Medical student Kathryn Burge Clair went to Africa last summer with a dream of what global health care entailed. After spending tough but rewarding times in Rwanda and making a couple of harrowing trips to the Congo, she returned to her studies at the University of Colorado Denver School of Medicine with a more realistic view of what it will take to heal the world. What follows are excerpts from her journals.
Part 1
I’m sitting in an ancient Daihatsu truck, wedged between two men in zoot suits that reach four inches off of each of their narrow shoulders, traversing a Rwandan road that my brother, Peter, and his friends would seek out for a four-wheeling adventure. Every time we hit a rock, I go careening into the side of one of them, prompting the one named Prince to say, “No problem, Kate. No problem.” We are on our way to a wedding and using the truck is a treat for the special occasion.
“Kate. I have a question for you,” Prince says as we hit a huge rut, sending all of us pitching forward toward the dashboard holes that once held the radio and glove box. (“No problem.”) “When are you going to get married?”
When I tell him I don’t know, he says, “Well, you are very old in Rwanda, but in America perhaps you are only middle-aged.”
I nod and go flying into his lap as we cross a log bridge.
“I think if you want Rwandese husband, you could be worth three cows.” I think he means this as a compliment. “You are tall and you have doctoring skills. But you have too much education so you do not obey enough. But two cows, no problem.”
We pull up to the Adventist church at the Mugonero Hospital complex, where the wedding we are attending is being held. In 1994, Hutus slaughtered over 2,000 Tutsi women and children in this church, led by a doctor at the local hospital, the pastor and the son of the president of the Adventist church. Prince was one of four survivors. He was twelve years old and was saved when one machete-wielding member of the interhamwe recognized him as the son of a childhood friend. The killer pulled Prince out of the church and told him to hide under a nearby tree until the attack ended. Prince was one of the original residents of the L’Esperance orphanage. I am spending the summer there between my first and second years at the University of Colorado Denver School of Medicine. I work as the orphanage administrator.
We pile out of the truck at the church and about 300 wedding guests gathered outside openly gape at me.
“Muzungu, muzungu,” I hear rippling through the crowds. This is one Kinyarwanda word that I know well; it means “white person.” In the bush outside of Kigali, it is said excitedly wherever I go. Children come racing toward us and stop short about ten feet away, shyly smiling and waving at me.
I am wearing a long brightly colored sarong that reaches to my ankles and a button down shirt; it was my last clean one when I put it on in the morning but I was ready for two hours before Prince came to pick me up, and now I have muddy paw prints down one side of it. Compared to the Rwandese, turned out in their finest clothes, I look unkempt. Lady, the orphanage pet, jumped up on me as Angée and Gideon screamed in my arms this morning. The two toddlers, like most Rwandese people, are terrified of dogs, even one as sweet and friendly as Lady. During the 1994 genocide, dogs ate the corpses and developed a taste for human flesh, becoming so aggressive that nearly all the dogs in the countryside were destroyed after the chaos was over.
“The only thing the UN is good for,” one orphanage staffer told me darkly, “is killing dogs.”
As we file into the church to sit packed together on woven straw mats, I realize that among all of the pungent odors in that church, the distinct smell of urine is coming from me. “Don’t pick up the little ones without feeling their bottoms first,” Aja, the Swiss girl who has lived at the orphanage since March had warned me. There are no diapers in Rwanda. But when two-year-old Susannah calls, “Ka-tee! Mama Ka-tee!” I pick her up every time.
The wedding ceremony doesn’t differ from a traditional Christian ceremony except for the fact that the bridal party danced in unison down the aisle to the tune of an electric piano and anyone who wanted to could run up on the altar to take pictures during the vows. Also, the bride and groom asked to have me in their pictures. “It is a great honor,” Prince explains, “to have muzungu at a wedding.”
For the reception, we walk to another hall and once again pack tightly onto benches while women in traditional dress and head wraps sashay down the aisles with giant crates of soda on their heads. They pass out warm orange Fanta that we sip from straws while we watch the bride and groom cut the cake and listen to the father of the bride give a long speech clad in an ill-fitting suit and a leopard print cowboy hat. Prince and I finish our drinks and walk back to the orphanage, passing one of the many mass graves that dot this area of Rwanda. At this point I’ve been in Rwanda a week and I’ve learned that the memory of 1994’s genocide is never very far away.
When I first arrived in Kigali, Aja picked me up at the airport and we went to the Convent Sainte Famille. It was clean, but very simple, with flush toilets and showers with no hot water at the end of the hall. The small rooms held hundreds of Catholic Tutsi families during the genocide. The former priest, Father Wencelas, would speak with the militia outside the compound and return with a list of names, dutifully rounding up all he could find and identify. Those who survived within the walls either never had their names called or managed to hide from Father Wencelas. One does not come to Rwanda to find faith in religion.
