Monday, June 4, 2007

Condoms Are a Girl’s Best Friend, or Things I Learned in Rwanda

Outlawing plastic bags can make a city cleaner! That, and paying people to clean the streets. Here in Kigali, women in grass-green dresses sweep the streets with brooms made of some sort of dried branches. Every day. But the law against plastic bags must make a real difference. After the genocide when the government tried to clean up Kigali, they found over a million plastic bags on the streets! There are lots of other types of trash that could make this a dirty city, but instead it is one of the cleanest cities I’ve ever seen. Much cleaner than Washington, DC. I guess political will—combined of course with the people’s desire to have a nice city to live in—goes a long way!

The Global Fund saves lives. Ok, before I came here I already knew this to be true. But in the abstract, in stories about people receiving AIDS treatment that was paid for with Global Fund money or in the statistics the Fund reports about treatment for AIDS, TB and malaria, bed nets and condoms distributed. But being part of writing a proposal is a whole new experience of the Fund. The fact that we can propose almost anything we can think of that will help prevent and respond to AIDS. The only rule is that we must demonstrate that whatever programs we propose will have a positive impact on the disease we are trying to address. Other major AIDS donors—the UK Department for International Development, the World Bank, and especially the US President’s Emergency Plan for AIDS Relief (PEPFAR)—have all sorts of conditions on how their money can be spent, on who receives it, which countries are eligible and what sorts of services are acceptable or truly part of the AIDS response. But with the Fund, we can propose a range of socio-cultural interventions that reflect the local context of the AIDS epidemics in the country. We can even propose to spend millions of dollars buying condoms, and another million on top of that for activities that will raise people’s awareness of condoms and tell them where to get them. All of these things may be paid for by these other AIDS donors. But with the Fund, we don’t have to pay attention to how much we spend on one thing versus another, ask for permission to do the things we need to do, find quiet, under-the-table ways to make certain people have the information and the services they need to save their lives. We just have to write a good proposal. And hope that the Fund has enough money to grant us what we seek.

We have to save the mountain gorillas. The experience of being surrounded by around 30 mountain gorillas, ranging in age from one month to 40 years, was breathtaking. These creatures are so human. Or, perhaps I should say, we are so gorilla. Their hands and fingers, feet and toes, noses, expressions, the depth of their eyes and the way they looked at me, the way mama gorilla cradles her baby in her arms, letting it suckle and sleep on her chest. There is no denying the similarities. But the gorillas seemed so peaceful, a real contrast to humankind in too many sad cases. And, of course, it is humans who are killing the gorillas. There are only 700 left in the world. Many have apparently been killed by the war in the Democratic Republic of Congo, which I would have entered had I summited the mountain on which I visited the gorillas. Poachers take more lives. But deforestation and exposure to human diseases may be their greatest threat. Humans have taken so much from nature. The group I visited was the one originally studied by Dian Fossey; I suppose it is up to us to continue her work, to support the passions for these gorillas that she lived and died for. Believe me: eastern mountain gorillas are too magnificent to lose.

“Never Again” should apply to everyone. I visited the Kigali Genocide Memorial here, a beautiful space dedicated to educating foreigners and Rwandese alike in what took place here and around the world during history’s other genocides—Armenia, Namibia, Cambodia, Kosovo, the Holocaust of World War II. Outside the museum building is a series of mass graves, about 260,000 bodies buried together in the hills above the city in which they were brutally murdered over 100 days in 1994. Only about 15,000 of those bodies have been identified; the long black wall on which these names appear is mostly empty, awaiting the possible identification of other bodies buried beneath concrete slabs. Every town in Rwanda has a mass grave, a memorial to the genocide. Whenever remains are uncovered from the genocide they are added to the nearest memorial, another anonymous death among so many. Yet, in every single town and at the entrance to each district and sector (a sector here is the subdivision of a district, like a county in the US) is a sign that says, paraphrased, “Genocide never again. Eliminate the ideology of genocide. Rwanda together as one.” The sentiment “never again,” which arose after the Holocaust, is apparently taken seriously here. It is clear that Rwandese people identify with those who have experienced genocides elsewhere in the world and in history; the museum at Kigali’s genocide memorial demonstrates that. Unfortunately, this firm belief in “never again” seems to have stopped at Rwanda’s borders. Genocide currently rages in Darfur, Sudan, and just across Rwanda’s borders is a massive war in the Democratic Republic of the Congo, which has claimed more lives than any war since World War II. Not far is the war in Northern Uganda, another conflict with ugly patterns that Rwandese seem to identify with. And, as with Rwanda’s genocide, the world is watching (or forgetting) these three conflicts, relatively quietly and always from the sidelines. Rwandese are most upset over what is taking place in Darfur, I think because it feels most familiar to them, but the people to whom I have spoken about Africa’s wars shake their heads and look down, a sense of recognition apparently coming over them. Why does it seem that we never learn our lessons that all human lives are equal and that no matter where the war and what the cause, we must stop and think about whether we are violating a pact that humankind made with itself sixty years ago? “Never again” should mean something everywhere. Not just in places where it has been violated.

