The End

Tomorrow, I will leave Rwanda for a few short weeks of vacation before heading home to start my Masters at Johns Hopkins School of Public Health. The past seven months have unexpectedly been an interesting progression. I started in South Africa witnessing the challenges and the horrors of trying to deliver care in resource-poor settings. I not only watched providers struggle with the lack of proper equipment, staff, or facilities, but I also saw the human consequences.

From there, I went to Tanzania where I spent time learning about what it was actually like to live in a rural setting, with no running water and no electricity. I watched for rain, and planted seeds, watching with sadness as only half of them took root.

After that, I came to Rwanda to contribute to a project that aimed to improve the system in a major way. I saw the potential for change when the right forces of political will and donor contributions align. I saw how the pieces do or don't fit together, when it comes to designing an accessible, quality system of care, particularly in rural settings.

I am grateful for these opportunities. I think of a woman who was with her son at one of the health centers that I visited here in Rwanda. She asked if we could give them a ride to the district hospital, since the ambulance would take three hours to come. About half an hour into the ride, the woman revealed that this was the farthest away from home that she had ever been. And here I was, half way around the world from my own home. Day after day, I reminded of how fortunate I am, not only in the life I live, but in the opportunities and in the resources that I have available to me. The time here has passed quickly. Too quickly. But the time has come to return home, at least for now, to regroup, and to figure out my next great adventure.

Thank You, Hillary

Even though I am across an ocean, I have been following the primaries closely. I supported Hillary Clinton, so it was with great sadness that I watched her give her concession speech. It is the end of a long road that has ended with yet another man. While I like and admire Barack Obama, I am sad that so often in this primary, it felt like there was still an impenetrable circle of testosterone that any amount of motivation, intelligence, class and spirit could not break. For me, it was not about supporting Senator Clinton because she was a woman. It was about supporting a politician in whom I believed. Yet, as Clinton admits defeat after a putting up a tremendous fight, we cannot help but reflect upon what it has all actually meant.

What we don't remember is that in 1872, Victoria Woodhull, another strong female with motivation, spirit, and independence was nominated for President under the Equal Rights Party with Frederick Douglass nominated as her Vice President. This was before women had the right to vote. The general public, offended by her support of Free Love in the face of male sexual hypocrisy and double-standards, claimed she did not have a right to vote, or to run, because she was a woman, and women were not legal citizens.

And now, here we are 136 years later, with another presidential nomination race that has brought gender and race to the forefront of the political dialogue. And once more, the American public has shown that it is not ready to acknowledge that a woman is capable of holding the highest office, that her lack of demureness and propriety is an affront on society, and that the kitchen and the White House are not the same thing. So while we should mourn that our society is not at a point where gender equality is a reality, and that sexism is not dead, we should remember that this has never defeated women before, and it will not defeat women now. One hundred and thirty-six years ago, a woman ran for the Presidency before women could even vote. It will be in our lifetime that a woman takes office, proving that these unjust defeats are not in vain. We must continue to have faith that as we always have, women will refuse to stay under the glass ceiling.

In The Name of God

About half of the health centers that I have visited are owned by a Christian diocese. They are by far the nicest facilities, and clearly have the most resources thanks to missionaries and donor projects that prefer religion to be part of the mission. Yet, many of these health centers refuse to provide modern family planning methods to their patients. With a burgeoning population, Rwanda is currently the most densely populated African nation. As a result, people are falling deeper into poverty, and food shortages abound. Families cannot afford to feed their five or six children. Mothers are at risk every time they are pregnant. With only around 50% of the women delivering in health facilities, maternal mortality remains high due to unhygienic birth conditions and the lack of access to emergency obstetric care. And though Rwanda's HIV prevalence is relatively low, the availability of condoms now has a much greater import. Additionally, people in rural Rwanda do not have the luxury of choosing which facility they visit, unless they want to add several more hours to their day. While I have no hard data on whether or not the health outcomes are actually any different in catchment areas that have a religiously-owned health facility as opposed to a purely government-funded one, I would question whether or not this trade-off is worth it. How can we say which life is more valuable?

I have visited at least one Catholic health center that "secretly" distributes condoms and other family planning methods unbeknownst to its owner. The sister who was the most open about this simply said, "With all of the babies who cannot eat, who run around without clothes on, dying of diarrhea and malaria, God understands."

I Love My Job

This past week, I visited one of the more remote health centers within one of the districts in which I am working. My driver, Sam, and I were running late, and I did not realize it was going to take us two and a half hours to drive there from Nyanza Town, so we did not arrive until 3:30 in the afternoon. We went through the survey with the titulaire, and he began to show us around the small, dilapidated facility. With the walls literally crumbling in some places, and nothing but a corrugated tin roof in others, this facility was not the picture of modern care. The beds in the maternity ward were at full capacity, and a stream of malnourished children followed us around the grounds, trying to get a good look at this strange foreigner.

