Wednesday, April 30, 2008

Rwanda’s Fight on HIV/AIDS: Strengths, Challenges, and the Catalyst

Interview with Highest Ranking HIV/AIDS Official in the Rwandan Government

High level executives at the UN Development Program described her as a wealth of knowledge. A Senior Advisor for PEPFAR praised her for her detailed approach and drive. An administrator from Partners in Health said she is the exact person you want to talk to. In every one of these meetings I thought - who is this Dr. Agnès Binagwaho? Well, she is the Rwandan government’s highest official in the field of HIV/AIDS. Her title reads Executive Director of the National AIDS Control Commission but she is much more than that. She is personable and insightful in her speech, straight forward in her talk, and pragmatic in approach.

I got the chance to interview Dr. Agnès during the break of a conference on monitoring and evaluating international aid effectiveness. Every African country was represented at this conference as its importance is crucial for achieving sustainable development. Money wasted literally costs people’s lives for many of these countries. It was in this setting that I got to discuss three key issues with the foremost authority on HIV/AIDS in Rwanda.

In a previous interview, the UNAIDS Rwanda Director highlighted the decentralized approach of Rwanda as one of its greatest successes. Dr. Agnès reponse built on this foundation. “What I am telling you is the government vision – we want to harmonize, to align people behind one unique action plan designed according to the needs of the country.” Some foreign governments, above all France, have been overly critical of the leading party, and in the past, some painted them as a new dictatorial regime. But how was this national plan created? “We put together all the constituencies, like the civil society, the development partners, the new private sector etc, and we ask them to tell us their needs”. Identifying needs is important, but what about the decision making? “They each have their own priorities but we try to figure out what we can work on at that time. They also decide with us what to take and leave out of the plan. It makes sure people are working with less frustration when they are part of the decision.” I stop and can not help smiling at the wisdom of that statement.

The National Strategic Plan is the heart of the successful approach, but where are the arteries and veins that circulate the vision and action? In 2006, Rwanda went through an administrative adjustment. It restructured its many districts into 30 larger ones and created 5 provinces (named in their relationship to the fifth province – Kigali City). The strategic plan is entirely implemented through the district level. Everyone at the above levels are coordinators and managers instead of implementors. Each district has an HIV/AIDS committee that is comprised of a multilateral membership. The director of each district’s health program, hospital, education, and gender initiatives are included and the committee is rounded off by two vital and crucial members of “civil society”; a religious leader chosen by the different denominations (mainly Catholic, Anglican, and Muslim) and a person living with HIV elected by the local network of people living with HIV. This committee is led by two officials that report directly to the mayor (who has the authority to make decisions but in conjunction with the national strategy and policies). This approach has led to a remarkable level of success throughout the entire country. Many of the measures of success, such as testing and people receiving treatment, have more than doubled since 2005.

There are a plethora of successes, but what are the challenges? Rwanda after all is one of the poorest countries in the world, and is heavily reliant on foreign aid; now ‘there’s the rub’. Although Dr. Agnes agreed with the UNAIDS Rwanda director that evidence and data are needed to target at-risk groups, she focused her response on the issue of foreign aid. “The big challenge is what is going on in this meeting right here. It is alignment harmonization of partners in our true priorities and action plans. People come and say we have come to do statistics but okay. They don’t come in and say, ‘We have come and want to help you. We have this amount of money. Where do you need to put it.’ This is the support we need. That is how you may have some critical sectors that are not funded. Without this approach it will be very difficult to create sustainable development and you can not fight AIDS without sustainable development.” What she is really saying is that their officials understand and have worked diligently to access and prioritize the needs of their own country. The call is for budget support and not vertical giving that is targeted based on the funding organization's priorities.

Dr. Agnes singles out PEPFAR as an example of the good that can come out of foreign aid working within the framework of the government. “PEPFAR is one of the success stories because PEPFAR here is aligned to our national strategy. They don’t do a vertical program. They integrate where they have to be. We still don’t like the way they break down the money and the cost of everything because it is not totally clear but they do it within our strategy. This is only because we had the political will to oblige them to do so.”

It leads right into our most interesting topic – what was been the catalyst for this united vision and this successful program on HIV/AIDS? Her simple two word answer is one that has stayed with me from a FACEAIDS conference keynote by Jim Kim – political will. She emphasizes that programs and initiatives that will help reach the Millennium Development Goals and other goals will be implemented. Politics used to be a deadly game in Rwanda, but this is the new Rwanda. “Really we never go for pockets, we always go for national. This is important to note also – it is because the previous regime before 1994 was based on exclusion and discrimination. The new orientation is inclusion and participation, which means no place in the country is left out, no portion of the population is left out, and everything is national. What is good for the north is good for the south. What is good for me is good for you. This is a policy that is implemented for the community and that is the difference. There are no pockets.” “No pockets” is another way of saying – favoritism and ethnicity no longer apply here.