Condoms are a girl’s best friend. Really. Condoms can save everyone’s lives when it comes to HIV/AIDS. But women benefit especially from condoms. First, women are biologically two to three times more likely to acquire HIV than men, because of the way our bodies are constructed. But socially, culturally and economically in every country in the world, women have much more vulnerability than mere biology. Women are more likely to be poor, which makes people do things they would never otherwise do to survive. They trade sex for food or their children’s school fees, stay in abusive relationships because their husbands earn the money, forgo an education so their brothers can go to school and they can gather firewood and water, and earn substantially less money than men for the same work. All of these factors mean that buying condoms is quite a luxury for many women, that knowing about condoms or where to acquire them is all too rare, that being able to insist on condom use is a near impossibility.

These are the reasons that women now make up more than half of the people living with HIV worldwide; here in sub-Saharan Africa they are 60%. And climbing. In Rwanda, only 2.5% of women have ever used a condom. It’s a wonder HIV prevalence here is only around 3%! Most women here don’t even know where to get a condom. And meanwhile fertility rates are through the roof, with the average family having 6 or 7 children even though most women say they don’t want that many kids. Let alone the question of whether they can afford that many kids. So part of my focus here is to increase the number of women, particularly young women, who know that condoms provide what we call “dual protection”: protection against pregnancy and protection against HIV. And that they know how and where to get condoms. And how to negotiate condom use with their partners.

My emphasis on condom use here is another reason I am glad to be working on behalf of the Global Fund. The US government’s AIDS program PEPFAR requires that countries spend one-third of all money for AIDS prevention on abstinence-only education. This means that countries have to be careful how much money they spend on condoms and related activities. What a relief that I didn’t have to think about this in writing Rwanda’s Global Fund proposal. Rwanda needs condoms and condom education, and that is what I will request. Meanwhile, President Bush has announced his request for the next five years of PEPFAR. Yes, he asked for a lot of money. But money with a counterproductive and dangerous requirement such as this one for abstinence-only isn’t as good as money that allows for countries to use it flexibly. This is what the Global Fund does—gives countries the flexibility to use money in the way they think is best. So, two lessons, embedded in one. First, the next five years of PEPFAR must erase the abstinence-only requirement and instead provide discretion to countries to use US AIDS money in the way that is best for them. Second, we must make sure the Global Fund has the money it needs. If it doesn’t, I hate to think of all the Rwandese women who will have to go without condoms, their lifesaving friends.

Friday, June 1, 2007

It's All About Saving Lives

It’s pouring rain outside as I write this. It’s the end of the rainy season here in Rwanda and the storms are just what you picture for a tropical rainy season: they come on fast and hard and the sound of the rain pounding on everything is an amazing reminder of the power of nature. There is a tree outside my window in which live at least 5 species of birds (those are just the ones I’ve seen and heard, including the one who insists on waking me up before the sun every single day). Every time it rains I try to see how the birds are fairing in a seriously blowing tree. But the rain is too blinding!

I’m glad the rain held off until the evening. Today I visited WE-ACTx, Women’s Equity in Access to Care and Treatment. WE-ACTx is another local organization supported by American Jewish World Service (but like so many local organizations, WE-ACTx still struggles for adequate funding).

