As we leave Rwanda, one word stands out in my head as the biggest lesson I learned here. The word: interconnected.

This is not a convenient word, given that people often feel the desire to create direct, singular answers to questions facing us. We want to have an X that leads to a Y. Or, we want to have an X that will fix a Y. And we say that if you cannot identify an X, you should keep looking. We see it with the AIDS crisis. People want a one word, or one phrase, answer that explains why it persists despite what seems like a great deal of attention and effort. And people want a singular answer that explains how to fix it.

I would have loved to come away from Rwanda with a one-word, or one-phrase answer to either of these questions. But, if one thing became clear during our time in Rwanda, it is that the AIDS crisis here is not the result of one problem, nor will it be fixed by one solution. This is not a novel concept, to be sure. Partners In Health came to Rwanda to provide the type of comprehensive care that recognizes the complexity of challenges facing the poor here and addresses these challenges head on. Watching them do it in action was a truly inspiring experience.

We saw how multiple issues are interconnected throughout our trip. We saw it when we traveled with Partners In Health’s accompagnateurs and social workers on their home visits. In the home visit I wrote about in our previous post, we saw the role of poverty, both individual and societal, in facilitating the spread of HIV. We visited Vestine, an HIV-positive woman who was pregnant and due to give birth in the coming weeks. In this developing and largely rural country, vast portions of the population have lived their entire lives without access to medical care. Before PIH came to Rwinkwavu two years ago, Vestine would not have had the option to give birth to her child in a hospital. She would have had to deliver her child at her home, with no medication, and subsequently begin breast-feeding. The chances that a mother will transmit HIV to her child during birth or breast-feeding without treatment are roughly 20-50% (www.avert.org/motherchild). Every year, hundreds of thousands of children become infected with HIV through Mother to Child Transmission (MTCT) despite the fact that it can be prevented through treatment and the use of infant formula. 90% of those infections occur in Africa where people simply do not have access to these options. PIH in Rwanda is now providing such access. PIH has developed a Prevention of Mother to Child Transmission (PMTCT) program at its hospital in Rwinkwavu, where Vestine and others like her can go to have their children delivered with treatment, by cesarean section, and put on a carefully monitored infant feeding program. Thanks to the development of this program, children in the Rwinkwavu district in Rwanda no longer need to be born HIV-positive.

When we visited the PMTCT program at the Rwinkwavu hospital, we saw again how the HIV crisis is connected to the problems of poverty, of the lack of infrastructure, and of the presence of other diseases and conditions. Before PIH came to Rwinkwavu and instituted its PMTCT program, many HIV-positive women would breast-feed their children due to lack of education or lack of options. However, even those who were able to receive infant formula faced the difficult task of finding clean water to add to the formula. In much of rural Rwanda access to clean water is limited. In one of our home visits a woman told us that her husband walks more than 5 kilometers every day to bring clean water from a pump. If he did not go, she would not be able to get clean water because the pump is so crowded that you need to push your way to the front or you can spend all day waiting to get access to it. We learned in Rwanda of the difficulty that many women have faced when they learn that breast-feeding raises the risk of transmitting HIV, find a way to obtain formula, only to mix it with contaminated water putting their infants at risk for bacterial infections that can lead to dehydration and even death. Now, PIH provides the mothers in its PMTCT program with infant formula, along with food packages and a stove, Jerry can, and gasoline in order to boil water to ensure it is not contaminated. The infants in this program are far less likely to receive HIV from their mothers than they would have been had they been born in Rwinkwavu just a couple of years ago. Still today many infants die in Rwanda and across Africa today due to the lack of access to clean water. This challenge served as yet another powerful reminder of the interconnectedness of the direct role of poverty in multiplying the health challenges facing poor people in rural Rwanda.