To get to the orphanage, Aja and I boarded a minibus about the size of a Chevy Suburban with 18 other men squeezed in as tightly as we could. I was seated next to Phillipe, a university student in Kigali who is studying law.
“I love United States,” he told me cheerfully. “Barack Obama especially. If he is president, it is a great day for Africa.”
I told him it would be a great day for the U.S., too.
He shook his head, as if I didn’t understand.
“But America always has great days,” he explained. “We don’t have so many in Rwanda.”
The orphanage itself is absolutely idyllic. There are flowerbeds, the largest orchard in Rwanda and neatly manicured lawns. I’ve somehow become used to the latrine although my first trip to it had me promising myself that I wouldn’t eat or drink for the remainder of the trip. At first, the kids looked dirty and I was saddened by their snotty noses, their perpetual thick coughs, their tattered rags, their lack of diapers and the fungal infections that left patches of discoloration on their skin and scalps. Now, I’ve stopped seeing all of those things. I realize that bringing my Western standards of hygiene and basic needs would condemn the entirety of rural Rwanda. The kids are educated, happy and rather well-fed. They live better than most of the children in the surrounding villages.
The orphanage is a cluster of five houses of 20 kids each, a baby house and the main house. I have my own room in the baby house with eight kids under the age of two and their house mother. This means that I wake up at 5:00 every morning when the 12-week-old twins start to cry. I’m usually in bed by 8:30 at night because we have no electricity and you can only read by candlelight for a couple hours.
The kids here have had littler if any medical attention. There is free HIV testing at the hospital, but the children haven’t been tested because the administration is worried that if the kids know they are positive, it will crush their spirits. Because several of the children lost parents to AIDS, I’m figuring out how to get all of them tested before I leave. Victor, the director of the orphanage, has also asked me to compile first aid kits for each house and to train the house mothers in basic first aid. My first step is figuring out how to help the babies, whose diaper rash (or whatever you call it when they don’t wear diapers) is so terrible that they are cracked and bleeding all over their butts and upper thighs. Since most have never seen a doctor at all, I’ve decided the most important thing I can do is try to get a pediatrician to visit the orphanage once or twice a year to do exams on all of the kids.
Right now they only go to hospital when they’re terribly ill. For example, Susannah was having 25 seizures a day before the staff took her to the hospital. Now, her epilepsy is under control. But one of the babies died a couple of weeks ago and because of that the staff seems open to letting me overhaul their system. I spent a week going through their admissions papers – usually penciled documents from mayors of local towns that hand over the children because their parents were killed in the genocide or are too poor to keep them. It was heartbreaking work. I thought I’d be able to pull together some sort of medical history, but other than finding several kids that really should get HIV tests, most of the information I found spoke of genocide and poisonings and witch doctors. When the kids were sent to the orphanage from the malnutrition center at the local hospital, there would be height and weight information that seemed almost physically impossible. This data accompanied stories of treating children found wandering in the village, abandoned in the fields, left at the hospital.
I came back to Kigali this week to get access to email and meet with Dr. Emmanuel, a Rwandese pediatrician who had worked with my mentor, Dr. Gustafson, when he was here last month. I asked Dr. Emmanuel what it would take to get him out to the orphanage twice a year to do physicals on the kids, and he told me that some of the NGOs pay him about 3000 Rwandan francs per child for physicals. He said he would help out the orphanage for 2500RWF (about $5 per child) if I would help him find a Masters in Public Health program in the U.S. and help him with the application process – specifically with all of the English such a program requires. I agreed, knowing absolutely nothing about MPH programs but knowing that finding a local pediatrician who cares was a special gift.
Rwanda is at once everything I hoped it would be and so much more. At the same time, it is harder, more frustrating and even sadder than I thought it could be. Aja has warned me over and over not to become attached to the kids because it’s unfair to put them through losing another important figure in their lives. But every time I cross the compound, I end up picking up several babies. Toddlers follow me around. Older girls ask me to play hand-clap games with them. They also want to play with my hair. Judging from the fact that about 30 kids gave me hugs when the motor scooter picked me up to take me away for a day to Kigali, I think I’m not very good at controlling my emotions.
I’m sure that, like Aja, I will end up with skin fungal infections, lice and worms. I’m just too close to the dirty ones all of the time. But even the fact that my head kind of itches can’t persuade me to keep my distance.
Part 2
Wednesdays are market days in Mugonero. People come from all over the countryside lugging bananas, millet, maize and cassava on their heads, while their young children follow, tugging goats and chickens to sell. Mugonero is the closest town to the Rwandan orphanage where I am spending the summer between my first and second years at the University of Colorado Denver School of Medicine.