WE-ACTx was conceived to meet the needs of women who were raped during the genocide and acquired HIV as a result. Estimates vary, but in general people believe that somewhere between 250,000 and 500,000 were raped during those 100 days, and 75% of them got HIV as a result. During the genocide, rape to pass on HIV was policy, a genocidal decision that means that for many women the genocide continues to this day. Although associations for women living with HIV had sprung up across Rwanda (and there are still over 1000 such PLWHA associations here, in a country the size of the state of Maryland) genocidal rape survivors needed more than just antiretrovirals to treat their AIDS. They also needed psycho-social care and health services for their families. So WE-ACTx decided to fill this need.

I met with a range of staff at WE-ACTx’s office and toured its downtown clinic (it operates two other clinics, as well as a clinic for voluntary counseling and testing for HIV). All of its 4000 clients receive free care, including pricey AIDS medicines and psychotherapy, both in groups and one-on-one when they need intensive mental health care. A number of the 4000 clients are children, and, if memory serves, around 400 of these kids also have HIV. It’s an absolute tragedy. Some got it from mother-to-child transmission during birth or breastfeeding, but surely others got it because they had high-risk sex—either they were raped or they traded sex for something they needed, one of the saddest decisions a poor person can be forced to make. But thanks to the compassion and vision at WE-ACTx, these kids, and their parents, can get the lifesaving care they need. As long as WE-ACTx can afford to buy the medicines.

Some of you may know that my mom and step-dad are both mental health workers, so I am particularly attuned to the need for mental health care, especially in a country such as this, where I believe that almost everyone suffers from post-traumatic stress disorder. In so many countries, especially in sub-Saharan Africa, mental health care is a luxury. Few universities offer training or degree programs, and few people could even afford to go to a therapist anyway. Plus the stigma of such a need is still really high. In many ways, Rwanda is no exception. The difference here is that something happened that made EVERYONE realize what mental health is and how it can affect life. As a result, the government developed a degree program for clinical psychologists at the university here in Kigali, and the Swiss development agency designed a training curriculum for lay-counselors to use in addressing trauma across the country.

Of course, there still aren’t enough counselors. But I’ve written into the proposal I’m here to produce a drastic increase in trauma counselors. I really hope we get funding for that activity. Not only is mental health important for its own sake, but it’s important for AIDS too. Traumatized people are less likely to consistently use condoms, and more likely to use drugs and alcohol—which we all know impairs our decision-making skills. That means that trauma is a risk factor for HIV/AIDS. So far, Rwanda’s HIV/AIDS prevalence isn’t as high as some neighboring countries, and we’d like to keep it that way. An important factor will be to address the trauma suffered by nearly every resident of this tiny, beautiful place.

Tomorrow I’m off to experience some of the local beauty—heading to Volcanoes National Park for a trip to see endangered silverback gorillas high in the mountains near the Congolese border. I can’t wait! It will be quite a change from budgeting and proposal writing here in the city. To be continued…

Wednesday, May 30, 2007

Raising Local Voices

A large portion of the work I do relates to the nexus of violence against women and violence against children and HIV/AIDS. Sometimes this connection seems fairly obvious, especially when we’re talking about rape. Sometimes it’s less obvious, like the case of physical or emotional abuse, but there are still important links (if you want to know more check out our Zero Tolerance report, linked below). In the US, if a woman goes to a doctor with bruises, broken bones, signs of violent sex, doctors will often ask questions to figure out whether she is being abused by someone. This oversight is even more pronounced with children, whose teachers are often the first to intervene in cases of child abuse, because they have been taught to recognize the warning signs. Of course, many many cases of abuse go unnoticed or are consciously ignored—even in the US we often think of abuse as a private matter. But it isn’t. It is a human rights and public health crisis, and it happens all over the world.

There are a lot of links between violence, especially sexual violence, and sexual and reproductive health (SRH). We often have to make this argument, but here in Rwanda, with this country’s history of violent rape associated with the genocide, and the serious sexual and reproductive health consequences of it, the links between violence and SRH are actually policy. And in fact, a major reason I’m here supporting Rwanda’s Round 7 Global Fund proposal is that the country wishes to expand services to prevent and respond to violence against women and violence against children as part of its national HIV/AIDS efforts.

