EHJ July 2004, pages 212-214
Ten years ago, one million Rwandans perished in the worst genocide since the Second World War. Stewart Petrie reports on how the CIEH Welsh centre is helping this traumatised country to recover from its recent history

The mere mention of Rwanda conjures images of bloody massacre, of genocide, of holocaust. Some may think of Dian Fossey and Gorillas in the mist. But most just think of a country, where, in a few terrible months in 1994, up to 1 million people were slaughtered by their neighbours, not with guns or gas, but with farm tools.

So it is not surprising that the mere suggestion that anyone should want to visit Rwanda is met with disbelief, quickly followed by questions as to their state of mind. But that is what Rowan Hughes, principal EHO with Vale of Glamorgan Council has just done. He undertook the trip on behalf of CIEH Cymru Wales with the objective of cementing a twinning agreement with Rwandan environmental health colleagues.

Rwanda, a land-locked country in central Africa, known as the "land of a thousand hills", is staggeringly beautiful. With five volcanoes, 23 Lakes and many rivers it lies 1,270km west of the Indian Ocean and 2,000km east of the Atlantic, at the very heart of Africa. This most densely populated of the African states has no rail link. Its crops are exported via road to the east through Uganda or Zambia putting Rwanda's tea and coffee growers at a considerable competitive disadvantage, forced to pay high transport costs.

The horrifying events of 10 years ago are rooted in an ethnic division which goes back 500 years. Rwanda has a rich African history, passed down from generation to generation. This oral tradition tells of the Kingdoms of Rwanda, where as early as the 15th century there is evidence of a division between Hutus (correctly the Bahutu) and Tutsis (Batutsi), a division which was to have such bloody consequences. Rwanda was closed to foreigners until the 1890s - even Stanley was forced to retreat.

It's a country with a chequered colonial past. Assigned to Germany as part of German East Africa in 1885, despite no German ever having been there, it was then invaded by Belgium in 1916. The Belgians held the territory until the end of the First World War and were entrusted with its administration. Rwanda is one of the few sub-Saharan African states never involved in slavery.

Not to mention the genocide would be to ignore Rwanda's recent history, and a major factor in the development of environmental health. The events leading to the butchering of so many Tutsis by their Hutu neighbours began in earnest as early as 1959, when thousands of Tutsis fled to Uganda, Zambia, Tanzania, Kenya and the Congo. The slaughter of 1 million Rwandans started on April 6, 10 years ago, and was the culmination of the systematic killing of Tutsis over decades. A third tribal grouping, the pigmy Twa (Batwa), arguably suffered even more than the Tutsis, losing a third of their number. The international community failed in its duty to help these people.

Eventually, the Rwandan Patriotic Front took power after fighting its way south from Uganda. With an English speaking president and the return of up to a million exiles, largely from the north and the east, came a huge change in the Rwanda's attitude to its own position in Africa. English was added to French and Kinyarwanda as the official languages. The largely Anglophone returnees continue to look to the east and the north, to Uganda, Kenya, and Tanzania. And it is in these relationships that the growth of environmental health in Rwanda is rooted. Rwanda is being influenced by its English speaking neighbours, all of whom have a tradition of environmental health and understand its importance.

So this is the setting into which Mr Hughes, accompanied by myself, Stewart Petrie, one of the founders of the charity Water for Kids, arrived last month. Our journey had started over a year previously, in May 2003, at a Welsh centre weekend school. During the weekend, delegates were given a challenge: "As friends of the human race, look beyond the borders of your local authority, beyond the borders of Wales, and lend assistance to colleagues in a developing country."

When EHPs heard that Rwanda was looking for assistance and that the Welsh centre should consider providing that help, there was a mixed reaction. But after the stunned silence, delegates warmed to the idea.

The first task for Mr Hughes and his colleagues was to work with the Rwandans to lay the foundations of a professional association. Here help was sought from outside Wales. Barrie Whitehead from the north west centre and Peter Minhinnet from the east midlands centre were recruited at the CIEH conference in Belfast, providing the project with time and expertise. Colleagues in Zambia and Tanzania also helped, in particular Dennis Mazali, an environmental health lecturer at the Muhimbili University in Dar es Salaam. Martin Fitzpatrick's book the Development of professional associations was much thumbed in both Wales and Rwanda.

E-mails flowed between Wales and Africa. Finally, a year later, on May 5, Mr Hughes and myself boarded a plane for the 20-hour journey to Kigali, via Amsterdam, Nairobi and Bujumbura in Burundi.