The market has a border of women bent over portable sewing machines, patching and taking in clothes that the local people bring in for tailoring. Next in sit the paraffin merchants, women dressed in bright clothes huddling in the shade of umbrellas bearing the logo of the British soccer team Manchester United. The women oversee large cans of fuel wrapped in banana leaves to keep the fuel cool. Most of the food merchants come next, with sparkling sardines from Lake Kivu and bright beans and fresh greens laid out on blankets and straw mats. At the heart of the market, enterprising merchants sell clothes and shoes that were donated by churches and charity drives in the United States. You can tell immediately which colleges have given the most. Catholic schools should be really proud, especially Notre Dame and Gonzaga. I met a Peace Corps volunteer in Kigali who is working in Tanzania. He actually found a pair of sneakers that he had donated a few years ago for sale outside of Dar Es Salaam for $15.
Mugonero is on the shores of Lake Kivu, one of Africa’s great inland seas. The border with Democratic Republic of Congo is in the middle of the lake somewhere, and every Wednesday, a group of huge canoes from the Congo comes across the lake, heavy with beans to trade for Rwandan bananas. This is a system that exists outside the rules of customs and passports. Watching men row dugout canoes filled with green bananas west at the end of the day seems like a time warp to a primitive economy.
As has been the case most places I go, I am quite the spectacle at the market because I look and act differently. Adults stare openly. Kids follow me around, delightedly calling out, “Bonjour! Bonjour!” until I turn around to wave. Sabemana, who is in charge of buying food for the kids at the orphanage, tells me that muzungu (white people) rarely get out of their cars when they come to the market. I think I might be misunderstanding his French. I can’t figure out which muzungu would be in this part of Rwanda. At that moment a sleek convoy of white Land Rovers speeds through town, churning up red dust in its wake. I am just able to catch a glimpse of the pale faces at the steering wheels and the UNHCR logos on the trucks before they are gone, en route to the huge Congolese refugee tent city of 25,000 across the valley from the orphanage.
I’m back at the orphanage now after spending several days back in the civilization of Kigali. I thought I would be excited to be in Kigali for the hot showers, electricity and a variety of food. Instead, I found myself antsy to get back to the bush almost as soon as I arrived. I stayed in a hotel in the middle of town and woke up each morning at 4:30 when the local mosque blasted the call to prayer. This is only a half-hour before the religion teacher at the orphanage bangs on the metal drum in the middle of the courtyard to call the kids to worship. So it wasn’t anything too out of the ordinary. But waking up to the sound of a musallee while sleeping under a mosquito net made me feel like I was somewhere completely foreign.
Kigali is quite a busy little city, full of urban Rwandese and muzungu NGO (non-governmental organization) workers. The only time you see a car less than ten years old, it is white and shiny, driven by someone equally white and shiny, and sporting the logo of some well-intentioned aid organization. You can’t help but wonder how much of the budgets of Save the Children, UNICEF and World Food Program is going towards buying brand new Land Cruisers every couple of years. It is a very safe city though, and I never feel even slightly uncomfortable spending time alone there.
I meet with Dr. Emmanuel, a pediatrician at Central Hospital of Kigali who has worked with my mentor in the Global Health Track, Dr. Gustafson. Dr. Emmanuel takes me with him to the hospital to go on rounds in the pediatrics ward. The hospital is quite lovely, surrounded by shady trees and lawns that serve as waiting areas. There are five main wards in the Peds department – a room for malnutrition, one for tuberculosis, one for chronic illnesses, such as heart defects and cancer, one for the “fevers of the tropics” – Dengue, yellow fever, typhoid and malaria – and a very impressive neonatal unit. The malnutrition ward is the most crowded. Starving kids with the two main types of malnutrition – the swollen bellies and edema of kwashiorkor and the skinny limbs, bulging eyes and sharp ribs of marasmus – fill the place. The children lie and sit listlessly on their beds, clinging to their mothers and sucking on packages of PlumpyNut, a peanut butter fortified with vitamins and sugar.
Often, I think that I am was looking at a young infant, but then the “baby” starts to move and I see a mouth full of teeth.
“It is my dream,” Dr. Emmanuel tells me in the midst of the room, “to find out how to treat malnutrition on a larger scale here in Rwanda. After I help you with your project at the orphanage, you can help me get a Master’s in Public Health, and then I will be able to help more than just the kids that they bring to this hospital.”
At that moment, in the midst of the most preventable type of unspeakable misery, I consider selling my house and everything I own to finance Dr. Emmanuel’s education. He has been a most helpful partner in my work here at the orphanage. He recommended a treatment for the scalp fungus that plagues so many of the kids and a special cream for the bleeding diaper rash that our infants suffer.