While I’m here I’m trying to gather information about how things work here, the types of services that exist and are successful, how much they cost, etc. So today I visited the Rwanda Women’s Network, which receives support from one of our close partners, American Jewish World Service. I spent a few hours talking to Mary Balikungeri, the founder and director of Rwanda Women’s Network, which runs the Polyclinic of Hope and the Village of Hope. These programs are innovative and exciting, and Mary’s enthusiasm for her work was absolutely contagious. The Polyclinic provides services for women and children who have experienced sexual violence—human rights awareness programs, trainings on legal procedures and support for the legal process for those who decide to file charges, basic health care and HIV/AIDS services, and socio-economic empowerment. I’m trying to apply this model as I write the SRH and HIV prevention components of the Global Fund proposal, and I learned so much today about the importance of empowering local communities to advocate for their own needs and to support one another when violence takes place around them.

At one point, Mary talked about how fundamental it is to consider Rwanda’s history (the genocide of course) in trying to plan programs that focus on letting Rwandans live together in peace. She said that she wonders if the genocide ever would have happened if communities, especially the women in them, had been empowered then as many are becoming now. She said that if Rwandans don’t want to go back to that point, they must focus on raising the voices of the Rwandan people starting from the most local level. I truly hope that the Global Fund will see that the voices of individual women and children who have experienced horrible violence must be raised, and that the best way to do that is for the Rwandan authorities to provide financial support to community leaders and community-based grassroots organizations so that they can articulate their own needs and desires. I am glad that Rwanda Women’s Network has been doing just that, and I (and Mary too!) am grateful for American Jewish World Service’s support of such an outstanding organization!

With this in mind, I’m now off to continue costing the HIV prevention activities we have proposed for Round 7. Those of you who know me are aware that math is not my favorite thing. Yet, when so many lives potentially hang in the balance, I will muster the aptitude and strength to do math all night long!

Sunday, May 27, 2007

Thoughts on Rwanda's Kids

I brought some DVDs here to Rwanda to watch on my computer, and last night, in honor of Friday and a weekend of work ahead of me, I watched the South African film Tstosi (mild spoiler warning here, but also a strong recommendation to those of you who haven't seen it; it's an exquisite, heart-rending movie). After it ended, I stood in the window of my hotel room looking out at the lights of Kigali spreading below me and up into the hills that surround the city, and I kept thinking of all the suffering—and all the surviving—that was going on at that very minute in the very place I am right now.

There was so much in Tsotsi that is real. The ways that people will do anything to live, find any way to keep going and to meet the needs that each of our bodies and souls have. Somewhere below me and all around this country are children who are alone. Their parents might have died in the genocide or of AIDS, or maybe they were abandoned or left home like Tstotsi did, only occasionally looking back, fighting for survival through pain and sickness, hunger and trauma, and above all, loneliness. They may not even be able to feel anything or to remember a time before this one, but no matter what, they keep going. I guess life just seems worth living. There are people who are driven to do terrible things in the name of survival, but in the end they are still human, still motivated by the same things that cause orphans to band together, women to sell their bodies to feed their children, men and boys to jack cars and sell them for parts before going home to kiss their mothers and wives hello. Somewhere in the hills around me is a group of kids trying to survive as one, dealing with whatever memories haunt them, still drawn to human companionship despite it all, no matter how much people may have disappointed or hurt them in the past.

Sometimes the work I do starts to feel like just any other industry, the business of saving lives. We can argue over petty things sometimes, or lose track of the big picture as we get bogged down in strategic details. Some people even lose their connection to their hearts and compassion, the things that drew them to this work in the first place. In Washington or here in Kigali, surrounded by people who work for USAID and the Global Fund and the UN and all sorts of NGOs from around the world, it can occasionally feel like a job is a job is a job. People joke that I am a do-gooder, trying to save the world. Sometimes I think my friends say it because they have the confidence that I can actually make a difference, but sometimes I think it is a comment on the fact that there are so many of us and that global health, human rights and humanitarian work are themselves just another field, like business or technology. But the truth is that we ARE trying to save the world, as many lives as possible at a time.

