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"Medical Tourism," African-Style

Every since a private insurance system was launched in Rwanda, its citizens regularly cross the Burundi border to get better, cheaper care.

Hospital in Ruyigi, Burundi
Hospital in Ruyigi, Burundi
Alphonse Safari Byuma

GAHARA – Nsengimana, a fiftysomething merchant from this town in eastern Rwanda, is ranting against his country's medical services. "Old Gerard died in May in the courtyard of Gahara's health center. The nurses refused to take care of him because he hadn't paid the health insurance fees for all of his family members," Nsengimana says.

As the anger rises in his voice, Nsengimana says that in Rwanda someone can be denied treatment even if just one family member has not paid for their health insurance card.

"The authorities lock us up in their offices for hours and demand that we sell our cattle so that we can pay for the card," adds Yoweri, a fellow merchant.

But just a few miles from here, across the border in neighboring Burundi, doctors and nurses don't ask any of that; the national health service is also much less expensive, and available both for Burundians and Rwandese.

"The Burundian health services are fast and efficient," says Yoweri. "One day, I noticed that they even took care of the Rwandese patients first because they had come from further away. I was stunned!"

Jacqueline Nyirahabimana, a nurse at Gahara's health center, says that a typical nurse can see as many as 300 patients in a day. "Some people go to Burundi for faster service," she admits. However, Nyirahabimana denies any mistreatment as far as her health center is concerned. "How could we refuse to take care of a poor, dying person because they don't have a health insurance card? But we don't automatically welcome those who can pay and don't have a card. If we did, the insurance system would collapse."

Bad citizens

Another advantage for the patients crossing the border is that several Burundian hospitals are close to the border with Rwanda. Going there costs less than being transferred to more distant Rwandese hospitals. Moreover, the subscription to a private insurance is optional in Burundi, as opposed to Rwanda where it is compulsory.

Finally, there is the role of the currency exchange rate in the medical exodus to Burundi. "One Rwanda franc is worth more than two Burundi francs. That's why it's cheaper there," explains Nyirahabimana.

The migration of Rwandese patients started as soon as the nation's private health insurance policy was launched, in 2009. The authorities did not understand why a large number of people living near the border had still not subscribed to this new method of universal access to health care.

A police officer from Gahara remembers, "At the very beginning, they were branded as bad citizens. But later, we understood that it was just about the financial reality." He added that the poor people from the overpopulated region of the North, who came east searching for arable lands, were the first to go to the Burundian health services.

But for the inhabitants of Gahara, such as thrift shop owner Kamanzi, "this has become the norm for Rwandese people who live near the Burundian border. We are already so used it, we'll go over the border just for a stomach bug."

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Paying tribute to the victims of the attack in Kongsberg

Terje Bendiksby/NTB Scanpix/ZUMA
Carl-Johan Karlsson

The bow-and-arrow murder of five people in the small Norwegian city of Kongsberg this week was particularly chilling for the primitive choice of weapon. And police are now saying the attack Wednesday night is likely to be labeled an act of terrorism.

Still, even though the suspect is a Danish-born convert to Islam, police are still determining the motive. Espen Andersen Bråthen, a 37-year-old Danish national, is previously known to the police, both for reports of radicalization, as well as erratic behavior unrelated to religion.

Indeed, it remains unclear whether religious beliefs were behind the killings. In an interview with Swedish daily Dagens Nyheter, police attorney Ann Iren Svane Mathiassens said Bråthen has already confessed to the crimes, giving a detailed account of the events during a three-hour interrogation on Thursday, but motives are yet to be determined.

Investigated as terrorism 

Regardless, the murders are likely to be labeled an act of terror – mainly as the victims appear to have been randomly chosen, and were killed both in public places and inside their homes.

Mathiassens also said Bråthen will undergo a comprehensive forensic psychiatric examination, which is also a central aspect of the ongoing investigation, according to a police press conference on Friday afternoon. Bråthen will be held in custody for at least four weeks, two of which will be in isolation, and will according to a police spokesperson be moved to a psychiatric unit as soon as possible.

Witnesses have since described him as unstable and a loner.

Police received reports last year concerning potential radicalization. In 2017, Bråthen published two videos on Youtube, one in English and one in Norwegian, announcing that he's now a Muslim and describing himself as a "messenger." The year prior, he made several visits to the city's only mosque, where he said he'd received a message from above that he wished to share with the world.

Previous criminal history 

In 2012, he was convicted of aggravated theft and drug offenses, and in May last year, a restraining order was issued after Bråthen entered his parents house with a revolver, threatening to kill his father.

The mosque's chairman Oussama Tlili remembers Bråthen's first visit well, as it's rare to meet Scandinavian converts. Still, he didn't believe there was any danger and saw no reason to notify the police. Tlili's impression was rather that the man was unwell mentally, and needed help.

According to a former neighbor, Bråthen often acted erratically. During the two years she lived in the house next to him — only 50 meters from the grocery store where the attacks began — the man several times barked at her like a dog, threw trash in the streets to then pick it up, and spouted racist comments to her friend. Several other witnesses have since described him as unstable and a loner.

The man used a bow and arrow to carry the attack

Haykon Mosvold Larsen/NTB Scanpix/ZUMA

Police criticized

Norway, with one of the world's lowest crime rates, is still shaken from the attack — and also questioning what allowed the killer to hunt down and kill even after police were on the scene.

The first reports came around 6 p.m. on Wednesday that a man armed with bow and arrow was shooting inside a grocery store. Only minutes after, the police spotted the suspect; he fired several times against the patrol and then disappeared while reinforcements arrived.

The attack has also fueled a long-existing debate over whether Norwegian police should carry firearms

In the more than 30 minutes that followed before the arrest, four women and one man were killed by arrows and two other weapons — though police have yet to disclose the other arms, daily Aftenposten reports. The sleepy city's 27,000 inhabitants are left wondering how the man managed to evade a full 22 police patrols, and why reports of his radicalization weren't taken more seriously.

With five people killed and three more injured, Wednesday's killing spree is the worst attack in Norway since far-right extremist Anders Breivik massacred 77 people on the island of Utøya a decade ago.

Unarmed cops

As questions mount over the police response to the attack, with reports suggesting all five people died after law enforcement made first contact with the suspect, local police have said it's willing to submit the information needed to the Bureau of Investigation to start a probe into their conduct. Police confirmed they had fired warning shots in connection to the arrest which, under Norwegian law, often already provides a basis for an assessment.

Wednesday's bloodbath has also fueled a long-existing debate over whether Norwegian police should carry firearms — the small country being one of only 19 globally where law enforcement officers are typically unarmed, though may have access to guns and rifles in certain circumstances.

Magnus Ranstorp, a terrorism expert and professor at the Swedish Defence University, noted that police in similar neighboring countries like Sweden and Denmark carry firearms. "I struggle to understand why Norwegian police are not armed all the time," Ranstorp told Norwegian daily VG. "The lesson from Utøya is that the police must react quickly and directly respond to a perpetrator during a life-threatening incident."

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