The day before my hospital visit with Dr. Emmanuel, a Canadian hedge fund manager named Lyndon has visited the orphanage. He sits quietly and watches me rub the antifungal shampoo onto 25 heads, demonstrating how to lather up for the five required minutes.
“Is this something that you see a lot in kids normally?” he asks me.
“No. In school we learned this is just something that happens if they’re extremely immuno-suppressed, like if they’re on chemo or if they have AIDS,” I tell him.
“But they don’t have AIDS, right?”
“No, I just had 20 of them tested and all 20 were negative. But they don’t have any protein in their diets so their immune systems are not that good.”
Although the orphanage where I work has enough food for the 100 children living there, the children get only beans and potatoes. Peanut butter and eggs are far out of our budget, and I found out today the babies only drink cow’s milk and porridge.
Lyndon seems mortified as he follows me to the baby house, where I rub on a prescription medicated cream that Dr. Emmanuel had given me to counter the constant wetness. “Where are the diapers?” he asks. The answer to that question is like the answer to all others: “No money.” But this is really just the beginning of the problem. When Lyndon speaks with Victor about getting 500 diapers to the orphanage, Victor argues that it would patch, not solve the problem. A diaper supply would disappear as soon as the muzungu money ran out and the staffing returned home.
This is one of many challenges I face these days. Lately, I’ve been spending time developing a system of medical files for the kids so that they will stop coming to me, saying “I am sick. It happened before. They gave me tablets. They worked, but the hospital doesn’t tell us what the drugs are.” Building minimal records has required multiple arguments with hospital administrators. They don’t seem too eager to write down diagnoses for outsiders like me.
We did get all the orphans scheduled for free HIV tests. Still, dealing with a lack of basic medical care is my ultimate goal. I’m searching for funding to bring Dr. Emmanuel out to the orphanage to do exams on all of the kids once a year. I met a pharmacist from Chicago who is working with an HIV clinic in Kigali for several months. He is going to get us bulk quantities of medicine for the worms that infect all of the kids. I also plan to train orphanage house mothers in basic first aid by making a kit for each house and teaching such skills as wound care and how to take temperatures. This is part of what Victor and I call our Health and Wellness Project.
I’ve really been having an amazing time with the kids. The ones that are old enough to have survived the genocide take a while to warm up to you, but now I have several girls who argue over braiding my hair and practicing their English with me. I was alone with the kids this weekend and we all went swimming in the lake. There were 40 of them, only 12 of whom could swim. We had 7 canoes, 5 pairs of water wings, 2 life jackets and me. All the boys were naked. The girls were covered knee to neck. I actually swam in pants and a T-shirt. We couldn’t really communicate with spoken words, but none of that mattered once I organized races and showed them how to do flips in the water and handstands on the bottom. The next day we spent about five hours playing Uno, the one card game that requires no common language, but that helped us all to practice our vocabulary for colors and numbers.
Meeting people who have been in the country for a long time and are entrenched in the NGO (non-governmental organization) world can be rather depressing. They have a rather dark view of Rwanda and all are quite certain that as soon as the current president, Paul Kagame, dies, the genocide will start again. The general consensus is that Rwandans” refusal to talk about the genocide, along with outlawing the identification of different ethnic groups in the country, simply buries deep a problem that is far from fixed. On the other hand, some of those accused in the mass murders continue to face trails conducted by village elders. And yet there are so many NGOs here that a lot of people think that Rwanda is completely dependent on foreign aid. Collective international guilt at allowing the genocide to occur has created an entire country with its hand out, begging for, expecting and receiving help.
The more I hear these things in Kigali, the more I want to return to our orphanage in the bush. Victor, the orphanage director, hopes to create an environment that will be completely sustainable after he leaves. He wants to bring in revenue from the orphanage’s extensive orchards and train one of the former orphans, Prince, to take over. He is especially enthusiastic that our health project relies on the Rwandese doctors and local health care system, not outsiders who may leave. I get to be a really small part of that rarest type of international aid – the kind that will continue to make a difference even after we have left.
Part 3
“Sustainability” is the watchword for all that we do at the Rwandan orphanage where I’m spending the summer between my first and second years at the University of Colorado Denver School of Medicine. The orphanage staff tries to plan everything to fit a system that can continue with or without foreign aid or foreign workers. In principle, it is a noble and important idea. It makes sense to refuse to distribute the box of deodorant that some well-intentioned soul just donated to the orphanage since nobody here knows what deodorant is. I can even understand why Victor, the orphanage director, rejected the idea of getting diapers for the babies. Most women in the surrounding villages just let their kids run around without. But when everyone argues that Rwandans are unwilling or unable to keep up important improvements in hygiene, standards of health care, or diets, I find myself hopelessly frustrated and discouraged.