Toward the end of our meeting, it was obviously growing dark. Because their solar panels are broken, the health center is forced to use kerosene lanterns, by which we finished our meeting. The wind was blowing a bit, and there was lightening outside; the titulaire was trying to hurry, because he was worried that if it started raining, we would not be able to get back to Nyanza due to the difficult road conditions. He spoke sadly about the babies that are delivered in the dark, and the mothers that die from infection, because the light is too dim to fully examine these women post-labor. He spoke of the people who die because ambulances can't get there in time, and the long hours the staff is forced to work. And he is making less than $25 a day.

At the end of all of my meetings, I ask the titulaires about which they are most proud. When I asked this man, he looked at me and said, "I love my job". I thought of all the difficult jobs that I have had in the past, all of the times I have said that I was unhappy. Never was I asked to do my job in the dark, to work for ten to twelve hours a day while making a mere pittance. Never was I asked to complete a task without being given the proper tools and equipment with which to do it. And if I had been, never would people's lives have been on the line.

Healthcare workers are often given a bad rap in low and middle income countries. They are often cited as lacking a sense of urgency or commitment to their jobs. We have all heard of the health centers across the globe that are unstaffed, because people simply don't show up for work. Yet, we must all stop to consider the conditions in which people are asked to work. Here was a man who was trying to create miracles with practically nothing by the light of a kerosene lamp. And he loved his job.

The Quandry of Aid

As part of my work here, I have been doing surveys at all of the public health centers and district hospitals in two rural districts in Rwanda. What I have found there has been revealing, not only in terms of the absolute need of these rural health facilities, but also in terms of the unintended consequences of donor aid.

HIV incidence is relatively low in Rwanda. In the two districts in which I am working, it sits around 2-4%, compared to over 50% in the rural district that I was in while in South Africa. Yet, every health center director - titulaire, as they are called - has told me that HIV is one of the top priorities for their facility. Never mind the lack of running water and electricity, the scores of children dying from diarrhea and pneumonia. One might wonder why these priorities seem so skewed, but it only takes a visit to the actual facility to understand. While the pharmacy, the consult room, and the titulaire's office might all be crammed into one tiny room, there will inevitably be a brand new building dedicated to Voluntary Counseling and Testing (VCT) or Prevention of Mother to Child Transmission (PMTCT) activities. These vertical programs and donor streams mean that money comes into Rwanda earmarked specifically for HIV-related (or other diseases-du-jour) activities. Forget the 60% of women who still are not delivering babies with a birth attendant -- dying moms don't bring the money. And when was the last time we heard about a diarrhea awareness campaign? It isn't that the titulaires do not care about these other, seemingly more pressing health issues. It is that they know this is where the money is. And it is precisely *because* they care about these other health issues that they continue to claim HIV as a top priority: more money means more staff, more supplies, more equipment. And if some of those inputs are used for the malnourished babies, then so be it. After all, donor aid is, in many cases, unstable. Rwandans, perhaps better than most people in the world, know that international presence is fickle, at best. Self-sufficiency is a major goal of this small nation, since the developed world turned its back on them in their darkest hour. What is preventing this from happening again? These inconsistent contributions make planning and programming difficult for any health center. Many of the facilities used to have nutrition programs for impoverished families. These have been stopped, because the donor pulled out. Or they have been indefinitely suspended.

I went to a health center this week that was in the process of finishing the construction
of a maternity ward, funded by an international NGO. It consisted of three new rooms -- a delivery room, a post-delivery room, and a pre-delivery room. The pre-delivery room could fit, at most, two beds...maybe not even that. And the post-delivery room which was supposed to fit eight beds was smaller than my own bedroom. When I asked the head of the health center
what his needs and priorities were, the first thing he said was more room for maternity. I asked if this meant beyond what had just been built, or if once up and running, this new space would suffice. He said, "No. This will not be enough. We asked for more money, but we only got a portion of what we needed. So we built what we could, but women will still be delivering on the floor."

So in the end, they will have a brand new building that does not begin to meet their needs. If they want enough space, they will have to build another maternity ward, and then require twice the equipment, or they will have to tear down that one and rebuild it, which has just wasted a lot of money and other resources. We must ask ourselves, as private donors and as members of a donor country if the restrictions that we place on the use of funds in a setting to which we have never been, and in a context that we don't take the time to understand, are ultimately doing more harm than good. One problem in development is that we have all convinced ourselves that something is always better than nothing. And after having seen some of the results, I question whether or not this holds true.

Volcano Trekking

Tired and breathless, we found ourselves at an altitude of 12,175 feet atop Mount Bisoke and staring at the largest crater lake I have ever seen...okay, at the only crater lake I have ever seen.

