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.

1 comment:

Crystal said...

People should read this.