I just spent a weekend exposed for the first time to the one of the most cynical types of people you encounter here – long-term ex-patriot aid workers. Victor had arranged for me to do some sightseeing in the area around the orphanage, along with Lyndon, a Canadian-by-way-of-London investment banker, and his Italian girlfriend, Mariella. Our tour guide was Francesco, a corpulent Swiss man in his late fifties with a deep appreciation of cheese, expensive wine and cigars. Francesco has lived in Kibuye for the last three years, working with the local government on efforts at decentralization.
Francesco rolls into the orphanage early on a Saturday morning in a new white Land Cruiser, accompanied by his college-age Swiss intern. He roars that our coffee is terrible and that he can’t wait to set us straight about Rwanda.
We bump along to a nearby tea plantation. As we drive, he points out various landmarks, most of which relate to the 1994 genocide that left hundreds of thousands of Rwandans dead. There are the hills of Bisesero, the only place in Rwanda where a significant resistance was mounted. Over 55,000 Tutsis fled to the region, hiding among the pine trees and fighting back against the Hutus as much as possible. At the end of three months, only 3,000 Tutsis were left alive. Francesco takes us to a mass grave that holds 50,000 people buried in a plot the size of a soccer field. The number 50,000 is far too large for me to conceptualize. What strikes me instead is the quiet, unremarkable nature of the area. Nothing ornate marks the memorial. It is simply an area of nondescript concrete tablets. A solitary rotted bouquet sits at one corner. I wonder at the lack of memorial sentiments. Then, I realize that there might not be any family or friends left to leave flowers for those who died. I feel sick.
The long approach to the tea plantation takes us through green fields filled with tea pickers toting large straw baskets on their heads and dangling from their necks. “Is it my American guilt,” I ask my traveling companions, “or does the word plantation make you feel uncomfortable?”
“American guilt,” answer the Guatemalan, Italian, Canadian and Swiss in the car, without missing a beat.
“Americans are excellent with the guilt,” Francesco calls from the front seat. “That’s why you’re all here in Rwanda.”
I want to ask what in the world they are all doing in Rwanda, but I hold my tongue symbolically and press my nose physically to the SUV’s window. I notice how many of the tea pickers are young children.
We tour the very impressive tea processing factory and find ourselves huddled around a bulletin board at the end of the tour, reading the goals for the upcoming year. Most important is improving working conditions to warrant a Free Trade designation in the U.S. This will earn an extra $0.50 per kilogram on the tea that gets sold.
I ask what it takes to get the Free Trade stamp.
Health insurance and higher wages for the workers, I am told.
Thinking that sounds pretty good, I ask how much more the workers would get paid. Right now, the answer comes, they get paid on production – 50 Rwandan francs (about 10 cents) per kilogram for adults and 25 Rwandan francs (a nickel) per kilo for the kids. Adults average about $20 salary a month. If they can increase salaries by 5%, they get the Free Trade certification. That’s the improved conditions we’re talking about – $21 a month for the adults and $10.50 a month for children.
After touring the tea factory, Francesco tells us of a local guesthouse that can feed us lunch. We pulled up to a neat, whitewashed cottage with blue shutters and a bleating goat in the front yard. Francesco hops out to speak with the woman who appears at the front door when she hears our car pull into the yard. She nods and waves at the car, shooting us a toothless grin as she reaches over to the goat and deftly slits its throat with a machete that appears from the folds of her long skirt.
“Excellent,” Francesco says as he jumps back into the car. “We’ll come back in two hours for fresh goat brochettes,”
While our extremely fresh goat grills at the guesthouse, we visit the Nyungwe National Forest, the only part of Rwanda that still has old-growth forest. Rwanda is about the size of Vermont. It is the most densely populated country in Africa. Seeing trees of any sort is rare. These trees would have been impressive anywhere. They rise over 100 feet high and have leaves the size of dinner plates. The forest is quiet – no bugs buzzing, no animal moving, nothing to disturb nature except a few forest rangers with Kalashnikovs slung over their shoulders. We find ourselves in an abandoned furniture factory built by the Swiss and hastily abandoned in the chaos of the 1994 genocide. It seems as if everyone stopped in the middle of a workday and walked away from the slaughter. The equipment remains, and half-assembled dressers and tables litter the middle of the building, covered in dust and leaves that have fallen in from holes in the rusted metal roof. “This is what happens when the muzungu leave an aid project behind,” Francesco tells us. “The Rwandans just let it go to crap. Why should they work if they can just get another aid project to give them money?”
