I recently saw a fantastic comic strip poking fun at every political scientist analyzing the spread of coronavirus without having much training in public health. I can’t find it now, unfortunately, but I am still thinking to myself, “I should join their ranks!” So, here are some very inexpert and cursory thoughts on COVID-19 in Rwanda.
The unprecedented global spread of the COVID-19 virus has devastated East Asia, Europe, and now the U.S., and many are warning of what is yet to come for sub-Saharan Africa. Experts warn of a “ticking time bomb” for the continent due to fragile healthcare systems, crowded urban areas, and a large number of people with pre-existing health conditions. Rwanda falls in line with many of these demographic descriptors. There is a high patient to doctor ratio here–1:12,000. Rwanda’s 12 million residents live in Africa’s most densely populated mainland country; this population density, along with large families and closely clustered homes, could make social distancing difficult. Nearly 1/3 of the population experiences extreme poverty or food insecurity, which are both linked to compromised health conditions that exacerbate the virus. Additionally, Rwanda has porous borders with its neighbors also battling the novel corona, particularly with the DRC, which struggled with Ebola last summer.
Yet, maybe we can think about Rwanda differently than other African countries. Maybe Rwanda has the potential to manage the spread of the COVID-19 better than its neighbors. It’s relatively robust public health capacity and strong rule of law indicate that it might.
Rwanda is the first African country to achieve nearly universal health coverage. There are a variety of plans, the most vital being the community-based health insurance scheme called Mutuelle de Santé, paid on a sliding scale and implemented for the benefit of Rwanda’s poorest. The country’s well-functioning health care system comprises 1700 health posts, 500 health centers, 42 district hospitals and 5 national referral hospitals, making access to a health center far easier than in other developing countries. Although wait times are long, most Rwandans know where health care is and can afford the cost of a consultation, which can be as little as 100 RWF for some. As the number of corona cases in Rwanda enters the double digits, the accessibility of medical centers could greatly improve both treatments for those afflicted and diagnostic capacity at scale.
The WHO has emphasized the importance of individual governments being able to measure and share statistics on the virus, and Rwanda is poised to do that. It’s has a relatively impressive capacity to maintain population statistics, particularly records on public health, through the National Institute of Statistics. The NIH’s reliable measurements on health outcomes are one of the key reasons that Rwanda is oft-successful in its bids for international aid and NGO contributions—the global community can assess the impacts of its public health contributions fairly well. This well-established international aid and NGO infrastructure poise Rwanda to easily receive the technology and experts necessary to manage corona in the coming months.
Importantly, Rwanda’s position as a darling of the international aid community is wholly dependent on its reputation as a stable and peaceful country in which to operate since its reconstruction after the 1994 genocide. There is no doubt about the rule of law. This robust government capacity has created the infrastructure, institutions, and processes that could translate well into mass management of COVID-19.
The Rwanda National Police and the national army, the Rwanda Defense Force (RDF), are ubiquitous presences on the streets. One regularly sees police officers in the capital reminding pedestrians to keep within the boundaries of the crosswalk and ticketing motorcycle drivers for speeding. Truckloads of RDF troops are a reminder that President Kagame is prepared to fight his opposition groups, some of which are operating in national parks like Nyungwe, as well as across the border in the DRC (Rwanda’s four national parks are officially closed for now). Kagame’s strong security apparatus has been developed primarily in response to anti-government opposition, small arms smuggling, and drug trafficking, but it could also aid in enforcing closures of businesses that could spread COVID-19, limits on public gatherings, and quarantine measures.
We can think of this use of state security capacity as the “militarization of public health”. It is galvanizing pre-existing structures, processes, and trained security actors, in this case, at porous borders, to contain the disease. It was evident in Rwanda’s response to the Ebola threat in the DRC, in which cross-border traffic was heavily stemmed in the summer of 2019. Some argued that it stopped Ebola from entering Rwanda from the Congolese city of Goma, barely across the border.
There could be a heavy cost to countries using security capacities to contain COVID-19, however. When populations are afraid of those who are supposed to be stemming the spread of disease, they could be more inclined to use unofficial transport routes and hide their movements from surveillance. Alex de Waal calls a militarized disease response alarmingly authoritarian, ominous for public health, and strategically counterproductive. He finds a militarized response to disease outbreaks much more expensive and less effective than their humanitarian counterparts, as well as reminiscent of coercive medicine under colonial rule. The impacts of military responses to disease spread in Africa needs to be measured.
Despite the drawbacks to the militarization of public health, the strong Rwandan state apparatus serves even a symbolic function that regulates individual decisions in a way that could stymy the spread of corona. The security sector fosters a deep culture of legality and rules adherence across the country and few Rwandans are eager to flout the federal government. Coupled with the strong sense of accountability to communal norms and behaviors, the widespread adherence to government advisories means a vast majority of Rwandans will comply when they are given health directives.
Rwanda’s most pressing concern may be fighting a coronavirus outbreak that subsumes healthcare resources also needed to tackle other pervasive medical problems, such as malaria, measles, TB, and HIV. We saw this with the thousands of secondary deaths during the Ebola outbreak, death from other diseases because care for them fell to the wayside. However, if a country’s strong state capacity as seen in the public health sector and ability to regulate the movements of citizens can minimize the spread of corona, Rwanda may be a promising case with the proper preparation and support.