But perhaps I should start at the beginning. After a tiring and busy week of work, Will, Graham, Ashley and I decided to escape the Novotel and Mzungu Marts of Kigali and head to the Virunga Mountains along the northern border of Rwanda. As part of the Albertine Rift and the Great Rift Valley, this chain of eight volcanoes joins the nations of the Democratic Republic of the Congo, Uganda, and Rwanda. Though most tourists flock to the "Parc National des Volcans" to trek gorillas, we went for some weekend hiking and for what I hoped would be a little training for Mount Kilimanjaro.

Arriving in Ruhengeri at night, we settled into a guesthouse and headed out for dinner. After speaking for awhile with someone from the tourism office, we thought we were set for a day of hiking...that is until we arrived at the tourism office around 7:30 am the next morning, and they informed us that we were too late. We had to arrive at 6! To our disappointment, we headed out in search of something else to do.

The Bat Cave

Unfortunately, aside from the National Park, Ruhengeri has few tourist attractions. After asking several locals in broken English-French-Swahili for suggestions, we were told to walk down the main road and ask people to direct us to the "grotto". The closer we got the elusive grotto, the sooner we realized that we were headed toward the grounds of a school where, though it was the weekend, a large group of children greeted us, and grabbing us by the hands, whisked us to the gaping entrance of a cave. We made our way inside, without knowing the serendipitous adventure that awaited us.


With a cathedral-like entrance, it took us awhile to realize that the cave went much deeper. With the guidance of a tiny headlamp that Will happened to have and some adventursome guides, the four of us ventured into the darkness. It was not long before the laughter of children gave way to a high-pitched chorus of shrill echoes, as the slimy rocks that we stumbled over gave off a musty stench. It took us a few moments to realize that the sounds and the smells, accompanied by small gusts of wind overhead, were bats. Scores and scores of bats.


It was not long before our excitement and wonder gave way to a morose malaise of curiosity as to what ghosts might be lurking in the corners of past atrocities that might have occurred here in this dark, dank passage. Like little kids, our imaginations turned to darker images and questions to which only the morbid half of us wanted answers. Only, unlike the minds of children that turn to dark fantasies, our adult minds turned instead to dark realities. (We later found out that this cave was reportedly the site of a large massacre during the Rwandan Genocide. Until recently, the cave had been littered with human remains. We found only a rubber boot as evidence of others who had passed there before.)

After two kilometers of darkness, we finally saw the light at the end of the tunnel. Emerging from the darkness, the kids led us to a nearby village where a football game was well underway. Once again surrounded by laughing children, mud huts, bent over men with walking sticks, and women with goats, we were reminded that we really were in Rwanda, and that our large two story house with wireless internet and cable television was some parallel universe. We played with the kids who led us all over their village, chanting "Ashley Gresh" and bursting into laughter.

Mount Bisoke

The following morning, we woke up early and headed to the National Park for the going rate of $60. Though the national tourism office is trying to make its operations more professional, it has not yet organized 4x4's to take tourists from the park entrance to the hiking trails. People must, therefore, arrange their own rides. Unlike in Tanzania, however, the price is non-negotiable. After arriving at the park, the guide who would lead us up Bisoke warned us that we would want gumboots. While we were skeptical that this was just another way to get money out of those unsuspecting Mzungus, we finally relented. And when we were up to our knees in mud, we were for once grateful that we had paid the extra money for some boots.

We wound our way up the side of the volcano, with a guide and two men with large machine guns (to scare off the buffalo) in tow, slipping and sliding in mud and I don't want to think what else, tearing up our hands on thorns and nettles. The lush, green vegetation was breathtaking, and the view from the side of the mountain was indescribable. In and out of cloud layers we wove until we finally reached the top. Tired and weak, we stumbled to the top of the mountain where we found Bisoke's crater lake.

After a small snack and quick nap, we slid our way down the mountain and back to the park entrance. It had been a weekend that was filled with unexpected pleasures and simple beauty. It was, in some sense, the very essence of the country in which we found ourselves: an amalgamation of beauty, harsh realities, simplicity, chaos, and an unparalleled purity and innocence born from atrocities and horror. Like the lush green rain forest and crater lake of Bisoke, though a volcano erupts in violence, it is not long before the hardened lava and the settled ash gives way, and life begins anew.

A Fractured History

It is the start of mourning week in Rwanda. In fact, the mourning period will last for the next three months, but it is specifically this week that people take the time to remember the genocide and to allow themselves the tragic luxury of remembering and reliving the horrific memories of what took place 14 years ago in 1994. There are many misconceptions surrounding the Rwandan genocide in the United States, mostly because of the ethnocentric blinders that we often put up. We receive our news through movies like Hotel Rwanda, a drama about Paul Rusesabagina, a hotelier at the Hotel Mille Collines, who shelters his neighbors and friends as the genocide picks up, though we receive that news ten years too late.