We saw the interconnectedness of issues again when we visited a 73 year old HIV-positive man who was nervous to let people, including his wife, know his status, for fear of allegations of infidelity. He had contemplated suicide. He also told the Rwandan PIH social worker that he thought HIV was transmitted by younger people and that at his age he could not transmit the virus and was not putting his wife at risk. We sat in his home and listened to the social worker talk to him about how HIV was not a death sentence, about how he could get treatment at PIH. We listened to her tell him about how HIV is transmitted, and why he needed to encourage his wife to get tested for HIV. In this house we saw the challenge of social stigma come to life. And we saw the challenges posed by the lack of education about the nature and spread of HIV come to life as well. This challenge was striking. How was this man supposed to know about the methods of transmission of HIV? Would I have known had I not been taught in school? Before PIH came, nobody had talked to him or his family about HIV. But with one simple visit from the PIH social worker, the man agreed to talk to his wife, and she agreed to come to the hospital for an HIV test.

So, rather than identifying an X, rather than identifying one thing that explains the persistence of HIV or one thing that will stop it, this trip only reinforced the need to provide comprehensive care that recognizes and addresses the interconnectedness of the challenges and the necessary treatments. Partners In Health provides this type of comprehensive care to the poorest of the poor in rural Rwanda. It treats people for everything from HIV/AIDS to cancer to malaria to broken bones. And it cares for people beyond the direct application of health care as well. It has provided hundreds of its patients with corrugated metal roofs to keep their houses dry - a preventive health care measure. It provides materials to ensure that HIV-positive mothers can provide their infants with formula that is mixed with clean water. It provides education for patients at Rwinkwavu on agricultural practices in addition to preventive health practices. And it supports income generating activities, such as the FACE AIDS pin project that we run in Rwanda, to help facilitate patients’ efforts to lift themselves out of poverty. Through this range of measures addressing health care on the treatment, prevention, and economic development fronts, we can see in Rwanda that PIH is helping people break the cycle of poverty and disease that has persisted for far too long.

-Dave

Partners In Health’s social workers visit their HIV-positive patients at their homes regularly in order to check both on the patient’s physical and mental status. They help patients with personal, familial, or social problems, and they hear any needs the patients have and report back to the hospitals. We traveled with these social workers to 3 homes. One near the PIH hospital in Rwinkwavu, and two near the PIH hospital in Kirehe. The visits provided an intense education about the issues facing people with HIV in rural Rwanda, and about how PIH brings health care to people who previously had none. Below is an account of one of those visits.

We left at 8 AM and drove about 20 minutes over dirt roads, heavily rotted and extremely bumpy, through a rural village near the PIH hospital in Rwinkwavu in east Rwanda, just 20 minutes from the border with Tanzania. We rode with a PIH-employed Rwandan driver, social worker, and health worker. We had some trouble finding the home of the woman we were going to visit. There are certainly no numbers, addresses, or street names (let alone streets) deep in these villages.

When we found the house, we parked the car (meaning we turned off the engine) and walked along a path dense with banana trees toward the woman’s home. Her house was about 15 feet by 15 feet. The floor was dirt - no different than the dirt outside. The walls were made of bricks of mud stacked on each other, with visible spaces in between the bricks where they weren’t fully flat. Flies clung to the mud and darted around in the dark room, and some rocks held down a corrugated metal roof resting on the top. The hut had two rooms. The main room, where we sat, was about ten feet by ten feet, with one small bench and table. The smaller room had room for just a bed.

Her name is Vestine. She is 40 years old, and is HIV positive. She is receiving anti-retroviral therapy (ARVs) from PIH and remains healthy. She has a 7-year-old boy who is not HIV positive, and is pregnant with another child. She had her 7-year-old with her first husband. Her husband had died at war after their child was born. When her husband was alive, they had lived in the north province of Rwanda. But after he died she moved to the Rwinkwavu area, in the east, where her brother lives. She had difficulty providing food for herself and her daughter as a single mother, so she decided to take another husband. He is also HIV positive.

The social worker asked her if she was happy about being pregnant. Vestine responded that she was not planning it, but now there is nothing she can do so she is fine with it. She then said that her partner is very happy about it. He has no children of his own.

