Virtual
War Memorial
Australia

A CHRISTMAS VACATION IN RWANDA

Dr Robert Black AM

In the early 1990s few in Australia would have known much about the tiny African State of Rwanda. But by 1994 most had read and learnt about one of the most brutal civil wars and genocidal atrocities ever committed, between rival tribes the Tutsis and the majority Hutus, in Rwanda.

Together with its neighbour Burundi, Rwanda occupies about the same surface area of our planet as Tasmania. The two countries possess a similar tribal mix but their citizens speak different official languages. They had been colonised later than most parts of Africa by Europe’s latest coloniser, Germany, in 1899. Both became part of German East Africa until World War 1, during which Rwanda was occupied by Belgium, and following which Belgium retained it as a UN Trust Territory.

With political changes in Belgium and the abolition of its monarchy in 1961 Rwanda gained its independence in 1962. But in the power vacuum created by Belgium’s withdrawal the majority Hutus asserted themselves. Thousands of Tutsis were murdered, and hundreds of thousands were displaced into neighbouring countries, particularly Uganda and Burundi. In 1990 the Rwanda Patriotic Front (RPF, later the Rwanda Patriotic Army, RPA) of displaced Tutsis invaded from the north attempting to overthrow the Hutu Government. During this civil war many fled into neighbouring countries as refugees. The Hutu Presidents of Burundi and Rwanda were both killed in April 1994 when a helicopter was brought down by a rocket propelled grenade. This was the trigger for the escalation of intertribal violence and genocide. Well over half a million were killed, predominantly by that weapon of mass destruction, the machete wielding human arm.

A 1993 UN assistance mission in Rwanda (UNAMIR I) had failed catastrophically with the murder and mutilation of Belgian Peacekeepers. Its successor UNAMIR II, after suppression by French troops, was formed in mid-1994. Australia’s contribution, Operation TAMAR, was to provide a Medical Support Force, including infantry protection and a surgical element. The majority of the several thousand Peacekeepers would be provided by Infantry Battalions or Companies, mostly from African nations. Its overall Commander was from Canada which also supplied specialist teams. From Australia two contingents of full-time tri-service ADF members were to be deployed for six months each. The surgical team specialists, almost all Reservists, would remain in country for six-week rotations, after a week of pre-deployment training and briefing at Randwick Barracks.

 I was privileged to join, at Randwick on the 17th of December 1994, a team of four with superlative skills and experience of my three colleagues. David Lewis, Townsville Orthopaedic Surgeon, had been a National Serviceman in Vietnam. John Pearn, then Professor of Child Health in the University of Queensland, adopted the role of intensivist as well as Consultant Physician, Paediatrician and negotiator/visitor to local NGOs and charities. He had spent time in Vietnam as a Physician. Both were then Army Colonels. Unsurprisingly John later became our first Reserve Surgeon General. The fourth member was David Griffiths, Naval Lieutenant Commander, of Hobart. He had all the anaesthetist’s multiple skills and attributes, could fix or mend anything, and provided an extra clinical opinion when needed.

We arrived in Nairobi on Christmas Day after journeying from Sydney via Perth and Johannesburg, did our tourist bit to places of interest, guided by David G, in Kenya and later boarded a Spanish Military aircraft, a Casa. My time in Rwanda was a busy one with clinical work each day and operating on most with the skill, charm, experience and ready willingness of two superb Army theatre nurses, Major Ros Bell and Captain Peta Durant and of equally willing Army medics. I also visited, some distance away, Cyanika, one of the UN tented camps for displaced persons, DPs, predominantly Hutus. It was at a DP camp like Cyanika at which there was a fatal shoot out during our tour. At another the Kibeho massacre occurred six months later. We were able to visit the UN Headquarters and the Australian Medical Support Force HQ on most weeks, and the Australian Support Force barracks on many occasions. Weekly clinical meetings were arranged that included medical Officers from all involved nations.

I had some memorable and satisfying experiences helping to treat some of the countless victims of war. We met many local Rwandan citizens. A few were most able and helpful interpreters. Every person we treated had lost family members, many were sole survivors. A few were still at grave risk, as they would become important witnesses to the genocide that would later be tried in the International Courts prosecuting war crimes.

In a century old Encyclopaedia I had seen a map of Africa in which Rwanda and Burundi were shaded to show that they were in parts of Africa “least suitable for European colonisation”! Why might they have been so described? Well, our “Soldiers’ Handbook” informed us of many venomous snakes including the Cobra, Puff Adder and Green Mamba. For locals historically there had also been the risk of water-borne diseases of dysentery and giardiasis, of diphtheria and tetanus, typhoid, malaria, sleeping sickness, interesting conditions like Leishmaniasis and Schistosomiasis and most recently the risk of HIV/AIDS, with among the world’s highest incidence. Moreover, playful monkeys, and we encountered some, might bite and give you rabies. However, I felt no real risk within the Australian Medical Support Force.

In Rwanda there was, of course, a risk that the cessation of hostilities might cease and that the local military RPA and Government Forces would discontinue their co-operation. The RPA barracks were across the road from the hospital. They would be heard early every morning, running and singing merrily as a platoon. I needed no alarm clock. 