My interview with Dr. Agnès was refreshing. It was a reminder that vision is vital to solve any problem and that a pragmatic approach can create hope even in the depths of devastating tragedy. Rwanda certainly has many challenges that lay ahead, but it can point to its health sector as a symbol of success. A symbol of something designed and coordinated by Rwandans for Rwandans with financial aid coming from an international community that perhaps is attempting to literally pay for past indifference.

Postmark: This entry has been published onto Rwanda's National Government AIDS Website

Sunday, April 27, 2008

The Rwandan Genocide Memorial and Education Centre

A Range of Emotions . . .

You make your way up the steep hill on a road that looks like any other in Kigali – a dirt wall on one side and a beautiful scenic overlook of the city on the other. However this road is different because half way up you see a large modern white house with spacious terraces that is set a part from anything else in sight. It is Kigali’s Gisozi Genocide Memorial and Education Centre – the final resting place for over 250,000 Tutsi and moderate Hutus.

In an attempt to supplement this entry I would ask that you read this article to gain some of the historical perspective of what happened in 1994 and why. It is not thorough and is somewhat slanted but it at least covers a good deal of events. I will concentrate on the range of emotions that come out of the path set out by the exhibits.

Anxiety -
I knew the time to write about the Rwandan genocide would come, but I find it hard to explain in only a few paragraphs. The story is too complex to breeze over, too important to not do it justice, too recent a memory to be forgotten. Everything in Rwanda comes back to the genocide. How can it not? 1.2 million men, women, and children murdered with bullets, machetes, and clubs in less than 100 days.

Neighbor kills neighbor, friend kills friend, and family kills family. How can such acts take place? 300,000 children left orphaned. A UNICEF study estimating 99.9% of children witnessed violence (rape, torture, or murder). A youth militia death squad brainwashed, trained, and armed by the government to wipe out a piece of the population.

Sorrow -
Videos of mass graves, actual chains used to bury couples alive, skulls and bones of those murdered, thousands of photos of men, women, and children who lost their lives for simply being “Tutsi” or a “Hutu that was a traitor”. A traitor may be spared death, and was any Hutu who married a Tutsi (a very common thing) or helped/befriended Tutsis.

Mass killings took place at churches, even catholic churches. The church went as the priest did. Some accounts told of priests who died trying to make peace or hide Tutsis. Others depicted priests that rounded up their congregations in their church for shelter and then worked with the militias to slaughter their own people.

Anger over the amount of carnage and the sheer evil and vile nature of the organized killings of people based on their “ethnicity”. Anger at how easy it was to pre-register the Tutsi, block off the main roads, and then proceed house to house with death squads. Anger over the idea that one group should wipe out another. Women and children were excessively targeted as the most important aim was to make sure no new generation would emerge.

“The Tutsi and Hutu are one people, one history, and one language”. The first documented violence (occurring in 1959) between the two came as a direct result of European colonizers creating – I repeat creating – a racial division between them in form of identity cards. Historians and military call it indirect rule through divide and conquer. Despair over the fact that the French armed the extremist government after peace accords were signed in 1993. Despair over the countless eye witness stories of French soldiers getting those hiding to come out and then quickly leaving before the militia arrived. Despair over the international community disregarding eight ethnic massacres from 1990-1994. There were plenty of warning signs. It does not stop there. The United Nations refusal to acknowledge the term “genocide”, which would have legally obliged them to enter and punish the perpetrators, the withdrawal of peace-keeping troops, and the “never again” acknowledgment of their “sin of omission” all strike a resounding and familiar chord with the past year in Darfur, Sudan.

A funeral was taking place as the remains of two recently found and exhumed bodies were laid to rest at the memorial. Before the funeral the memorial became filled with Rwandans. Screams, heavy sobbing, and cries filled the rooms creating an intimate and pain filled atmosphere in which I felt like nothing more than an intruder. These were survivors. People who lost their loved ones in heinous acts and crazed ideology.

The use of the gacaca courts, a traditional tribal way to deal with transgressions. 250,000 local judges were given training on law and judicial ethics and the perpetrators of the genocide were given town hall style trials with at least 15 judges and 100 witnesses to make quorum. The most important stress is on identifying the victims (which many knew personally by name) and then establish the extent of the crime. A truly remarkable approach that has its critics but has led to starting the healing process. Click here to learn more about it.

No one in Rwanda is allowed to say the genocide did not take place. Since the genocide Rwanda has not backed down from its stance that the international community completely and utterly failed its country. It has focused on the fact that all Rwandans lived peacefully and together before the colonizers came and created the divisions. It is now known as one of the safest countries in all of sub-Saharan Africa and unity wins out over division. Moreover because it knows the chaos and pain of genocide, it has sent a piece of its army as part of the peace-keeping initiative in Darfur.