She expects to deliver her baby in the end of September. The social worker told her that it was very important that she go to the hospital to deliver her baby and not have it at home. She said OK, but then the social worker asked her how she planned to get to the hospital. Vestine pointed to the sky and said, that’s in God’s hands. The social worker replied that it is not entirely out of her control, that there are things she can do to prepare for it. She asked Vestine if she could take a minibus or taxi to the hospital when she feels the onset of labor. Vestine replied that they do not have any money, and that her partner works in agriculture but only enough to barely buy food, and they just tried very hard and saved enough money to put a corrugated metal roof over their house, so now they have absolutely zero money, but she will try. The social worker then started asking about her partner. Vestine said that she is concerned about how her partner will support her and her children, as they have had issues in the past over the support for her child from her previous marraige.

The social worker reminded Vestine that she was due for a check up appointment at the PIH hospital on September 20th. The social worker took a deep breath and smiled, having finished the session. She then asked a final question: do you hope to have a girl or a boy? Vestine smiled and replied, I don’t care, so long as my child is healthy.

Visiting Vestine taught me so many things. But the number one thing I took away was a question: what would she have done before PIH? It seems certain that she would not have had the option to receive medical care for her HIV, nor to deliver her baby in a hospital. It is still difficult for Vestine. But now that PIH is there, and directly reaching out to her to ensure that she takes advantage of their presence, she has the opportunity to safely deliver her child. She has the opportunity to enroll in their prevention of mother to child transmission program, which will drastically increase the chance that her child will not be born HIV-positive. And she has the opportunity to receive anti-retroviral therapy so that she can live many healthy years to provide love and support for her two children. What would Vestine, and so many others like her in the 170,000 person catchment area that Rwinkwavu serves, have done before PIH? I knew the answer to this question before we went on the visit. But I guess sometimes a story can make a person understand better than a number.

-Dave

As I mentioned in my first post, this week is when I officially step aside as Executive Director and into my new position as Chair. Dave Ryan will now be the Executive Director. This final post from me is the letter I wrote to all of the students involved in FACE AIDS. It’s meant for students, but I’d love for anyone else following along to read it! If you are a donor or supporter of some other sort, you’ll receive a letter in the mail from us soon.

Thank you all for the support!

Dave is a phenomenal writer, so keep reading the blog as we finish up our trip!

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Dear FACE AIDS student leaders,

I hope all of you are starting the school year well!

I’m writing from the Partners In Health Hospital in Kirehe, Rwanda. It has been a dream of mine for years to see Partners In Health in action, and it has surpassed my expectations. I can’t tell you how great it feels to see the impact that Partners In Health, and all of your fundraising, is having in rural Rwanda. As I said in a post on our blog, “This hospital out in the middle of nowhere is the frontline of the battle for social justice for the poor. This is where one of the most important questions of our generation – are all people’s lives, rich and poor alike, equal? – is being answered with a resounding yes.” It is a privilege to be here.

It’s also a nice place from which to send my final email as Executive Director. I am moving to the position of Chair (which will primarily entail fundraising for operating costs and challenge grants), and to the position of college undergraduate. =) As I return to school this year, I hope you’ll welcome me into the ranks of student volunteer. The past two years have been the best of my life. Nothing about FACE AIDS makes me want to leave this position. I love our mission. I love the people. And I love where it is going. I am stepping down to finish school, and to ensure the longer-term sustainability of our organization by turning the reigns over to a new generation of leaders. I firmly believe that the people replacing me can do a better job than I can at growing this organization into what it can and has to be. They are amazing! So now let me introduce you to the full-time FACE AIDS team:

Dave Ryan, Executive Director

Dave told us in November that he wanted to work full time to help build FACE AIDS. It was an exciting moment for us, because Dave is a great manager and leader. From January to June, Dave led a research team to look at many of the biggest social movements of our time and develop ideas for how our organization can improve going forward. He’s got a great vision for the future of FACE AIDS, and is going to lead us incredibly well.

Katie Bollbach, Africa Program Director

Katie is one of the co-founders of FACE AIDS. She worked full time during the 2005-2006 academic school year developing our programs in Zambia, returned to school for the 2006-2007 school, and is spending this year setting up our new program in Rwanda. What she helped create in Zambia was amazing – the new program in Rwanda will be even better!