Regrettably a much greater lingering danger for local people resulting from war was the presence of anti-personnel land mines. They are small, often made of plastic, and look interesting to children. Dealing with shattered limbs, amputating legs of children, is not a most satisfying task. Nor is it one that would appear often on a general surgeon’s list in Australia. But it had to be done. There were other procedures that I would not normally tackle at home but were needed in Rwanda.

The need for surgical services was immense. Yet the defined task for Operation TAMAR was to provide medical services to the UN Peacekeepers. That could be achieved before breakfast. There were some medical problems among UN troops: respiratory infections, injuries, TB and AIDS, and reactions to the anti-malarial Mefloquine, among them. But accepting the challenge to cross into the Kigali General Hospital, staffed by US volunteer surgeons working for the charity “Samaritan’s Purse”, and treat the population of Rwanda was too obvious to resist. A few of the full-time serving members felt that this mission creep was too demanding. It created a potential for tension that needed to be carefully managed. My specialist colleagues were not officiously demanding. We did not seem to experience any resistance.

This “mission creep” involved members of the Australian Medical Force co-operating with potentially overwhelmed volunteers where possible, moving patients from one hospital to operate at another, doing outpatient clinics, sharing ward rounds and joining forces at times of extreme urgency and in major incidents. On one day mine detonations resulted in multiple casualties including children. The principles of triage would then be employed, selecting those likely to benefit from time consuming treatment and putting aside those less likely to survive, or not requiring immediate attention. Even so it was heartbreaking to spend time on a severely injured child then see that all was in vain for lack of ongoing care in the general hospital ward.

One ward in the Kigali General Hospital, in which the local citizens were meant to be treated had a prominent sign outside indicating that it was the surgical ward. Literally translated, however, it read “House of butchery”.  The orthopaedic ward housed many patients with chronic osteomyelitis of limbs, the result of untreated compound fractures from gunshot wounds. This condition is rarely seen in Western countries. It would lead to years of suffering and ultimate invalidity. Amputation would lead to a quicker preferable outcome but could hardly be recommended in a country with such limited future support for the disabled.

The list of cases and interesting problems that this general surgeon felt the need to tackle in a land with few doctors. Amputations might normally be performed by vascular or orthopaedic surgeons. Excision of a 39kg tumour in a pregnant woman was almost a general surgical operation. The pregnancy continued. My very first operation in Rwanda, on day one, was a plastic surgical procedure to put skin grafts onto the injured thigh of a 2-year-old boy whose mother had died in the blast that injured him. He was carried to theatre by his 9-year-old sister who wore her late mother’s shoes. She remained with her little brother throughout his long admission and would, metaphorically, walk in her mother’s shoes for some time thereafter. As it transpired skin grafting was the commonest procedure that I performed in Rwanda.

My last two operations in Rwanda were for UN Peacekeepers, our primary “clients”. I repaired a hernia and, dealt with an anal condition on my last day. There had been other UN soldiers requiring my service: two required laparotomies after trauma, another an appendicectomy and others needed treatment of various other injuries. Rwanda was not immune from civilian type injuries including those from the many vehicular accidents. My surgical services, however, had mainly been for Rwandans, assisting in the management of countless sufferers, too great a task to be left for the wonderful volunteers in Samaritans’ Purse and a few returned local medical staff.

We returned to Australia via a tourist experience in Zimbabwe, visiting the Victoria Falls and having a surprisingly inexpensive drink in the nearby, grandly appointed, Victoria Falls Hotel looking over the Zambesi River and bungee jumping from the bridge to Zambia. Our journey together ended in Sydney, whence we went our separate ways. I had the good fortune to work with three skilful, caring, well qualified and highly esteemed colleagues. Together we had dealt successfully with some very satisfying medical challenges. We had shared the grief and disappointment of failures. We had witnessed the stoicism and heroism of people determined to lead more satisfying and safer lives despite unimaginable personal and family losses. They would be provided few services to help them overcome their posttraumatic stress. Nor would they be compensated for the resulting mental health disorder.

Yet those experiences were so harrowing to many young Australian service men and women that their mental health has suffered. Witnessing shocking injuries in children, who might have been of their own children’s age, or seeing apparently unpreventable deaths on a frequent basis, cannot be easily assimilated. Surgeons may, perhaps, be used to seeing, even causing, pain and suffering. It may have been hard to live with on return; but it had never previously been easy!

On reflection it seemed that the Australian Medical Support Force had done well, and that Rwanda might gain, from that support, a brighter future. It is difficult to know. News of the country is seldom seen in our media, as had been the case in 1990. A multi-national UN convention, banning anti-personnel mines, came into being two decades ago and I believe that this scourge has been eliminated, or almost so, in Rwanda.

A more peaceful Rwanda became a mecca for British bird watchers some years ago. I had watched, through binoculars from my glassless window, pied crows that resembled our magpies and recorded seeing several others that were new to me. A new heron, a red bishop, - or was it a cardinal?- and a yellow-bellied sunbird were all spotted one day, and a so-called flower pecker on another.

In recent days we have seen cheerful athletes, Tutsi and Hutu, marching together as a team at the Olympic Games in Tokyo, under the banner of Rwanda. Another team has been identified from Burundi. They each seemed united in competing for their separate nations. I hope that impressions do not deceive me.

Robert Black AM RFD MD MS FRACS FAMA.

July 2021.