Refugees Magazine, 1 June 1995
An ambitious reproductive health programme for Rwandese refugees in Tanzania targets everything from safer childbirth to the prevention of sexually transmitted diseases.
By Heather Courtney
International Rescue Committee, Tanzania
Food, shelter, latrines, clean water, and medicine are all essential services at any refugee camp. For Lumasi, a Rwandese refugee camp in Tanzania, add reproductive health care to the list.
The International Rescue Committee's reproductive health programme in Lumasi marks the first time that UNHCR, with IRC as its implementing partner, has introduced such an extensive reproductive health programme, separate from other health services, into a refugee camp so early. Usually, most reproductive health services are incorporated into general health services after the emergency phase has ended.
"Family planning, STD [sexually transmitted diseases] and AIDS education and services are usually low on the health totem pole in refugee camp settings," said Ruth Strasser, IRC's medical coordinator in Tanzania.
Perhaps even more unusually, the refugees themselves were the main catalyst behind the introduction of the reproductive health services in Lumasi.
"Before the IRC reproductive health programme started, I was asking, and so were many other refugees, when is the family planning programme going to start? Because, to us, it just seemed natural to have these services available," said Verena, a 31 year-old Rwandese midwife who works in IRC's maternity/antenatal clinic. Rwanda had a fairly extensive family planning programme, called ONAPO.
Verena, who asked that her last name not be used, says that she was working at a general health clinic in one of the Ngara camps, but joined IRC's programme as soon as she heard about it.
"We are refugees ... but our lives have continued, and in this way our need for family planning services is just a continuation of our family planning needs in Rwanda," said Verena.
IRC's reproductive health programme began with the training of 50 AIDS community educators (ACEs) and five ACE supervisors at the end of September. The first maternity/antenatal clinic opened in October. Since then, IRC has built two antenatal outreach clinics in Lumasi, and held over 30,000 individual and group consultations on AIDS, sexually transmitted diseases, and family planning issues. The clinical and educational components of IRC's reproductive health programme work hand-in-hand. The ACEs go out into the community providing information on AIDS, sexually transmitted diseases, contraception and child spacing, and at the same time refer certain cases to IRC's clinics. The clinics, in turn, offer confidential counselling and treatment in a less threatening environment than a general camp clinic, and in addition provide educational sessions, child immunization, and a supplementary food distribution to pregnant and lactating women.
"Before, if someone had a problem ... like an STD, they had to go to the general clinic, and wait in line a long time," explained Verena. "Then after waiting a long time, they were just quickly seen and no one ever noticed if they came back.
"Here, the time is taken to get the full story, explain the problem and treatment, and then provide good follow-up," she said.
Emilieu Ngerageze, 20, and Didace Nkulikiyumukiza, 29, two AIDS community educators, agree that it is important to have the right kind of forum to discuss these issues.
"The community knows who the ACEs are, and what their responsibility is, so people understand that everything they tell us (as ACEs) will be confidential," said Emilieu, who was a student in Rwanda before fleeing. "There is a certain trust there."
Didace agrees that having a programme like ACE makes it easier to get these issues out in the open, and easier for people to seek help.
"If a community member has a problem, it is easier for them to approach an ACE – someone they are familiar with," Didace explained. "In this way, ACEs are an important link to the whole community."
And both agreed that these issues need to be discussed, especially in a refugee camp setting.
"The way we live here in Lumasi is very different than in Rwanda," Didace explained. "Here we are very compact, very close together, so the problems of spreadable diseases, such as AIDS and STDs, are magnified," he said.
He cited the use of razor blades as an example. "Many men in the camps share razor blades for shaving, because there aren't very many to go around in the camps. When discussing how AIDS is transmitted, we have to remind people that sharing razor blades is one possible way of transmission, something that wouldn't normally be brought up in an AIDS education programme."
He added that in Rwanda, hospitals were easily accessible and many services were available, whereas in Lumasi there are fewer services, so it's important to tell people about preventive measures.
With prevention in mind, the ACE programme is branching out into the Lumasi schools. After receiving the go-ahead from teachers at Lumasi's 10 primary schools, IRC, in conjunction with UNESCO and the Norwegian People's Aid (NPA), planned to sponsor a three-day training seminar on AIDS education for primary school teachers at the end of April.
"It's important to make people aware that AIDS is an infectious disease that anyone can contract," said Brenda Clause, who runs the ACE programme. "Education is important, not only for students, but also for parents, families and teachers."
The training, which will include the introduction of an AIDS curriculum translated and adapted from the Tanzanian Ministry of Culture and Tanzanian Red Cross (TRC) curriculum, will cover 4th, 5th and 6th grade levels.
ACEs also discuss issues related to child spacing and contraception, topics that can be quite sensitive in the setting of a refugee camp.
"At first, the community asked many questions about family planning issues, because many wanted to have children to replace the children they had lost in Rwanda," Emilieu said.
Both Emilieu and Didace remarked that the potential food shortage, caused by serious funding shortfalls, had also sparked many discussions on pregnancy prevention.
Verena says that most people come to the clinic for contraception, although there are a few cases who come because they wish to have children.
"A woman came recently and asked to have her Norplant [an intra-uterine device] removed. With the war, they have lost their children and want to conceive again," she said.
Conception is the point where the traditional birth attendants enter into IRC's reproductive health programme.
Traditional birth attendants, or TBAs, make home visits to provide antenatal and postnatal care, and assist in deliveries in the home. It is estimated that roughly 80 percent of deliveries in Lumasi are in the home, with only first-time deliveries or complications being dealt with at the clinic.
Many of the TBAs already had experience in their communities in Rwanda. However, with many new challenges facing them in Lumasi, they have upgraded their skills through IRC's training programme.
"It is difficult in the camps," said TBA Eugenie Mukamazimpaka, 36. "We don't have the resources to offer them here, like food, clothing, blankets. In Rwanda, we had much more to give them."
Also, in Rwanda, everyone in the community knew their traditional birth attendants. If there was a problem, they knew where to find them. In the camps, the TBAs have to be much more proactive. Each day they go house-to-house, offering services and information to women, as well as providing counselling and referrals if necessary.
"The TBAs see things from a different angle," said Ruth Ketyenya, 39, a midwife who runs the TBA programme. "They understand more because they have a holistic view."
And holistic is what IRC's reproductive health programme tries to be, integrating general health education and preventive services with family planning, child spacing, antenatal/postnatal care, and sexually transmitted diseases and AIDS education and treatment. IRC's health information technicians (HITs), who provide health education to individuals and groups on a variety of public health issues, also have a role to play, referring certain cases to the clinic, or pointing AIDS community educators towards certain people in the community.
"[IRC's reproductive health services] fit in with the health programme in general," explains Didace. "Plus for me, when I was in Rwanda, I didn't know how to explain about STDs or AIDS. Now, I can tell my friends and family about these issues and it makes them healthier people."
Both Didace and Emilieu agreed that this type of programme should be continued in Rwanda.
"The same problems exist there," said Didace, "This programme should not end in Lumasi, and the good thing is, now we have the knowledge and skills to bring it back.
Source: Refugees Magazine Issue 101 (1995)