Annie Kalt, Managing Director

Annie has been involved in FACE AIDS since we first got started. She designed many of the educational materials you received, and helped plan both of our conferences. This summer she worked in Mwange Refugee Camp with FORGE, educating women in the community about maternal health. Last summer she worked in Brazil on TB. She is a great advocate for the poor, and an incredibly kind person.

These three are amazing people. That said, FACE AIDS is about the student movement. These guys can’t do anything if you aren’t on board. So, I hope you will stay involved, recruit more people, and make this a part of your life for the long haul!!

As a final note, I want to tell all of you about a boy named Bisengye. Bisengye was born in a refugee camp in Tanzania after the Rwanda genocide. We don’t know how, but his parents died, and he was adopted by a kind elderly couple. At 11, Bisengye suddenly fell ill. He dropped below 20 kilos (44 lbs), and his body was covered with lesions. His surrogate parents brought him to the newly opened PIH clinic. Upon arriving here at Kirehe, he was hospitalized, and immediately put on treatment. Bisengye is now a healthy 12 year old boy.

The drugs for treating a child with HIV cost only $0.20 a day, yet the vast majority of children with HIV don’t have access to treatment. If Partners In Health hadn’t started their program here in Rwanda, Bisengye would not be alive today. It’s possible that Bisengye is one of the patients whom PIH was able to reach because of your hard work and fundraising. And if it wasn’t Bisengye, it was someone else who would not be alive today if not for the funds you’ve raised, the events you’ve held, and the compassion you’ve shown. Thank you for everything you have done.

But we’re just getting started. This has to be just the beginning. If we grow this movement into the force it needs to be, Bisengye will not be an exciting exception, but the norm. With your energy, I am confident that we will do this. Thank you for helping build this movement!

Sincerely,

Jonny

Katie and I visited the National University in Butare this weekend. This is the best school in the country, so it was a great privilege to get to spend several hours with the leaders of the Anti-AIDS League. We met 5 leaders in total, but spent the most time with Peter and Ambrose – two fourth your medical students. They gave us a two hour tour of the University and had a long conversation with us about the future of our respective groups, and the broader issue of AIDS in Africa. It was extremely interesting.

The University is very impressive. Ambrose told us that 9,000 students in total attend the school, all on a full ride from the government. They told us that admission to the University is entirely based on merit, which they were both very proud of. The campus is really very beautiful. We saw the medical school, the gym - which was packed with soccer players, the main quad, the genocide memorial, and the library – pictured below.

Seeing the campus was very fun, but the evening conversation with Ambrose and Peter was the highlight. These guys are both incredible student leaders. Through their work with the League, they educate students at local high schools, work with cooperatives of people affected by HIV, make sure condoms are available all over campus, and organize big public events, including a conference on AIDS for medical students from all over East Africa happening in December. They are both extremely dedicated and impressive. They take their work very seriously. We met up for a few drinks to talk about our work, and they quickly pulled out pens to draft an agenda for a conversation. We each asked each other a few questions, and had a great conversation.

One quote stood out from the night: “Life first, the rest can follow. You have to deal with AIDS…once you have life, you can seek other means to survive.”

This was Ambrose’s reply to our question of how HIV can help lead to other development work. We were struck by how strong this quote was. He was adamant that HIV must be addressed first. He talked about how when a family member has HIV, he slowly destroys his entire family, not just his own life. AIDS kills entire families, he says.  If hundreds of thousands of patients have a death sentence that is going untreated, then hundreds of thousands of families are relegated to poverty. It makes sense that HIV must be addressed first.

That said, the second part of the quote is a chilling reminder that treating someone with HIV is only step one to lifting oneself out of poverty. While they wanted to drive home the importance of addressing AIDS now, they also shared the belief that this is the first step in a longer path. Being treated does not make one a survivor. Being treated gives one the opportunity to work hard to become a survivor… in the face of yet more structural violence working to impede progress. It was a good reminder for how hard this chapter of Rwandan history will be. It’s a good thing this generation has leaders like Ambrose and Peter to help take on this challenge. These two are incredibly busy students living on a budget of just $45 a month, yet they chose to spend their free time fighting HIV. It was an honor to talk to them, and an honor to have them propose that we partner.