After our brochettes and beers at the guesthouse, we return to Francesco’s lakeside cottage for a pizza night with other local ex-patriot aid workers. Francesco has installed a brick pizza oven. Wine flows freely. An air of camaraderie hangs over the very diverse crowd. Unfortunately, one of the main things the guests share is a deep-seeded pessimism about the futility of aid work. As the sole American at the gathering, many were eager to offer me their opinions about why USAID and other American NGOs have poured so much money into Rwanda in recent years.
“So optimistic!” yelps Francesco. “How can you all be the same like that? Even your foolish president – he continues to think he will do something right. And why is Kigali simply overrun with Americans? The foolish thought that you can make a difference. You can’t help but stick your noses in every country’s business.”
“Yes, optimistic,” agrees Marie, a stately German woman. “But the most important thing for Americans is the greed. You only give aid to countries that are rich in resources.”
“But what about Rwanda?” I argue. “Rwanda has nothing and you keep talking about how many Americans are here.”
“That’s just guilt,” counters Francesco. “Guilt for allowing the genocide. Guilt for the original sin of slavery. You’re lousy with guilt.”
“No, it’s not guilt; it’s greed,” Marie’s husband, Paul, interjects. “They’re just here to get a foothold so they can steal the riches from the Congo. Rwanda is a safe jumping off point for that.”
“So we’re ridiculous for getting involved here and more ridiculous for allowing the genocide to occur?” I shoot back. “Damned if we do, damned if we don’t? Do we really need to talk about some of the less savory moments in the last century in your home countries?”
Francesco laughs good-naturedly. “That’s the burden of great power, darling. What’s fabulous about Americans is how so many of them are like you – liberal idealists with wildly expensive educations, running from posh families, coming to Africa to save it from itself. Why aren’t you doing anything to help poor children in Colorado? Europeans lose their naïveté much earlier, but Americans can keep it forever.”
Smarting at his eerily accurate description of me, I ask, “So how is that different from you? You’re living here and your wife and kids are back in Switzerland so you must be doing something that you care about.”
Knowing that Francesco’s post in Rwanda ends in a month, I ask him, “Will you be happy to get back to Switzerland or will you be sad about what you seem to think was a three-year waste of time?”
“Switzerland!” he cries. “Darling, I’m not going back to Switzerland. My next post is three years in Zambia.”
It is nice to have pizza and long stimulating conversations in English, but the overall hopelessness of the aid workers presses on me for the rest of the week. It’s the first thing on my mind when I open my door in the morning and find a line of kids waiting for me, calling, “Kate, I am sick,” and showing me a scrape or bump. It’s what I think about when one of the house mothers comes to me because one of her little ones seems sick and she doesn’t even know how to take the child’s temperature. When I discover it is 104, I tell the house mother that she must go to the hospital.
“Right now?” she asks. “Could we wait for two days until the truck gets back?”
I picture Francesco shaking his shaggy head at me as I tell her she should really go to the hospital immediately. She does and doctors there diagnose the 5-year-old with malaria.
Watching one of my hour-long morning Band-Aid sessions, Victor shakes his head and laughs at me. “They’re just looking for someone to fuss over them,” he says. “When you aren’t here, they just walk around and bleed and it’s fine and it makes them tougher.”
“I like fussing over them, Victor,” I reply. “It’s why I want to be a doctor.”
“But you’re making them soft,” he argues. “They’re tougher than us because they have to be. When you make them like us when we’re here, they die when we leave. You give them clean water and take away their bugs and they’re as poorly prepared to live in Africa as we are. Leave them alone and the strong ones will make it.”
“Social Darwinism is a surprising philosophy to find in the director of an orphanage, Victor,” I say.
“I am an egoist,” he tells me sweetly. “I like what I do here. I am building them an orphanage that will be supported by its own orchards when I am gone, but I’m not trying to change the way they live. Just to let them live.”
I suppose it’s inevitable to find that we can’t do as much as we hope to help a country like Rwanda. My epiphany comes on the evening of the Fourth of July. I am on the phone with my dad, listening to him describe their Independence Day celebration in Steamboat. “Nobody cares that if these kids live or die,” I wail to him. “Our budgets have $10,000 a year earmarked for evangelistic missions, and I can’t find enough money to get them medicine so their skin doesn’t rot off!”
I’m sure that many people working here have such revelations. But there must be something to keep people going once they realize that they are fighting a battle against nearly impossible odds. I have too many professors who have spent years devoted to global health, making differences large and small. Whether it is naiveté, blind American idealism or a restless need for adventure, there’s something that keeps them going. It will be a combination of all of those things that will keep me going for the rest of my summer in Rwanda.