Most of us believe that the Rwandan genocide was a result of old tribal conflicts being kicked up (here is where I insert some comment about the savage African), but we are wrong. The genocide was manufactured and fuelled by European colonists. For centuries, the distinction between Hutus and Tutsis existed, though the distinction transcended any ethnic implications and was, instead, one of socioeconomic status. The Tutsis were primarily the herders while the Hutus were the farmers. The Tutsis, as the wealthier class, were most often the ruling class, but social mobility was possible, and one could transition between Hutu and Tutsi status.

With the arrival of Belgian colonists in 1916, this socioeconomic distinction became an ethnic one with the introduction of identity cards. At that point, the label of Hutu and Tutsi became a much more permanent part of one’s identity. They sought physical distinctions that determined one’s class, attempting to divide the Rwandans even further. Though the Tutsis had always been the ruling class, and not always a fair or civil ruling class, now with institutionalized favoritisim for the Tutsis by the colonial power as well as the elimination of the element of fluidity between Hutus and Tutsis, the seeds of resentment were planted and a clash between classes deemed inevitable.

The year 1959 brought social revolution led by the main Hutu nationalist party, the Parmehutu. With independence, a Hutu-led government was born in 1961. This marked the beginning of the Rwandan Civil War, as Hutus took many opportunities to retaliate against the favored Tutsis which led to the death of several hundred Tutsis and the Diaspora of thousands more.

Finally, in 1990, the Tutsi-led RPF returned to Rwanda to reinstate Tutsi power within the nation, inciting racial tensions and increasing violence. In August 1993, a peace agreement was signed, the Arusha Accords, between the rebels and the Rwandan government, essentially taking all power from the President, Juvénal Habyarimana, and giving most of the power to the RPF. The extremist Hutu party, the Coalition for the Defense of the Republic (CDR), refused to sign the accords. When at least they agreed to accept the terms, they were opposed by the RPF, resulting in a stalemate between the two parties.

The Rwandan Genocide did not start overnight. It was a well-planned, well-strategized mass-killing that followed years of violence and conflict. It was discussed openly in cabinet meetings, and involved the supply of arms by colonial powers. Yet the world did not see what was coming, despite all of the warning signs. In January 1994, a UN Force Commander in Rwanda by the name of Lieutenant General Romeo Dallaire warned the Military Advisor to the Secretary-General of the UN that there were major weapons caches and plans by the Hutus for a genocide against the Tutsis.

On April 6, 1994, an airplane carrying Rwandan President Juvenal Habyarimana and the Hutu President of Burundi, Cyprien Ntayamira, was shot down, and both men were killed. It is still unknown if the RPF or the Hutu extremists were responsible, but whomever the culprit, this event launched the start of the genocide. Thanks to tireless planning and strategizing beforehand, the genocide was executed quickly and efficiently. In the 100 days of the genocide, an estimated 800,000 Tutsis and moderate Hutus were brutally massacred in the streets of Rwanda. Finally, in July 1994, the Rwandan Patriotic Front (RPF) overthrew the Hutu regime, officially ending the genocide 100 days after it had started.

Many blame the French for supplying the weapons of the genocide, and after the French-led Operation Turquoise, an operation that established a safe zone for Hutu refugees to flee Rwanda, the colonial involvement in the genocide was cemented. But it is mostly the Western non-involvement that is the most striking. In an age of technology, where international news is able to reach us the same day it is happening, many leaders continued to turn a blind eye, believing that the genocide was nothing more than a tribal conflict resurfacing. When they could have done something, they did nothing.

These are facts and statistics, but the reality was much worse, as neighbors killed neighbors, friends turned against friends, and husbands killed wives. It is a reality that I, as an outsider, could not even begin to understand. It is difficult to find a Rwandan who does not know someone who was killed in the genocide, and, if he or she was living in Rwanda at the time, probably witnessed violence and horrors much greater than we could ever have imagined. Yet, Rwanda has somehow managed to rise above. It has somehow managed to move on from the deep pains of the genocide to become a unified nation with its eye on development, modernity, and self-sufficiency.

In the aftermath of the genocide, the general attitude has been to forgive and to forget, though the French embassy still remains empty at the command of the Government of Rwanda. It is now extremely inappropriate to ask anyone is he or she is Hutu or Tutsi, even if motivated by genuine curiosity. Instead, one should respect the new mantra, “We are all Rwandan”. While this philosophy of forgiveness and unity has displayed the strength, the courage, and the determination of the Rwandan people, as history has proven time and again, old hatreds die hard. Still, Rwanda must be admired for the way it has risen from the ashes of a fractured history to become the nation that it is today.