While working with American students alone is exciting, a true global movement of unified students would be unstoppable.

I know they are reading this – thank you Peter and Ambrose!

I promised that today I would write about how PIH does what they do.  It’s a bit too much for one post. I’m going to write a post about the nuts and bolts today. My next post will be about some of the individuals who are impacted by it.

Rwinkwavu Hospital is the center of an amazing health delivery system serving a “catchment area” of 470,000 Rwandans. The hospital itself has a welcoming entry, a women’s ward, a maternity ward, a pediatrics ward, a malnutrition ward, an advanced laboratory, an x-ray room, a pharmacy, a fully functional operating room, and a room for processing electronic medical records. The walls are covered with beautiful murals and before and after photos – of both people and the buildings themselves. You can see how one room went from a small dirty hole-in-the-wall to an advanced medical lab – complete with a machine for performing CD4 counts (a measurement of the strength of an HIV patient’s immune system).  You can also see how baby Jennipher, an HIV positive girl with tuberculosis, was brought back from the brink of death at PIH. It is an amazing place to walk through.

That’s just the hospital itself. The Rwinkwavu complex also has a massive warehouse full of food supplements, staff housing, a training center that can hold up to 150 visitors, and a garden used to teach mothers of malnourished children how to maximize their farm space to keep children well nourished. The grounds are covered by beautiful landscaping, and even a fish pond. If it is done in the developed world, PIH will do it in Rwanda. One of my favorite stories about PIH is the night blooming Jasmine. Paul Farmer planted them behind the maternity ward so that pregnant mothers could smell them at night.

I am writing from Kirehe Hospital, the second major hub of Partners in Health in Rwanda, which is currently under construction. Henry Epino, who many student leaders will remember from his amazing speech at our conference at Stanford last fall, is leading the development of this hospital. The hospital will have all the same facilities as Rwinkwavu. The PIH physical infrastructure also includes 6 “health centers”. These centers can serve patients with many ailments, but refer more serious cases to the hospitals.

While the hospitals and health centers are phenomenal, the core of the PIH model is how PIH reaches out into the community. Despite a catchment area of 470,000, there are no long lines at PIH. This is due to the genius of the “accompagnatuer” model that Partners in Health pioneered in Haiti.  Hundreds of Rwandans work as these accompagnatuers (accompaniers), or community health workers. The community health workers deliver treatment to patients, and ensure adherence to drugs. Many infectious diseases require treatment that must be taken every day at specific times for long periods of time. In the case of HIV, these pills must be taken for a patient’s entire life. The community health workers help people on treatment stick to their therapy. In addition, they identify cases that need to go to the hospital, educate communities about ways to stay healthy, and provide social support to the people they work with. While it may sound simple, these community health workers – poor Haitians, Peruvians, and now Rwandans, are the key ingredient in proving to the entire world that the poor can adhere to advanced drug regimens. And in turn, these community leaders have taken away any excuse for not providing health care to everyone.

The POSER program is another unique element of Partners and Health that is truly amazing. Many of the HIV patients are burdened with a variety of other problems – many of which impede their health improvement. POSER  – Program on Social and Economic Rights – helps address the problems. Right now, this program primarily provides new roofs and homes for patients – an essential step to improving their lives. POSER also works to create and provide jobs for patients, so that they can help lift themselves out of poverty. This is the program FACE AIDS will be working with most closely.

That’s the basics on the PIH model. This post is long, but whether or not you believe it, this is still just the surface. There are other very interesting pieces. I haven’t event touched on social workers, or on the amazing Prevention of Mother to Child Transmission Program. I also haven’t talk about the amazing people that make it all run. Either Dave or I will write more soon!

Thanks for reading!