Part 4
Just at the point of being totally overwhelmed by my summer adventure, I have been completely recharged by a few weekends outside of Rwanda. My best friend from medical school, Jenn, and Haley, another friend from home, have been studying in South Africa and came up to Rwanda to visit. We decided to rendezvous in the Rwandan beach town of Gisenyi in order to take a day trip across the border into the Democratic Republic of the Congo. This war-torn African country that was the inspiration for Conrad’s Heart of Darkness now harbors one of the deadliest conflicts since World War II. One day across the border, we decided, would be safe enough and great fodder for some stories. After all, DRC is the REAL Africa.
Goma, in the North Kivu region of the Congo, has been in nearly constant turmoil for the last ten years. Rwandan Hutu interhamwe escaped here in 1994 and bouts of Hutu-Tutsi ethnic sparring have been nearly constant since that time. It has left the North Kivu region extremely volatile, with nearly 50,000 refugees within their own country – known as Internally Displaced Peoples or IDP’s. They crowd into refugee camps that flank the northern edge of the city. In a particularly African twist of fate, the volcano that casts an eerie glow over Goma in the evening and a hazy cloud in the daytime erupted in 2002, burned the city, then buried about half of it under six feet of lava.
Crossing the border from Rwanda to the Congo, the neatly tended tree-lined avenues of the Gisenyi resort give way to lava-covered gravel roads, full of UN vehicles and aid trucks with large signs that indicate that automatic weapons are never allowed inside. The sheer number of UN trucks boggles the mind. Blue-helmeted peacekeeping troops pack the streets, and so many agencies operate that we found ourselves trying to guess the meaning of the various acronyms that popped up on buildings and SUVs. Nothing green appears for as far as you can see in any direction. Even the houses are made out of the black lava rock that covers everything.
“If there is a hell,” Jenn muttered at one point, “it definitely looks like Goma.”
A family friend had put me in touch with a non-governmental organization that offered to host us for our day in the Congo. HEAL Africa is a medical relief organization that combines an impressively modern hospital with social services and vocational training for the patients it treats. After riding through the blackened streets of Goma, the white stucco walls of HEAL Africa almost glow with promise. After hearing a basic outline of the mission, I felt like I had received a Vitamin B12 shot in my enthusiasm for aid work. “Our secret,” explained Judith, the brisk and efficient executive director of HEAL Africa USA, the fund-raising arm of the organization, “is staying small. Minimizing the bureaucracy. And training the Congolese to practice medicine themselves. But to do it better.”
After being given a tour of the hospital, we piled into one of HEAL Africa’s trucks and made our way to the market. Slaughtered cattle hang by their ankles in clouds of flies and stench, only steps away from great piles of loose spices and fabric booths, where women recline in front of their wares with the casual and seductive ease of one of Modigliani’s reclining nudes. Young homeless boys sleep under the booths, scavenge for food and aggressively fight each other to carry shoppers” bags. None of the boys attend school, many are addicted to a form of methamphetamine, and all have a disquieting hungry desperation in their eyes. When we returned to our truck to leave the market, the market children stormed the vehicle. They climbed all over, hanging onto the racks and door handles, pressing their faces against the windows to look in at us with hollow eyes, crying for food and money. Luckily, we noticed that one boy had lain down in front of the tires before we ran him over. “Vultures,” muttered Patrice, our Congolese guide. “They’re always trying to be hit by a car full of muzungu.”
Patrice was joined by Carlton, a filmmaker from LA who was ending a month with HEAL Africa to make a documentary shot by local Congolese people. Carlton drove the harrowing and dilapidated streets at a breakneck pace, passing aid vehicles and honking with abandon, spending most of the ride with his arm casually slung across the passenger seat so he could turn fully around to face us and speak at length about his twin passions: Catholicism and Congolese cuisine. He only briefly interrupted his monologue from time to time to roll down his window and scream an obscenity in pidgin French at the people in the road who struggled to push giant rickety wooden tricycles laden with goods across the uneven terrain.
Carlton and Patrice took us to the Don Bosko orphanage, a huge sprawling complex tucked behind ten-foot walls of barbed wire near the base of the volcano. Don Bosko is absolutely huge. The staff tends to 1,500 kids with the help of an onsite malnutrition center, daily visits from a doctor, schools for the younger kids and education programs for the older kids in computers, welding, tailoring and mechanics training. Cafeteria workers prepare food, supplied by the World Food Programme, in vats in a huge cafeteria that calls to mind Oliver Twist. Entering the baby house, home to 50 kids under the age of five, we meet a clamoring mass of humanity, fervently demanding to be held. These children appear desperate. We found some locked in a series of rooms filled with rows of bunk beds and cribs. Jenn discovered a four-year-old deftly lifting her wallet out of her pocket; “I guess my guard was down,” she whispered in shock. “How silly of me to not expect to be robbed in a room full of toddlers.”
