Legislation Drafting in Rwanda

The atrocities committed during the Rwandan genocide left lasting psychological scars on the majority of its survivors, making the drafting of its mental health legislation all the more poignant, says Laura Davidson.

In 2013 I was asked by the Rwandan government to draft the country’s first mental health legislation and to advise on its mental health policy. Consequently I took a sabbatical from my practice at the Bar and set off for East Africa.

Before beginning work, I visited old friends in Kenya where I had worked as a volunteer teacher for a year as a teenager. I then climbed Mt. Kilimanjaro to raise funds for the continuation of the John Grace QC Scholarship in schizophrenia. Many at the Bar will remember John with great fondness. Previously my head of chambers at 3 Serjeants’ Inn, John and I set up Mental Health Research UK in 2008 in order to fund research into the causes of mental illness with the aim of developing better treatments with fewer side-effects. John had a particular interest in schizophrenia research as a result of a family connection. Tragically, he died from a brain tumour in 2011, and we set up a PhD award in his memory. I’m relieved to be able to report that, despite appalling altitude sickness and a horrendous storm during which a guide was killed by lightning, somehow I made it to the summit of Kilimanjaro, Uhuru Peak. We have offered John’s scholarship for the last two years, and donations earmarked for it are still gratefully received (http://www.mhruk.org/make-a-donation/).

Background to the legislation

Thereafter, I travelled to Rwanda and was introduced to team members of the Mental Health Division of the Rwandan Ministry of Health. This tiny country is within people’s consciousness
due to the atrocities of 1994. April to June 2014 will be the 20th anniversary of the Rwandan genocide, and the wounds remain raw. Nearly 1 million people lost their lives. The volume of people slaughtered in the most cruel ways possible as they gathered together for protection – often in churches – is hard to take in. Noone living in the country at that time escaped the horror. The Rwandan government now runs a tightly controlled ship; perhaps not surprising, given that the country’s main radio station was used by the genocidaires to incite racial hatred and exhort the Hutu majority to slaughter the Tutsi minority, whom they dehumanised by labelling ‘cockroaches’. The barbarity of the massacres was beyond comprehension, with many genocide memorials bearing the evidence of bullet holes and blood on walls where the heads of babies were dashed, with vast piles of the bones and clothes of the dead remaining. For three months of terror, torture, rape and death by machete were the fruits of daily organised human hunts across the hills seeking every Tutsi in the country. To the shame of the international community, the genocide was not halted by the UN peace-keeping force present in the country (Kofi Annan and other key players refusing the pleas of General Romeo Dallaire for a mandate to disarm the drunken, slaughtering militia), but rather by current President Paul Kagame whose army of exiled Rwandese entered the country via Uganda.

Shortly after I arrived, I visited a young man’s home and he showed us his photo albums. Instead of smiling members of his family, the turning pages revealed the cleaning of his mother’s remains, her bones discovered only two years previously, and the funeral finally laying her to rest. Many children who survived the genocide lived for years in orphanages until the Red Cross had the foresight to begin posting photographs of the children across the country, whereupon, if they were lucky, a surviving parent might recognise them. I quickly learned never to ask about family – so very precious and extended in most other African nations. The existence of relatives in Rwanda can never be assumed.

The job in hand

As part of my situational analysis, I interviewed many of those working in relevant Ministries and NGOs about their views on new mental health legislation. It was essential for me to try to
understand the cultural context. I visited various hospitals and interviewed both staff members and patients. Although aid agencies and NGOs did their best to provide untrained lay counsellors to help the survivors, an enormous need for psychological support remains, even so many years on. Rwanda now trains its own psychologists, but the numbers remain entirely inadequate to deal with the extent of the post-traumatic stress disorder prevalent, not to mention other mental illnesses, many of which are likely to have been triggered by the events of 1994. Furthermore, the entire country has only six psychiatrists all of whom are in Kigali, only one psychiatric hospital (Ndera Neuropsychiatric Hospital), and no step-down facilities in the community.

