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On the Long Road: Burundi
By Alexandra Douglas and Dr. Alexia Nibona


War and Health

Health and Peace

A Community Peace and Health Model

FWA’s Philosophy

On the Long Road: DRC
By Alexandra Douglas and Zawadi Nikuze


The Story You Need to Hear

Learning From Within

The Worst Place to Be a Woman


War and Health

Different scholars provide varying views on the origins of Burundi’s 12-year civil war; that is to say, on why Burundi’s civil war broke out at that particular place and time.

The war, without doubt, was an ethno-political war. By 1993, politics were almost solely determined along ethnic lines. This was the result of the colonial legacy and the post-colonial struggle for power. For many Tutsis, the struggle against Hutus was rooted in the “social revolution” in Rwanda from 1959 to 1962 where the majority gained control of the government. For Hutus, it was rooted in the massacre of tens of thousands of Hutu intellectuals in 1972 by the Tutsi controlled military. By either accord, the “tipping point” was reached in 1993 when Melchoir Ndadaye was elected the first ever Hutu president of Burundi and, after 100 days in office, was assassinated by the Tutsi military.

The conflict in Burundi is sometimes termed a “popular” conflict. This means that not all actors responsible for acts of violence were members of the military or ‘extremist’ or ‘ideological’ rebel groups. Many so-called “perpetrators” were ordinary citizens who, under extreme pressure, chaos, and destruction, did things they would never imagine doing under ordinary circumstances. Neighbors killed, looted, and raped their neighbors. The question is: why?

In the Burundi context, the meeting point between politics and chaos cannot be played down. On the night of Ndadaye’s assassination, the Tutsi military also assassinated most of Ndadaye’s cabinet and party leaders. The majority Hutu population woke up to learn that the first ever democratically elected leadership of the country was dead. Retaliatory actions by Hutus—mostly in the countryside—killed thousands of Tutsis and, from there, the “kill-retaliate” nature of the war began.

However, the escalation of ethnic conflict was also deeply structural. Burundi is one of the poorest countries of the world. The GDP per capita is estimated at $138 per year, even though in poor urban communes and/or rural areas, a person may see less than $60 pass through their hands in any given year.

Even before the war began in 1993, Burundians faced short life expectancies due to the effects of poverty, often dying from treatable and preventable diseases. Infant and maternal mortality rates were high and the emerging HIV/AIDS crisis was just beginning to wash through Burundi’s urban neighborhoods. Despite the existence of effective treatments for nearly all of these causes of death, the average Burundian did not have access to them.

The reality of pre-war Burundi was that people could not provide for their families. They did not have access to basic health services and deeply mistrusted a juridical sector which was controlled—or was feared of being controlled—by someone of another ethnicity. Perhaps the saying “desperate times require desperate measures” provides an accurate analogy, especially when people’s lack of personal health, safety, and security is placed in the context of extremely polarized local and national politics.

Ultimately, however, the 12-year civil war, or “crisis” as it is called by the Burundian people, only exacerbated the extreme poverty and public health crisis faced by the country before 1993. Deadly conflict has a huge health impact on communities. Approximately 300,000 people were killed in Burundi between 1993 and 2005 as a direct result of armed conflict. Many more were physically injured by gunshot, machete, or grenade attacks. And this says nothing of the health consequences caused by people fleeing their homes, hiding in the bush, or living in overcrowded internally displaced person (IDP) or refugee camps. Under these conditions, lack of water, malnutrition, and communicable diseases became major public health concerns.

Instances of sexual and gender based violence also rose dramatically during the years of the war. In some instances, rape was deliberately used by the military and rebel groups to perpetuate fear among the population. However, instances of “civilian” rape also rose.

As discussed above, the war in Burundi was a “popular” war and was perpetrated at all levels of society. Risk of HIV and other STI transmission becomes much higher under such circumstances. Poverty is already a main risk factor for HIV transmission. This risk is multiplied when a concentrated group of individuals such as soldiers, rebels, or members of one community aggressively (which, among many other implications, implies without protection) have sex with many people. HIV positivity rates therefore grew dramatically in Burundi throughout the war, especially in areas like Kamenge which were epicenters of violence. Today, a moderate estimate for HIV positivity in Kamenge is 16% of the adult population.

All of these issues—physical wounds, malnutrition, communicable disease, rape, HIV and STI transmission—took place on the backdrop of an overtaxed and deteriorating medical system. Amidst losing everything, Burundians did not have the ability to meet their basic health needs. Therefore, many more people died—unnecessarily—as a result.

The deterioration of health services had a particularly devastating effect on women. Women who experienced sexual violence could not seek physical or emotional support. Women, who were frequently becoming single heads of households, could not provide for the health needs of their children. Lastly, even on occasions when medicines and treatment were available, women did not receive them due to on-going gender inequality and discrimination.

To this day, Burundi feels the effects of war on its public health system. Despite great increases in health needs the country has less than 300 medical doctors to treat its population of 8.6 million—this is the equivalent of the state of Maryland having 137 doctors instead of its actual 13,500. However, this is still an improvement from the years of the war when the number of doctors was only half of what it is today.

Looking at Burundi’s experience, it goes without saying that war had a devastating impact on health. But what we at the Friends Women’s Association are asking is: What impact does health have on peace?

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