Muraho from the people of Rwanda. The ACEP President-Elect, Dr. David Seaberg, led an ACEP People to People Citizen Ambassador delegation on a medical exchange to Rwanda from August 12 through 20.

The delegation consisted of 10 emergency physicians and spouses that included an emergency nurse, a pediatrician, and a social worker. The delegation toured numerous medical facilities around the country and delivered presentations on emergency medicine and trauma care at the main teaching hospital in Kigali (the capital) and the district hospital in Gisenyi. Rwanda is in the process of rebuilding its medical system after the 1994 genocide and is seeking advice in the areas of emergency medicine, trauma system development, and EMS.

It is impossible to consider any aspect of health care in Rwanda without some understanding of the 1994 genocide, how its impact lingers on in the population, and the effects of the measures being taken to reconcile the population.

For decades leading up to 1994, the minority Tutsi population (and moderate Hutus) were progressively demonized as scapegoats for the country’s poverty by the military dictatorship of Hutu General Juvènal Habyarimana. As with the Holocaust, this marginalized group of citizens chose to put their faith in the government to protect them rather than arming themselves, and again as with the Holocaust, it was the government itself that was orchestrating the genocide behind the scenes.

Beginning within minutes of General Habyarimana’s plane being shot down over the Kigali airport on April 6, 1994 (in all likelihood by radical elements in his own party), and continuing for the next 100 days, 1 million people were tortured, raped, and shot, clubbed, or hacked to death with machetes.

Rwanda’s current president, Paul Kagame, a Tutsi, and his expatriate Tutsi “rebel” army ended the genocide by defeating Habyarimana’s military forces and Hutu Interhamwe militias 100 days after it began. Having just won a second 7-year term, he is in the process of creating a balanced government with representation from Tutsi, Hutu, and Batwa, and the country is hard at work putting the genocide behind it by seeking a full understanding of why it happened.

Ironically, the Tutsi-Hutu division was an artificial distinction created by the Belgians for their own colonial control purposes. The old ethnic tribes of the early 1800s had blended inextricably before the Germans colonized the country in the early 1900s, and the Belgians assumed control as part of German reparations after the First World War. The Belgians issued identity cards that designated anyone with 10 or more cattle as a Tutsi and the rest as Hutu, believing the more successful minority “Tutsi” would make better colonial managers, and it was this identity division that enabled the demonization to occur.

The old Belgian identity card system is gone today, and people no longer speak of Tutsi or Hutu but of Rwandans. There are numerous memorials throughout the country and regular meetings between perpetrators and survivors with the goals of apology and forgiveness. Genocidaire trials continue in gacaca (traditional village-based) courts, but they are increasingly rare with the genocide now 17 years in the past. Throughout the entire process of bringing nearly 1 million genocidaires to justice, voluntary and preemptive admission of guilt has been met with leniency in the name of societal healing.

Rwanda had been a French-speaking country (in addition to the indigenous Kinyarwanda language) from the time the Belgians assumed control of the colony. Habyarimana curried favor with the French as well, and France was proud to count Rwanda among the Francophone countries – that group of countries that speak French as their primary language. But France supported the Habyarimana regime despite knowing of the genocide, so today the old French signs are coming down and signs in English, now the official language, are going up.

The United States also failed to help Rwanda despite knowing of the genocide. On then-President Bill Clinton’s orders, Madeline Albright vetoed the United Nations order that would have sent 5,500 U.N. troops to stop the genocide. Mr. Clinton has since formally apologized to Rwanda, and his foundation is playing an active role in rebuilding the country.

With English becoming the official language, all communication in the country is in transition and getting along in Rwanda requires a bit of French, Kinyarwanda, and English. But with English now the official language, there is a excellent opportunity for organizations like ACEP to make a difference in helping the local physicians develop emergency department standards and a trauma and EMS system.

Based on our 8 days of meetings with medical personnel around the country, it is clear that they have much of the knowledge they need but have critical deficiencies in training, equipment, and supplies, in addition to the challenge of dealing with a slow-moving and semi-impoverished government bureaucracy.

Our delegation left behind our presentations, reference books, interactive CDs, and EM protocols – as well as money, several dozen soccer balls, 40 stethoscopes, two otoscopes, two dozen sheets and blankets, and the clothes off the backs of some delegates who perceived the Rwandans’ needs to be greater than their own. But it will take much more to make a sustainable impact.

The main Kigali teaching hospital handles 30,000 visits in two rooms and regularly runs out of disposables and critical medications. The ICU has six monitors for 70 beds. X-ray and CT are available but often out of service due to breakdowns, and there is no MRI. Of perhaps greater import is a culture of mostly learned resignation. The physicians for the most part know what should be done, but after years of confronting overwhelming demand and insufficient resources, they have become resigned to these conditions and lack confidence in the possibility of change.

On the positive side, 92% of the population has health insurance. Even the poorest Rwandans purchase the $7 per year government insurance plan – both to demonstrate their civic commitment and because farmers (90% of the population) are denied access to improved seed stock if they don’t buy the health insurance.

Civic commitment is encouraged in other ways, as well. The last Saturday morning of every month is Community Service Morning, and every family is expected to send one person to work on neighborhood improvement or clean-up projects from 7:30 a.m. to 10:30 a.m., followed by a neighborhood-wide meeting to discuss neighborhood problems. Those who fail to participate must pay a fine.

So while there are many things we can teach Rwanda, Rwanda has some things it could teach us as well.

“Our People to People delegation to Rwanda was fantastic in terms of the cultural, medical, and social experiences we encountered,” Dr. Seaberg said. “We learned a great deal about the Rwandan people, and we hope to continue our mission of helping establish emergency medicine in Rwanda.”

If you haven’t done so in a day or two, take a minute and count your blessings. A few days spent in East Africa brings into stark relief how incredibly fortunate we are despite our problems, which are in fact relatively minor when viewed from the Rwandan perspective. Our delegation’s hope is that they will say of us Yaámpaaye inká! – “He (or they) gave me a cow,” meaning that we will remain friends forever.