Thursday, April 24, 2008


Pre-visit Research Meets First Impressions

“The hills are alive…” but it’s not the sound of music. Instead we find many sturdy houses, mostly accessible roads, and hordes of people going to and fro. Kigali, Rwanda’s capital, is a city built on several hills marked by trees, greenery, and beautiful scenic views.(see photo) It is known as one of the safest cities in all of sub-Saharan Africa and it is a symbol illustrating the amount of change possible when leaders, organizations, and people are willing to work together toward a common goal.

When I started my background research on Rwanda I did not know what to expect upon arrival. The facts that I usually look into (recent history, life expectancy, health risk etc) were not too encouraging. Recent history focused on the 1994 extremist genocide that saw 14% of the population brutally murdered. For a perspective driven juxtaposition: 14% of the US population would be 45 million people and Rwanda is only slightly larger than New Jersey. Life expectancy read: women 45 / men 42 (nearly 66% that of India). Health risks were plentiful: a nasty form of malaria, an HIV prevalence rate of 3%, and a slew of warnings about cholera, meningitis, and yellow fever. Switch gears to providing care - are there enough healthcare practitioners to combat or address these needs? Well the figures show 3,900 people per nurse and 50,000 per doctor. These stats should jump off of the page, but the point I emphasize is what I am seeing in light of what I read.

One cannot glance over Rwanda’s status as a developing country (its 2007 GDP is 1/10th of New Jersey’s 2007 state budget). Needless to say the country is very dependent on foreign aid. Moreover, threats and struggles are realized in varying arenas, such as border tension with the Congo, the growing global crisis on staple food prices, and the everyday ills of poverty, that make Rwanda’s successes fragile. For instance, poverty in Kigali is not as visible, or “in your face”, as in Mumbai or Surat, but that certainly does not mean poverty is not a problem or it does not exist in large numbers. Perhaps it is better hidden or more likely a layered issue that takes some time to piece together? With only four days in country I can only comment on what I observe. What I see is many beautifully groomed main roads lined with trees, trimmed bushes, and freshly cut grass. More importantly, I see direct responses or positive steps toward addressing my previous fact-finding results. I see HIV awareness billboards all over the paved streets (see photos). I open the newspaper and read about the government launching an integrated health system through Partners in Health and the Clinton Foundation. A measure that will train 21,000 health advisors and rise to 40,000 as time goes on. It is a joint style that believes in high quality medical services for all people and focuses on holistic approaches (infrastructure, provisions of water, electricity for health facilities etc). Also of note is the daily public reminders of the genocide but the approach is meant to build unity not make excuses or deny the past, which are jailable offenses.

Many of the daunting facts that built an impression before stepping foot in Rwanda are present in the media and appear to be an issue that a plethora of organizations are combating together. In all my travels I have never seen such a presence by the international community as I do in Kigali. Visibility is of course enhanced by Kigali’s small size, but it does not dismiss the shear volume of organizations. There is still much work to be done, but there is a sense that the direction and ingredients are here on the ground.

Sunday, April 20, 2008

Setting the Stage

A Movement in Rwanda is Catalyzing Hope

The first piece of the three-stage flight to Rwanda is complete. I write from Amsterdam’s international airport with a looming 4 hour lay over. This gives me the opportunity to do something I normally do not – set a stage before arriving.

When I began planning this project I knew that the sub-Saharan portion would most likely be the most difficult. It would prove the most challenging to plan, the most expensive to price (an airline ticket is nearly double the cost of any of my other flights), and perhaps the most telling in the effects of HIV on a community, a country, a region. The efforts of Partners in Health in Rwanda has been something I have wanted to see, witness, and document since helping raise thousands of dollars for its cause through my FACEAIDS chapter at Fairfield University. We would get emails from the field and personal stories of success making Rwanda this intimate yet intangible part of our motivation. The culmination of why over 120 universities had FACEAIDS chapters was exemplified in Dr. Paul Farmer’s keynote address at last November’s national conference.

Farmer’s speech highlighted the unified efforts of the Rwandan government, the Clinton foundation, and Partners in Health (PIH) to develop a national healthcare system that maintains the model that has made the Boston based ngo the gold standard of HIV treatment organizations. It was the message of a combined effort that resonated with me during his talk. So many players on this stage, yet one clear mission – creating and implementing a healthcare system that brought health, development, and human rights together. The “story” is best explained in this recent article from the Boston Globe. It is full of insight and spirit and best explains why it is a privilege to document the work being accomplished. I only hope my writings from Rwanda capture the same vivid message of what I call a movement.
I was introduced to the “movement” through Partners in Health’s projects, but the more I researched about work being done in Rwanda I saw that many entities are invested in making a difference in the country. It is this movement that is bringing hope to the “Land of a Thousand Hills”. It paves the way for a bright future that no one could have predicted following the 1994 Rwandan genocide. In the aftermath of 800,000 Tutsi and moderate Hutu deaths Rwanda has found a way to reconcile and move forward with the goal of the whole in mind.

