them gently to bring them back to reality,” says Alphonse Nkurunziza, who works as a psychotherapist with the AMI association, a local group that looks after people suffering from psychological traumas.
The fact that the scars of the past are not fully healed is sometimes manifested in a less spectacular way.
“A lot of Rwandans don’t want to take part in the commemorations. They go into avoidance mode and refuse to go through the grieving process. This is often an indirect sign of serious trauma,” said Nkurunziza.
Whole swathes of the population are unable to find peace. Constantly on their guard, survivors react to the slightest sound that might recall the genocide. The mere sound of children whistling can sometimes be enough to bring back the terrible memory of the extremist Hutu militias.
Lyamuremye is worried by a new phenomenon. “Some of the children born after the genocide present symptoms of post-traumatic stress. They cannot bear to hear the stories told by older people.”
The privatisation of violence is another important aspect of this collective injury.
“The traumas suffered are having an impact within families and are a source of conflict,” Nkurunziza said. “It’s reflected in domestic violence and the use of drugs and alcohol.”
Rwanda, a developing country, has only one child psychiatrist and fewer than ten psychiatrists for adults. Given the size of the task, this might seem very meagre. But huge efforts have been made to re-establish a mental health system after the devastation of the genocide, even if the government has sometimes been accused of going too fast in trying to overcome the evils of the past.
Lyamuremye believes that the awareness-raising work conducted by the authorities – it is now a criminal offence to discriminate against the physically and mentally ill – and the establishment of a mutual insurance system for all has made it much easier for people to have access to mental health services.
Lyamuremye proudly enumerated the services that have been launched in the past few years: clinical psychology, addiction, mental illnesses and HIV, psychotherapy, and a neurological service for epilepsy sufferers.
“Specialists from neighbouring countries come here to gain experience. We also regularly host African and European students.”
But without the support of international funding agencies the Ndera hospital would not be able to function to the same standards. From 1996 to 2008 the Geneva University Hospitals (HUG) and the Swiss Agency for Development and Cooperation (SDC) helped set up a psychiatric care network in Rwanda, of which Ndera is the linchpin.
The project has been handed over to the Rwandan authorities – a good indication of the confidence placed in the local partners. But the HUG is still
cooperating with training on an ad hoc basis, as André Laubscher of the HUG told swissinfo.ch.
There are 250 in-patients, and another 100 are treated every day at Ndera. Lyamuremye is not resting on his laurels. He would like to see just two patients per room, as opposed to eight at present. That all depends on funding.
He has faith in the future, given the healthy competition he says is typical of Rwandans. “Everyone wants to prove he is capable of achieving the highest standards. Mental health is no exception.”
International organisations working on mental health issues in Rwanda must often adjust their practices to local realities. For example, placing the individual at the centre of care isn’t always possible.
Therefore, a collaborative effort must be made to treat traumatised people, including biological, social and spiritual aspects. In Rwandan culture, people generally don’t speak about their feelings, so relaxation techniques like breathing exercises are used instead.
To maintain traditional village structures, the government adheres to the concept of Ubudehe, which addresses small problems on a community level.
This method allows conflicts to be addressed before they escalate into something larger.
(Translated from French by Julia Slater), swissinfo.ch