A few sessions ago, we discussed primary health care and what exactly that term means to us. What services fall under the umbrella of providing primary health care? Most people would argue that primary health care includes the basics, providing immunizations, preventative care, and emergency care. But where does the category of mental health belong? I think the majority of the time, mental health tends to fall into the background amidst larger international efforts of trying to combat the global killers including HIV/AIDS, malaria, TB, etc. Unfortunately mental health is not only underrepresented in terms of allocated resources, but also in terms of recognition as a significant health issue.

Last summer, I spent some time traveling throughout Rwanda, and I was reminded of those memories as we discussed mental health in post-genocide Rwanda in the seminar. Walking through the streets of Kigali, it was difficult to imagine the destruction and horror that gripped the country in 1994. From an outsider's perspective, it appeared that everyone now identified as a Rwandan. Not once did we hear the words Tutsi or Hutu come up in casual conversations. It appeared the country had successfully moved on; the infrastructure was impressive in Kigali and a quiet peace seemed to resonate through the small city. But upon closer inspection and some deeper conversations with some Rwandans, it became apparent that many people had not forgotten--the hotel owner in Kigali who lost both his mother and father and most of his siblings--the young woman working at the Gikongoro genocide memorial where over 50,000 people, mostly women and children, were slaughtered and buried in mass graves. Now walking through the streets, I would look at each person and wonder the impact the genocide had on them. Were they old enough to remember seeing their parents killed? How many family members did they lose? Or how many people did they kill? As these thoughts and questions ran through my head, I began to wonder how oftenRwandans asked these same questions in their own heads, adn what effect these thoughts would have on their overall wellbeing and health. Many of the survivors stories have been shared at the Kigali Memorial Centre, and here are the words of 11-year-old survivor Chantal, "The killers should be put away where I'll never have to see them again. Life imprisonment would do. Just as long as I never have to come across them somewhere, looking after their children, after they took away our parents who brought us up so lovingly."

While post-genocide Rwanda provides a somewhat radical situation to consider the mental health needs of individuals, it is a good place to start. Making mental health a priority post-genocide in Rwanda was recognized as an important strategy for regrowth and rebuilding; however, how often is mental health regarded as a priority or key component in health initiatives in other countries with less drastic circumstances? The challenge remains that health is complex, and it becomes increasingly complex as we consider the impact that stress from poverty, violence, war, etc. can have on an individual's mental health and overall wellbeing.