Within an hour of landing at Kigali Airport we met Theresa Bishagara, director of Kigali Health Institute (KHI). This is a 9,000 student tertiary institute, providing education for supplementary professions to medicine. It is the staff from KHI who have been at the forefront of forming a professional association for EHPs.

It is at the lakeside campus of KHI at Kivu Lake that students study for the advanced diploma in environmental health with the first 34 students expected to qualify next June. The college is looking for help to develop their syllabus into a BSc degree, which is now underway, as we could draw on experience gained in Tanzania and Zambia.

The next morning began with a drive west, to Kibuyu on the shores of Lake Kivu. This two-hour drive along good roads revealed the stunning beauty of the country. But it also provided us with a grim reminder of Rwanda's recent history as we passed memorials to those slaughtered in 1994.

Lake Kivu could be mistaken for the Austrian or Italian lakes. Outstandingly beautiful, and happily crocodile-free, Kivu shows the beginning of an embryonic internal tourist industry. Swimming, water-skiing, boating and high-class accommodation are already attracting weekend visitors from the capital. No doubt in years to come, international visitors will recover here after an encounter with the gorillas.

At this beautiful lake-side campus we met the course lecturers Laurent Iyikirenga, head of environmental health sciences and a returnee from the Congo, Dr Kato Njunwa, a Tanzanian, and Zachary Bigirimana, a Ugandan, along with students and the campus administrator.

By the side of Lake Kivu we put the finishing touches to the constitution and the Rwandan Association for Environmental Health (Rwaeh) was born. This new professional body was heralded into the world by a tropical storm which lit up the lake allowing us to glimpse the neighbouring Congo, a country still being torn apart by internal strife. It is estimated that in addition to the 1 million who died in Rwanda, up to 5 million more perished in the Congo and in Burundi.

The following week, we visited the rural hinterland. Communities where the nearest bus is a six-hour walk away. Even such remote areas were touched by the genocide. Widows and orphans are being encouraged to stay on the farms through imaginative projects, such as the production of essential oils from geranium farming.

Genocide memorials are everywhere. At one memorial, the guide is a lady who survived a massacre in her church where 5,000 people took sanctuary and locked themselves in. Hand grenades were used to gain access and the people were slaughtered over six hours. To be the first is unthinkable, to be the last unimaginable, and to survive the murder of friends and family because you were shielded by their dying bodies is beyond all comprehension. The bones and belongings of these poor souls lie largely where they fell. A skull still rests on the blood-stained alter. A few of the pews, rough planks on concrete blocks, have been cleared and the skulls arranged in a macabre display. All bear the signs of attack. Some have machete cuts, some still have the spikes used in the slaughter. Some are still in the headscarves which allowed identification of the bodies.

NGOs have set up communities to look after the widows and orphans of both the genocide and the growing HIV/Aids problem. A cursory inspection of these facilities reveals a desperate need for EHP involvement at every stage, including the planning, construction and running of these refuges.

Schools have no books and children are forced to grow up too quickly. We meet a 13-year-old who is now mother to her six-year-old sister, having lost her father in the genocide and her mother to Aids. She now faces nursing her sister as she watches her die from Aids. Drugs are many miles away and far too expensive. Rwanda is a country of stolen childhoods.

General provision of water and sanitation is poor. Within feet of the impressive hospital in the capital, children are gathering foul and stinking water for their families. Malaria prevention is generally non-existent. Bed nets are seldom used, window nets rarely seen and mosquito breeding sites abound.

But it is all too easy to feel a sense of hopelessness when confronted with such tragedies. Rwanda is a beautiful country suffering many problems. But with the formation of the Rwaeh there lies hope. It already has a growing membership of professionals dedicated to address these problems and the new degree course at KHI will start to redress the shortage of practitioners.

The twinning between the CIEH Cymru-Wales Centre with the Rwaeh, along with Welsh sponsorship of the new professional body's membership of the International Federation of Environmental Health, now provides a link between colleagues in Wales, Africa and around the world. Links that will grow as the twinning matures and develops.

Our trip was rounded off with meetings with the head of the Department for International Development at the British Council, with the British ambassador providing positive support, and decent tea. Our 10-day trip was at an end. New friendships had been forged, new plans made and we learnt that despite its turbulent past, Rwanda is a country that feels it has a positive future. Colleagues from Wales will be in Rwanda in June 2005 to celebrate with the first 34 students as they receive their advanced diplomas.

If you wish to become an overseas member of Rwaeh (£10) and support the CIEH Cymru-Wales Centre twinning with Rwaeh or learn more about the initiative in Rwanda or the celebrations, please contact Rowan Hughes, rowanhughes@onetel.com