Kigali calls

Reading EHP can be life changing. In June 2007 Teresa Isaacs read about Helen Perry and her husband Paddy working in Rwanda at the Kigali Health Institute, she as an environmental health lecturer, he as a linguist.

Six months later, Teresa and her husband Steve were unpacking their bags at the same institute’s campus. They were four hours drive west of the Rwandan capital Kigali on Lake Kivu, on the Rwandan-Congo border.

Steve, a civil engineer, and Teresa, an EHP, are no novices to Africa, having previously worked together for two years on a public health education project in Gambia. However, this did not stop them being shocked by Rwanda.

Known as the land of 1,000 hills, Rwanda is a country of breathtaking beauty around which the government wants to base a thriving tourist economy. Its high-altitude forests are home to the world-famous mountain gorillas, while Lake Kivu has beautiful beaches, jutting peninsulas and an archipelago of islands.

But it was not the landscape, compared with sun-baked West Africa, that surprised Teresa. It was the country’s palpable national pride, demonstrated by how clean and well organised the country has become.

“Unlike other African states, plastic bags are discouraged and even banned and everything is incredibly clean and organised. There is a collective pride and a real sense of community beyond what I have experienced in other parts of Africa,” explains Teresa.

Studying Rwanda’s environmental health legislation, Teresa later learned that for one day a month shops, businesses and banks are required to close down and everyone is asked to come out on to the streets to clean.

“It is part of their legislation and they actually do it. Every month they close all the banks in the main city and everyone goes out and sweeps and cleans. It genuinely happens; they also return to their villages to clean them, too,” says Teresa.

This monthly ritual is one of a number of innovative approaches Rwandans have adopted to improve their quality of life.

After reading the EHP article, Teresa first contacted Helen, and then the overseas group supporting the Rwanda Association of Environmental Health (RWAEH). CIEH Wales region set the group up to support the Kigali Health Institute, which is training Rwanda’s next generation of health professionals.

Since 2003, when CIEH Wales twinned with Rwanda, Helen Perry and the oversees group chair, Sarah John, along with Welsh colleagues have forged strong links with the Kigali Health Institute, raising money and sending out books, computers, microscopes, sampling kits and other equipment to help support courses.

The region has also worked with Rwandan colleagues to set up the RWAEH. The association held its first national conference this year, focusing on developments and challenges in East Africa. The Welsh EHPs have also arranged for colleagues to visit Rwanda to support environmental health teaching there.

Charismatic leader

Environmental health is in ascendency in Rwanda thanks to the lobbying of Zachary Bigirimana, the charismatic Ugandan head of the institute’s environmental health department. As a result of his campaigning, the Rwandan health ministry recently agreed to fund more EHOs and this year the government will pay to upgrade the Rwandan environmental health qualification from diploma to degree status.

The ministry has also published a health policy, prioritising the effective delivery of environmental health. In the policy, published in July 2008, health minister Dr Jan Damascene Ntawukukiryayo argues that strong environmental health interventions could help eliminate most causes of mortality among the under-fives. He sees environmental health as a way of breaking the link between poverty and disease.

“The negative state of environmental health conditions influences the diseases burden which, in turn, contributes to poverty,” says Dr Ntawukukiryayo. “The children, the elderly and the immuno-compromised individuals get sick more frequently and more resources are spent on curative services to restore their state of health, thus increasing poverty at household and community level.”

When he learned about Teresa’s desire to help, Mr Bigirimana invited her to design, with CIEH Wales, and teach an environmental health law module for the new degree launched in January. Steve was invited to teach health and safety on the degree. “We saw our key role as training the trainer, so going in, passing on our skills to new EHOs, adding new elements to make the degree and then leaving,” explains Teresa.

Unlike former British colonies in Africa, which have complimentary legislation and local government structures that adopt the environmental health model, Rwanda is a former Belgian colony so the government’s stated desire to prioritise environmental health is radical.

One of the problems Mr Bigirimana faced was that because environmental health is such a new concept in Rwanda, few people know what it is. Steve arranged for a marketing colleague to come to the institute to teach students how best to market and promote their profession.

Without a legislative or local government structure to deliver environmental health, Rwanda is adapting the British model. Food safety in major cities, for example, is delivered through local government, and in rural areas environmental health is based in hospitals and with NGOs.

Teresa’s first task was to study the Rwandan legislation and apply it to environmental health. “Unlike Uganda, Tanzania and Kenya, where the legislation is similar to ours, in Rwanda the legislation looks like a directive. It contained good principles, like the polluter pays, but parts of it are unenforceable. We would discuss what the legislations contain and how the students would apply it.”

A lack of resources hinders teaching. With two copies of the legislation, no photocopier, few books and 50 first-year students, Teresa had to be innovative. Role-play, group discussions and going into the community to work through examples became staple teaching techniques.

Language barrier

Role-play was also used to get over what is a curious language barrier. French was the colonial and Kinyarwada the local language. However, during the 1994 genocide many refugees fled to neighbouring Kenya, Tanzania and Uganda and returned after the civil war speaking English. Last year English became Rwanda's first language. Government work and teaching in schools and universities is all now in English.

“The problem is we speak with an English accent, while they are used to English with a French accent,” explains Teresa. “We could tell they were not understanding us, so we also had to split them into groups of linguistic ability.”

This move to English is seen as part of a broader political desire for Rwanda to ally itself to East Africa rather than the French-speaking former colonies. Teresa studied the Ugandan environmental health law in anticipation of Rwanda at some later date adopting parts of it.

In February President Paul Kagame invited former British PM Tony Blair to advise on government co-ordination and the use of think tanks in forming policy, further distancing Rwanda from its former rulers. Two weeks ago Rwanda also joined the Commonwealth.

Passion to learn

Overcoming language and resourcing problems is relatively easy when students have a passion to learn. “They are very keen, they arrive in class an hour before we start, they want to do homework and if you run extra classes at the weekends they are packed,” says Teresa. “It is inspirational how dedicated the Rwandan students are for themselves, their families and their country.”

This sense of national pride appears throughout Rwandan society. It has also been key, Teresa believes, to helping the nation deal with the aftermath of one of Africa’s most bloodthirsty civil wars. A tribal conflict that erupted between the Hutus and Tutsis in 1994 when neighbour slaughtered neighbour resulting in the death of more than 800,000 Rwandans.

Teresa and Steve noticed that, unlike other African states, people describe themselves as Rwandan and not by their tribes. “They never say what tribe they are from and we would avoid asking,” says Teresa. “Everyone says they are Rwandan and for the people, the civil war is history. The president is so positive about working a way out from the past as a country that the people we taught remembered the civil war in a remembrance sort of way but they have moved on and want to get better as a country.”

Tragically, HIV Aids may be helping in this process. With life expectancy at only 46 in Rwanda, the 14 years since the atrocities is practically a generation ago. The government has set up community courts known as gacaca to try more than 100,000 suspects from the genocide war. Local people come to watch the pre-colonial form of justice run by panels of “people judges”.

“There would be certain days when you noticed that the town was not busy and you realised there was a people’s court. This would be their chance to deal with it, an outlet that is ringfenced,” says Teresa.

Teresa and Steve have now left the Kigali Health Institute, having handed over both the law course and health and safety module to Rwandans to teach.

They say Rwanda was a life changing experience. “If you are thinking of doing something like this, then do it,” says Teresa. “It is open to everyone and because of the way the course is structured, you can go for a few weeks or a few months. They will welcome your skills.”

If you with to support the Kigali Health Institute contact Sarah Johns, email sarah.johns@pembrokeshire.gov.uk. To join the CIEH international SIG email membership@cieh.org