Although it was just a movie, Tsotsi reminded me that I do this work for a reason. Yes, I'm a bleeding-heart who just cried through a movie and then cried harder looking out my window. Yes, I believe that people are good, and that when people do bad things they deserve our compassion and our effort to understand the experiences that drove them to it. And, yes, every now and then I feel like my job is just that: a job. But I look around the streets of Kigali and I remember what happened here in 1994 and I look at the hope that is here now, the very clean streets, the sense of complete safety I feel walking alone through the city or getting into any taxi I see, the sincere desire of the government to make this country the best it can be, and I know that through all the tragedy and trauma and sadness and heartbreak, underneath it we all want life. Joy and laughter and love, too, but most importantly, life. Yet, in trying to preserve life, we manage to sometimes find those other things, too, even when life is as hard as it can be.

In a meeting yesterday with the consultants writing Rwanda's Global Fund proposal we discussed the number of orphans and vulnerable children here in Rwanda. The new assessment is astonishing: 56% of all Rwanda's children are estimated to be orphans or otherwise vulnerable. The thing is that, unlike most of the rest of the world, this proportion is expected to decline over the next few years. While progress in fighting AIDS and in providing treatment for those who need it is part of the reason, another reason is that the last of the kids orphaned by the genocide will turn 18, will no longer be kids. So where does this leave them? I guess the lucky ones got services, got an education, will be able to have healthy educated families that will rise out of poverty and contribute to this new, post-genocide Rwanda. But many still struggle, living in shacks or in ditches or doorways, wandering the city barefoot and begging for food in a language I cannot understand (today one of my new young friends was needlessly hit on the head by a policeman's baton while he sadly watched me drive away in a taxi), shaking with malaria's fever or dying of AIDS.

It sounds so melodramatic, so hopeless. But it isn't. Here are a few truths: People will do almost anything to survive because something inside us tells us that life is an adventure worth living; and we can help them. Yes, my job is part of an industry dedicated to making the world a better place. But our goal is what's important, not the size and scope, or the fact that sometimes we spend too much time away from the reality that we try every day to get Congress to confront. So many people do not know pure happiness, don't remember their mother's loving arms or their little brother's laugh—or maybe even the sound of their own—but there are ways to make this world a better, brighter place. I guess in the end, no matter how sad it sometimes makes me, I'm glad I've found my way to contribute. I hope that everyone else can find a role to play, too.

Thursday, May 24, 2007

I'm In Rwanda!

I never thought I'd be able to say (or write) this, but I'm in Rwanda! I'm here as an advisor for UNAIDS to work with the Country Coordinating Mechanism of the Global Fund to Fight AIDS, TB and Malaria on its HIV/AIDS proposal, due in July. That's a mouthful! Actually, it's very exciting. Links between sexual and reproductive health and HIV/AIDS seem obvious--both have a lot to do with sex--but very few countries have made a real effort to integrate these services and to make them available nationwide. Rwanda, along with a handful of other countries, is prioritizing this integration for its Global Fund Round 7 proposal. And I get to help them do it!

Sexual and reproductive health (I'm calling it SRH from now on, 'cause that's too much to type every time) includes things like family planning and contraception, pre-natal and post-natal care, HIV counseling, testing and treatment for sexually transmitted infections, and recognition of and response to gender-based violence, especially sexual violence. Sadly, Rwanda has a history of sexual violence stemming from the 1994 genocide, during which as many as 500,000 women were raped and about 75% of them acquired HIV. Unfortunately, the phenomenon of widespread rape has apparently continued, with mostly orphans and other vulnerable children being the target. Thankfully, Rwanda's leaders in responding to the HIV/AIDS epidemic here recognize the importance of incorporating SRH and gender-based violence in all settings that provide HIV/AIDS services. So I'm here to help them figure out how best to do it.