Jonny

I’m sorry that we’ve been here for three days without writing! Time has flown by. We celebrated Katie’s birthday Saturday night, right after we landed in Kigali and then left for Lake Kivu the following morning. It took three hours by bus to get up to the lake, which was a perfect way to get a better lay of the land. We saw the famous terraced farms of bananas, tea and coffee that cling to every inch of open space here. Rwanda is beautiful. We’ve spent most of our time catching up with each other, planning for the school year, and talking about the future of FACE AIDS. It has been great. The photo below is of us at the PIH house in Kigali.

I couldn’t sleep last night. We all sat up working until 3:00, and then I still couldn’t drift off when I finally got in bed. Today was the big day – we arrived at Rwinkwavu, Partners In Health’s core site in Rwanda. It is surreal to finally get a chance to see PIH in action. I’ve spent much of the last two years talking about their model, their mission, and the movement they lead. It is their example and drive that inspired me to get involved in global health, and the same is true for many of the leaders within FACE AIDS.

It’s hard to explain why this is so special, but I want to try. This is not just a trip to some neat nonprofit. This hospital out in the middle of nowhere is the frontline of the battle for social justice for the poor. This is where one of the most important questions of our generation – are all people’s lives, rich and poor alike, equal? – is being answered with a resounding yes. If you haven’t done so yet, I highly recommend you read Katie’s blog post on Josephine and her son: http://katieinrwanda.faceaids.org/?p=4.

That’s what this is all about. Do we live in a world that values Josephine’s son’s life as much as a boy growing up in America? The answer, sadly, is no. Can we play a role in changing that? I think so. And if our society ever does reach that point, we will have Partners in Health to thank.

More tomorrow on how they do it.

Thank you for visiting the FACE AIDS Blog! 

During the next two weeks I will be traveling in Rwanda with Katie Bollbach, co-founder of FACE AIDS and Director of Operations in Rwanda, and Dave Ryan, our incoming Executive Director. 

We have two main goals for the trip: to visit Partners in Health’s operations in Rwanda, and to spend time with associations of people living with HIV. It’s going to be an amazing two weeks.

We will spend the majority of our time at the Partners in Health site in Kirehe. Henry Epino, PIH’s Medical Director in Rwanda who is based in Kirehe, is a great friend of FACE AIDS and will be our host in Rwanda. We will also spend time in Rwinkwavu, PIH’s first site in Rwanda. Thus far, FACE AIDS has raised more than $750,000, and most of that has gone to Partners in Health. It is going to be an honor to write back to all of you who have supported the work of Partners in Health.

Our direct work on the ground, spear-headed by Katie, is focused on income generation for patients receiving HIV treatment through Partners in Health. When we founded FACE AIDS two years ago, our first task was to help create an association of people with HIV in Mwange Refugee Camp, Zambia, where no such group existed. In Rwanda, these associations already exist, and so our work now is to partner with these community organizations to help create sustainable income-generating activities for their members. Our plan is to use the beaded-pin project as a bridge into more locally sustainable activities, by helping HIV associations to save capital and prepare business models. We are all lucky that Katie has decided to work her magic once again! You can read about her work here: katieinrwanda.faceaids.org.

In addition to these primary objectives, we will be traveling around the country, meeting other NGOs, Rwandan youth, and leaders in government and business, visiting memorials of the genocide, and enjoying spending time in one of the most beautiful countries in the world.

Also, on a more personal note, this trip to Rwanda will be my last two weeks as Executive Director of FACE AIDS. I will be posting a note as I transition out of this leadership role and on to my new position as Chair of the Board, and our amazing new Executive Director will post on his vision for the future of FACE AIDS.

I told you about two of our main tasks, but we have a third one that is extremely important to us – arguably the most important. We want to let you experience as much as possible of what we do in Rwanda. We are carrying cameras, digital recorders, notepads, and video camcorders. Whether you are a student organizer, a donor, an advisor, or a supportive friend, you’ve helped shape this organization and we want you to participate in this trip along with us and see the impact you are having in Rwanda.

I hope you will keep reading!

Jonny