Rainclouds, reflection and role play: a report from Rwanda

The first of seven countries set to participate in a second phase of UNHCR project Caring for Refugees with Non-Communicable Diseases, a PCI team has just returned from Rwanda. Our purpose was to help medical staff who work with refugees from neighbouring Burundi and Congo in seven camps dotted around the country improve the care they provide for patients with chronic conditions like diabetes, high blood pressure and asthma. Visits to at least some of these camps are essential for helping us to imagine the working lives of the doctors and nurses we will train. Rural Rwanda is a far cry from Kigali, which gleams with handsome houses, expensive hotels and the headquarters of countless international organisations. To reach the camps we travelled for several hours along roads that wound through steep hills and intersecting valleys, under rain clouds that burst over intricate terraces supporting crops of maize, sorghum, bananas and beans.

The Burundian refugee camp has sprung up rapidly in a noticeably poor area of Rwanda, near villages of barefoot, ragged children where over-burdened women hack a living from the red soil. Usually the UNHCR responds to a refugee emergency by providing temporary shelters, but in the last three years the Rwandan government has banned plastic bags and sheeting. This has made it impossible to use tents and has forced the organisation to build semi-permanent houses for the 55,000 people that have fled Burundi over the last two years. From a distance the clusters of mud houses with tin roofs look almost like a picturesque town, but the dwellings are constructed above a swamp that marks the border with Tanzania and provides a perfect breeding ground for malarial mosquitoes. As a result, more than two thirds of the camp’s population had malaria last May and June. We try to keep this fact in mind as we meet the small medical team that staffs the health centre and while they show us around.

Two days later we visit one of the camps established over twenty years ago for Congolese refugees. This camp is not picturesque at all, despite the army of smiling, curious children who seize our hands and demand to know our names the minute we step down from the outrageously comfortable and secure UNHCR Land Cruiser in which we have arrived. Rain is thundering down, eroding the gullies between the crude huts, relentlessly dissolving inadequate shelters into a mess of liquid mud. There is only one doctor here and he has given up trying to live in the town at the bottom of the hill below the camp, preferring to travel three hours to and from the health centre every day. When he is on leave or absent for any reason, the nurses cope by themselves. The nearest referral hospital is a treacherous 45 minute journey away, down a steep hill.

Each time we start a training course we are apprehensive and wonder how we will be able to connect with clinical staff who live and work in circumstances that are so very different from our own. Understandably, it takes doctors and nurses some time to open up and engage. During the breaks and over lunch we try to draw them out, listening hard to what they have to say about their families and the challenges they face at work. We respond to what we learn by making changes to the programme and the teaching methods. On the third day we rather nervously invite the participants to practice communication skills through role playing scenarios that we have tried to make as realistic as possible. None of them has ever experienced role play before. To our astonishment they take to this with gusto, and the atmosphere of the course is suddenly transformed. One of the doctors tries to explain that when he played the role of patient he realised for the first time that patients might not think the same way as their clinicians about their illnesses.

After this we do not look back, and the course sails to an end with lots of laughter and learning. We finish with group photographs and the establishment of a WhatsApp group so that we can all stay in touch. In addition to this, a new monitoring and evaluation framework will help us all to track project progress and share learning across the different African settings that will form part of this programme over the coming three years.