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…