A steady broadcast of wars, massacre and death over the years has made many immune to human suffering. But the genocide in Rwanda more than a decade ago was so staggering the impact is still being felt. The brutal slaughter of 1 million inhabitants within a short period of 3 months defies imagination.

It was in April 1994 when news began to filter out to the world that this small, land-locked country in central Africa was convulsed with mindless violence. The healthcare infrastructure had been in neglect before the tragedy but with a large number of nurses, including midwives who were the mainstay of healthcare in the country, among the victims of this orchestrated killing, the country continues to be in urgent need of healthcare providers.

A nursing program in Kigali Health Institute in Rwanda, which offers both bachelor and diploma nursing programs, is set to meet the demand for new nurses. It came as a great privilege when the Kigali nursing faculty accepted me as a volunteer for 2 weeks in September 2010.

Great Need

According to the Ministry of Health of Rwanda, its population of 9.3 million is essentially young, with 67 percent of the people younger than 20 years. Its ratio of doctors-to-people is 1-per-18,000 and the nurse ratio is 1-per-1,690.

The infant mortality is 62 per 1,000 births; and for children younger than 5 years old, the mortality rate is 103 per 1,000. Malaria claimed many young lives and lack of access to trained health personnel resulted in a maternal mortality rate of 750 deaths either during delivery or shortly thereafter of every 100,000 pregnant women.

Following the genocide, an increase in mental illness cases has been observed, creating a need for psychiatric nurses. It was extremely poignant to be told by the students I taught of their experiences, which explains why the country experienced an increase in mental health issues: murder of family members, young children witnessing rape and slaughter, and displacement. The state psychiatric hospital has crisis units, recovery and rehabilitation centers and interdisciplinary treatment to address the country's mental health needs.

The lifespan of an average Rwandan is 52-53 years, according to health ministry statistics. There is considerable pressure on the nursing faculty to widen the base of knowledge of students in preventive care. The majority of the population lives in rural areas leading a subsistence life. Therefore, prevention practices to combat malaria, alcohol and tobacco use, tuberculosis, typhoid, hepatitis and HIV are paramount. The nurses' and midwives' role is vital in pre- and post-natal care, childhood vaccinations and nutrition to reduce mortality.

Educating New Nurses

The Kigali Health Institute was established June 1996. The University of Western Toronto, nursing faculty and volunteer nurses from Belgium and Australia assisted in developing the curriculum according to North American Nursing Diagnosis Association standards, which promote the use of nursing diagnoses in all branches of the nursing field, including practice, administration and education. Initially, nursing faculty were recruited from neighboring countries of Zimbabwe and Uganda. Gradually, nurses graduating from the Kigali program were sent to South Africa for graduate studies and returned to join the faculty.

My involvement with Kigali began during a trip to Tanzania where a Rwandan physician encouraged me to volunteer to teach in their nursing school. She assisted in establishing communication with the head of nursing who requested me to forward my credentials. Once the board of nursing approved, I discussed what they would expect of me and what their needs were. The head of nursing expressed that textbooks on med/surg, midwifery and mental health nursing would be welcomed. She also requested I teach psychiatric nursing and analytical writing of care plans. I also compiled a manual of communicable and chronic diseases particular to Africa.

I spent my first week at the state psychiatric hospital where students were doing their clinical rotation. Almost 44 students from both the bachelors and diploma programs attended my workshops. The first generation antipsychotic medications Haldol and Thorazine were the common drugs prescribed. I made great emphasis on patient interview for a good care plan, and thorough understanding of pharmacology so students were familiar with classification, side effects and patient/family teaching. Each student received a certificate and a manual at the end of the workshop. 

During the second week I was requested to update the knowledge of fourth-year students on heart disease including CPR, skin disorders and wound care. I also gave a public health lecture on stress, anxiety and its effect on daily life.

The government of Rwanda marked World Mental Healthy Day in October 2010, raising awareness of mental health issues and the importance of seeking appropriate, timely care. The nursing faculty at Kigali Health Institute gave me an opportunity to widen the body of knowledge of psychiatric nursing for their nursing students. 

Mala Kadar is nursing supervisor, Center for Comprehensive Health Practice, New York, NY.