Our own mental health legislation (the Mental Health Act 1983, as amended by the Mental Health Act 2007) is far from perfect, and I did not intend to use it as a blueprint. In any event, it became abundantly and swiftly clear to me that in many respects it would not ‘work’ in Rwanda. Whilst some common aspects were required to ensure compliance with international human rights standards, such as the right to regular review of compulsory detention and treatment and the need for independence of any review body, other provisions would be less appropriate. The commendable health insurance system which is cheap and compulsory for all (around £7 for an adult per annum, although unfortunately many people can still not afford it) does not cover travel to hospital or a pharmacy. Whilst the UK’s welfare system may not be perfect, a visit to a pharmacy will not be precluded, and medication is free where necessary. In Rwanda, where the majority of the population remain subsistence farmers, the £1 cost of public transport from the village to the nearest town is often prohibitive, and the alternative of a six hour one-way journey on foot by someone in fragile health completely unviable. Consequently, the prescription will not be collected, or the long-term psychological therapy prescribed will end prematurely.

The second part of my consultancy – the actual drafting of the legislation – was daunting to say the least, given my lack of experience in that department. However, I do have a PhD in mental health law and human rights from Cambridge and many years of practice at the Bar in healthcare law with a particular focus on mental health and capacity issues. In addition, I enjoy the precision in the drafting of orders. Drafting legislation was an extension of that precise process, and I found the process intellectually stimulating and thoroughly rewarding. I undertook four drafts, with input from the Mental Health Division after every stage, and incorporated feedback from key stakeholders following a seminar day. Once I became aware of the extent of the mental health issues and significant stigma attached to them, the resulting law was rather more expansive than I had anticipated. As WHO has stated, mental health legislation can be used as a framework for policy – a way in which to enhance rights in the future. Given that Rwanda had not had a mental health law previously – and thus there had never been a legislative basis for the detention of the mentally ill – this wonderful opportunity at its inception would allow the country to take massive strides towards high standards of healthcare, and to enhance human rights’ protection.

Reflections on the experience

There were significant differences in my daily routine compared to life at the Bar. My colleagues began work at 7am and finished officially at 5pm. For reasons I never fully understood, they never ate lunch. As a Consultant I did not have set hours, but tended to reach the office at around 8am via motorbike taxi, eat a packed lunch at my desk, and work until 7pm (sometimes later). My work-life balance may have been an improvement in Africa, with less frenetic deadlines, but I was still extremely busy. Kigali is a modern city; the President is extremely anti-corruption, and all government workers have a commendable work ethic.

However, I did find time on some weekends to enjoy visiting pockets of the small landlocked country. I made it to Akagera National Park, hiked in Volcanoes National Park where I had the
privilege of spotting a gorilla or two, and visited many lakes, including Lake Kivu which stretches down the western part of the country. Rwanda is known as ‘the land of a thousand hills’ for good reason, and the scenery, with its vast patchwork of steep terracing, is absolutely stunning. I also learned to play tennis with a wonderful coach who had infinite patience, and I was able to take up my former hobby of painting upon invitation from a local art centre, spending many Saturdays with wonderfully passionate Rwandan artists.

Despite having been self-employed for the entirety of my career, I am well used to working collaboratively with solicitors and other (mainly medical) professionals. Nothing, however, prepared me for some of the challenges I encountered in working for a government – particularly a foreign one with its own political agenda of which I knew nothing. Whilst the consultancy was not always easy, it was always interesting, and most of all worthwhile. Whether or not the legislation ever makes it onto the statute books in its current form is a moot point – and certainly the government will need partner support for implementation. Nonetheless, mental health tends to be a low priority in the majority of developing and post-conflict countries. The Rwandan government’s recognition of the importance of developing a complete mental health strategy in a country which is still in the process of rebuilding itself is to be much commended.

Contributor Laura Davidson, No 5 Chambers, London

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Laura Davidson

Laura is a barrister at No.5 Chambers in London, well-known for her expertise in mental health
and capacity matters. She appears regularly in the Court of Protection and in cases in the High Court involving healthcare law.