In two weeks time I will be onsite at PIH’s countryside hospital/clinic. Before that I will be in the capital of Kigali meeting with representatives of the United Nations Develop Program, the Rwandan health ministry, and the US President’s Emergency Plan for AIDS Relief (PEPFAR) as well as other organizations, such as Orphans of Rwanda and FACEAIDS. The meetings will focus of how each of these entities plays a role in the movement. It is with great anticipation and over two years of “hearing, reading, and fundraising” that I embark on this leg of the Global AIDS Project.

Thursday, April 3, 2008

On the Hill

Two Days at the Capital give Insight into the World of the Public Sector and HIV

I have had the privilege to document some of the most effective models of providing HIV treatment and prevention around the world. I will soon be departing for Rwanda to cover Partners in Health’s famous model that addresses the HIV epidemic through development and working with local communities and the Rwandan government. The United States of America is responsible for much of the increased funds that support and foster the progress that has been made throughout the world in combating HIV. Both the public sector, through programs such as PEPFAR (The President’s Emergency Plan for AIDS Relief), and the private sector, such as the Clinton and Gates Foundations, have made great strides in addressing the vital components of treatment and prevention. However there is a startling rise that is calling our government officials to take a deeper look domestically and maybe learning from programs abroad.

The Washington Post ran an article covering a recent report, which in the words of government officials I ate dinner with, shocked the Hill. One would think the story was about an exposed affair or high level corruption charges but it was not – it centered on the alarming rise of HIV in Washington DC. When people think about an HIV epidemic and children infected during birth, their minds travel to “other” places, such as India and sub-Saharan Africa. However, the study reports DC in a “modern epidemic” and shows cases of infection through birth; something unthinkable in the states because of readily available drugs that can greatly reduce the transmission rate from mother to baby. Lastly, the report strongly emphasizes that there is a clear racial component to being HIV infected in DC – the subtitle reads “More than 80% of HIV Recent Cases were Among Black Residents”.

This Washington Post article on the rise in HIV infection was followed by a recent announcement by the CDC that "1 in 4 teen girls has at least one sexually transmitted disease". The core facts of the study show that there is a serious issue of sexually active teens who are at risk of dangerous consequences, such as infertility, cervical cancer, and HIV. Many factors play a role in the alarming figure. The taboo nature of discussing sex within families, schools, or churches, the inadequacy of many health education programs to cover the in depth issues of STDs and condom use, the sex drive of teens, and simple myths or misunderstanding create an arena where HIV and STDs can flourish.

Given these two reports that highlight HIV on the rise and the prevalence of sexually transmitted diseases, I posed a question to US Senator Tom Coburn of Oklahoma and Congresswoman Michele Bachmann of Minnesota if they would support universal sex education that approached the issues in an objective fact based scientific manner. Their responses spoke volumes. Coburn, an obstetrician by trade, acknowledged the reports as very serious and concerning. His response focused on the difficulty of presenting all the issues properly, such as that condoms do not always protect a person from HPV (the virus that causes cervical cancer) or herpes. Congresswoman Bachmann spoke of the role of family values and her strong support of science but did not delve into anything of substance. I attempted to push the issue and discuss the merits of empowering teens through teaching about transmission of STDs and the role of condoms in preventing HIV. However, her assertion that science has not shown condoms can completely prevent HIV transmission left me dumbfounded. Was she arguing that condoms do not have a 100% yield or did she simply not know her science; after all the CDC has hailed latex condoms as “highly effective when used consistently and correctly” for deterring HIV transmission.

The prevalence of STDs and the alarming fact that HIV cases are both rising in some cities and are heavily racially disproportionate depict the importance of the public and private sector to reassess how we address HIV and STD prevention. One non elected official spoke candidly how we can learn from the successes of the projects abroad and implement them here in the states. It caused me to think back to the various organizations that I have covered. Though differing in region, culture, and religion many of them maintained the approach that to affect change in a population you must start with the individual and community. Here the goal is the empowerment of the person through education and awareness and it is a concept that can find support in both the public and private sectors. Unless we expect our sex-sells culture to change or the biological sex drive of teenagers to disappear, then the answer for prevention has to be found in obtaining a level of understanding about STDs and the various methods of prevention, such as male and female condoms, abstinence, and faithful monogamous relationships. I would heed Senator Coburn’s advice on the challenges that sex education can present but I would assert that a comprehensive lesson plan can be achieved and should be achieved.