I'll write more later on work stuff. For now I have a few more personal things I want to say. First, Kigali is a beautiful city. There are tree-covered hills everywhere you look. People are so friendly. But there is still a weight here, a memory of horrible atrocities that took place only 13 years ago. The Rwandan people have tried so hard to build a harmonious and compassionate society in the wake of the genocide, and I can tell how important this is to them. They have a quota system, so that at least 30% of elected officials and high-level offices have to be women. I've been told this is because they believe that if more women had been in power in 1994 the genocide might never have happened. There are signs of hope everywhere. Yet driving down the streets I keep picturing the film "Hotel Rwanda," and it almost makes me cry to think of what took place on these quiet streets filled with women carrying plantains in baskets on their heads and men strolling into downtown. Everyone points out the Hotel Mille Collines, the hotel in which "Hotel Rwanda" takes place, as if it's assumed I know its history. It's really intense. And yet my purpose in being here is evidence that things are changing, that the government and the people are determined to set an example for post-conflict development and peace. I know they can succeed!

So, I'm off to eat dinner and prepare comments on the current Round 7 proposal, so that tomorrow we can really begin the work of building SRH and violence services into all HIV/AIDS services here in Rwanda. Till then...

Tuesday, February 20, 2007

Final Thoughts

Well, I'm back in the States and finally beginning to process all the fascinating and wonderful experiences I had with my colleagues in South Africa. I've posted a sort of wrap-up on another blog, RH Reality Check, a blog that focuses on reproductive health rights, including the intersection of HIV/AIDS and violence against women and children. So check out my final installment at and then explore RH Reality Check (the homepage of the blog is

Saturday, February 10, 2007

A Global Movement

There is something wonderful about being part of a global movement, particularly when your work is in solidarity with the people whose lives you are working to improve, tethered to a reality beyond the gilded marble halls of Congress. Yesterday’s National Executive Committee meeting of the Treatment Action Campaign (TAC) was so inspiring, a real reminder of why I do the work I do. Paul and I were invited to observe the meetings with a range of South African partners and TAC’s coordinators from the 6 provinces in which they work. The day began with a long delay, because it was the opening of Parliament. This meant that there was a series of parades, a band in kilts (why kilts I have no idea!) and then all three branches of the South African National Defense Forces and the police. After a long while motorcades made their way down the street and to Parliament, where President Mbeki gave his State of the Nation speech. He mentioned HIV/AIDS, apparently for the first time. But whether this will lead to actual change remains to be seen. The pomp and circumstance was typical of governments everywhere, and only reminded me of the incredible economic disparities in and around Cape Town, and in all of South Africa, for that matter. It was very interesting to stand in the 15th floor window and watch this hoopla on the street below.

When the meeting finally began, we had a fascinating briefing on the current court case in India against Novartis, a case that will hopefully result in lifesaving (and expensive) AIDS drugs being available in cheaper generic versions (for more information see the website of Doctors without Borders, We also learned about Extremely Drug-Resistant Tuberculosis (XDR-TB), which appears to be exploding here in South Africa. TB is the number one killer of people living with AIDS, so a version of TB that essentially cannot be treated is a very serious concern. And then one of the women present began a beautiful song, I believe in Xhosa but possibly in Zulu. A minute later, almost everyone was on their feet singing along, clapping, dancing in their places. A reminder that we were in Africa, and a spirited beginning to a really powerful day.

The folks from TAC discussed the current political climate here, but also the programs they will focus on in 2007. One of these is violence against women and children. TAC is supporting a few of its members in their court cases regarding rape, trying to ensure that the investigations and cases are carried out appropriately and in full respect of equal dignity and human rights. This program is called Access to Justice. I really like that name; it mirrors the common AIDS-related phrases “access to comprehensive prevention” and “universal access to treatment,” situating violence against women and children squarely within the context of HIV/AIDS.

Throughout the day I really came to feel that the work we do at the Global AIDS Alliance—fighting for evidence-based prevention and universal treatment access, for primary school for everyone, for the protection of orphans and other vulnerable children, and of course, for the prevention of and appropriate response to violence against women and children—is exactly the work that people in South Africa need, and are doing themselves. I felt empowered. And inspired to go home and continue this work. And hope that I get to come back to South Africa again to see my new friends and get a renewed lease on my conviction that we can do something about this terrible pandemic that will eventually kill some of these new friends, and will certainly kill many people that they know and love. It’s good, righteous work, and I’m glad to be in an international community of people doing it together.