As Rwanda’s Health Care Improves, New Woes Arise : Africa: More and more children live past age 5. But hunger, malnutrition and overpopulation are worsening.

Down from the foggy hills of eucalyptus and pine came Kezia Uzamukunda, her 3-month-old baby boy strapped to her back, for the injection of a measles vaccine that she knew would keep him healthy.

Braving a cold morning rain, the 34-year-old woman hiked with 29 other peasant mothers, all of them barefoot, arriving after four hours at a remote health clinic here run by a Roman Catholic order called the Sisters of Notre Dame.

A mother of nine children, Uzamukunda has made this trip five times a year for each of her last five babies. “Some of the mothers don’t,” she said of her neighbors. “They don’t learn, so they are very unhappy. Their children become sick.”

In this tiny, landlocked nation of 7 million that straddles the forests of central Africa and the great savannas of the east, remarkable progress is being charted in health education and the eradication of such diseases as measles, polio, tuberculosis and diphtheria that periodically plagued this land as recently as four years ago.

Today, more than 82% of the Rwandan population has been vaccinated against the diseases, a result of an effective program funded largely by the Roman Catholic Church and international aid donors such as the United Nations Children’s Fund.

But these gains, including a 97% drop in reported cases of measles over the last decade, are now being compromised by a different kind of health crisis, one that is classic for Third World countries where food production is a constant worry.

As more and more Rwandan babies survive infancy because of better access to health care, greater numbers are severely hurt by malnutrition and vulnerable to fatal diseases related to hunger.

An annual report on the state of the world’s children released by UNICEF in Washington in December noted that although childhood immunizations in the developing world have risen in the last decade from less than 10% to more than 70%, malnutrition is looming as one of the critical problems of the 1990s.

The report urges political leaders to pay more attention to the needs of children. It advocates greater allocation of resources for child health in the Third World as the nations of the West and East cut military expenditures.

“We make progress, but life gets so much harder every year,” said Sister Leny Droogh of the Sisters of Notre Dame, who has been working in health care in this country since 1962. “We can give shots to prevent disease, but now the children die of nutrition problems.”

The inoculation program is administered largely by the Rwandan government, which is widely commended for its commitment and efficiency.

“We spend $2 million a year here,” said Ofori Akyea, UNICEF’s resident representative in Rwanda. “Without a doubt in my mind, the money is more effectively spent than anywhere else in Africa.”

But many children who survive the first health hazards of life are succumbing to second-stage illnesses wrought by hunger and overpopulation. According to a UNICEF report last year, more than 28% of Rwandan children younger than 5 are critically malnourished and prone to often fatal diarrheal diseases. That figure is likely to rise, officials say, as food production here stagnates.

Rwanda still has one of the 15 highest mortality rates in the world for children under the age of 5--206 deaths for every 1,000 births. The mortality figures are no more promising for adult Rwandans, about a quarter of whom are estimated to carry the AIDS virus.

During a four-hour drive over Rwanda’s misty hills, a visitor is very rarely out of sight of people--people ambling along the roadsides, people tilling the terraced fields, people hiking mountain trails with hoes in hand or toting produce to market. People, people, people.

In ancient times, this little corner of central Africa on the shores of Lake Kivu was said to be the heart of a civilization whose robust population spread to neighboring regions that now constitute Zaire, Uganda, Burundi and Tanzania.

That pulse of population growth continues to swell 3.3% annually but is tightly bottled up within borders that have been well defined since independence in 1962.

Unlike many of its neighbors, Rwanda enjoys stable government. Of the nation’s three main ethnic groups--the Hutu, Tutsi and Twa peoples--the Hutu make up about 80% of the population and dominate the government. This is unlike Burundi, where a Tutsi minority wields power, and occasional tension erupts in bloodshed, as it did last year when more than 5,000 people died in ethnic violence.

French-speaking Rwanda is exceptionally well-organized politically, from the commune level, which comprises about 300 families, to the basic cell, to which about 50 families belong.

On Saturdays, large numbers of citizens take part in community self-help projects, such as school construction, road sweeping and tree planting.

Even convicted criminals, clad in government-issue bright pink shorts and pink shirts, are a common sight in Rwandan parks and roadsides, industriously swinging hoes or long knives called pangas under the relaxed gaze of rifle-bearing guards.

Much of the pine forest that once covered vast stretches of Rwanda has long since been cleared for farmland, but still there is far from enough food for everyone.

Rwanda is afflicted by one basic problem: overpopulation. This is Africa’s most densely populated country. More than 350 people share every half-mile of arable land here.

The government has appealed to the world for 250,000 metric tons of food to counter the effects of a drought in western and southern Rwanda that is raising the specter of famine for tens of thousands of people.

In a country where 90% of the women have a minimum of five children, and 33% have 10 or more, according to a recent study by the Rwandan Office of Population, family planning has become a focus of attention for both government officials and leaders of the Catholic church, which claims 40% of Rwandans as members.

Therein lies the greatest dilemma here: how to reduce population growth without ripping the social fabric of a country that relies deeply on traditional values.

In rural government offices, it is just as common to see portraits of Jesus, the saints and archangels as it is to see color pictures of President Juvenal Habyarimana.

“Until recently, Rwandans were hardly informed and little aware of the demographic problems, their complexity and their consequences,” wrote Bonaventure Habimana, leader of the ruling National Revolutionary Movement for Development, in response to a reporter’s question.

Habimana pointed out that the country’s official family-planning program was started only in 1981 and explained that Rwandans “were traditionally attached to the idea of having as many children as possible because children have always constituted a form of wealth.”

The biggest social change in the last decade is that “people are now discussing family planning,” said Interior Minister J. M. V. Mugemana, adding that the government has been considering a maximum suggested family size of four children.

“But we can’t impose such things on the people,” he said. “Change must come gradually.”

That opinion is shared by Archbishop Vincent Nsengiyumva of Rwanda, who, admitting the need for family planning here, argued that the question is one of “morals, not condoms.” The church advocates the rhythm method as the best and most responsible way to reduce the rate of population growth.

The church started its own family planning program four years ago, and officials boast that 4,800 Rwandan couples are now practicing the rhythm method.

But there is a conflict between the urgency of the population crisis here and the gradual methods of controlling it that the church and government advocate.

During a recent meeting in Kigali among the archbishop, church officials, two foreign journalists and several Rwandan and international observers, that conflict became evident in several spirited exchanges.

“Isn’t the rhythm method contradictory to the way we live in this country?” asked a Rwandan social worker.

“This arrogant question has been put to us many times by the intellectuals, as if the peasants cannot think,” a church leader testily replied. “The peasants do understand. That is why it is working.”

“We do have a grave problem, but it will take time,” said the archbishop. “We are human beings, not veterinarians.”

In the UNICEF report, a hypothetical point is made that diverting 5% to 10% from the world’s military spending, or about $50 billion annually, could enable children everywhere to receive their basic needs of food, water, health care and primary education.

Here in Rwanda, the point seems as fantastically wistful as hoping for manna from heaven.

“Are you joking?” replied Jean Habyahmana, a medical attendant at the Gikoro clinic, when asked what he needs most to make life better for the 150 peasants and children who trek to the clinic each day. “Everything.”

He paused. “I could use some help. I am the only trained person here.”