Leaving the orphanage, I couldn’t help but compare it to our little orphanage in Rwanda. While Don Bosko certainly had resources that we lacked – not only running water and electricity, but high quality food, computers, high tech vocational training and constant medical attention – the place felt sad compared to L’Esperance. Black lava covering the orphanage yard. The children played on abandoned truck tires. Barbed wire separated the sexes to keep the boys from raping the girls. Without the village structure of L’Esperance, Don Bosko felt institutional, cold, impersonal and a little scary. “It’s the difference of rural poverty and urban poverty,” Haley noted. “Urban poverty has so much more for basic resources, but it’s always much more depressing. They may not have much in the rural areas, but the family units are more in tact and the agrarian setting just looks better.”
As we crossed the border back to Rwanda at sunset, I found myself both excited to return to the protective warmth of L’Esperance and sad to leave the Congo. For once, the white aid trucks looked anything but out of place. Sustainability, with all of its challenges, would never be discussed in a place of such chaos. In a way that seemed simpler.
A few days later in Kigali, I told my friend Katelin about my fascination with the Congo. “For once, it didn’t seem like all the aid workers were there for themselves,” I explained. “If they weren’t there, things would really fall apart.”
“You’re just attracted to the sexiness of disaster relief,” she replied. A former Peace Corps volunteer, Katelin worked in Kigali for the summer with a micro-finance organization. “Development doesn’t look as worthy of 60 Minutes,” she said. “But it’s where the real progress is happening. You can’t just run away from sustainability because it’s hard.”
I returned to the orphanage for my final weeks there with her words ringing in my head. I didn’t want to be someone who took the easy road, one more American who came to Africa with high hopes and left frustrated by the knowledge that the only benefit to come out of my time there was the inevitable personal growth I had experienced.
I wanted to see medical progress. As I thought about it, I realized that I did see progress. After numerous letters and several meetings with the medical director of Mugonero Hospital and a case of Fanta orange soda for the AIDS center nurses, the HIV tests for the orphanage residents were finally scheduled. I showed up for the results with Prince early one morning. Nervously, I thought about the many kids who had lost one or both parents to AIDS. I read the nurse each patient number and he flipped through his huge ledger, finding the results written in pencil in the margin. “Negative negative negative ” he droned listlessly. By the time he got to the seventy-fifth and final “negative,” I promptly burst into tears.
“Ah, Kate, you do not understand,” Prince said sympathetically. “In Rwanda, negative is good.”
As I walked back to the orphanage, I marveled at our good luck. “It’s some kind of miracle,” the nurse had said. “In seventy-five tests, I would have expected ten positives. But none? L’Esperance has God on its side.”
Maybe, but L’Esperance is most blessed by the people who care so much about about it and the children who live there. As I put together first aid kits with supplies from Kigali and trained the house mothers in basic first aid – how to take temperatures, dose Tylenol, clean a wound – I was struck by how seriously they took their tasks. Each mother wanted to practice using her thermometer over and over. They asked so many questions about the protocol Prince and I had translated into Kinyarwanda that explained when it was necessary to take the children to the hospital that the children had to come find them to tell them it was time to make dinner.
In my final days at the orphanage, I found myself thinking it was time to leave. I worried that the children depended on me too much. This feeling hit home when Sam, the dean of the orphanage, woke me once at three in the morning.
“It’s Susannah,” he said, wild-eyed and breathless. “She is possessed by demons. You must fix her.”
Susannah was actually having nightmares. I lit candles, rocked her and read quietly to her. Eventually, she fell back to sleep.
“See, you must never leave,” Sam said the next morning. “You even know how to get rid of demons.”
Five days before I left, a distraught father dropped his three-year-old son off at the orphanage. Jule was in danger, he explained to us, tears welling up in his eyes. He had nowhere else to go. Jule’s stepmother, a Tutsi, kept threatening to poison the little boy for being Hutu.
Here was so much of Rwanda’s problem summed up in a single child. Although the Genocide Memorial in Kigali proudly noted that Rwandans no longer identify themselves as Hutu or Tutsi, the ethnic tension still bubbled beneath the surface in the countryside. What kind of help can I offer with growth charts when children are threatened with murder in their own homes?
Jule integrated briskly into the L’Esperance family. On the evening of his first day at the orphanage, he sat on Mama Ancila’s lap as she peeled cassava. He played and laughed with the rest of the kids at the playground the next day. Best of all, I merely observed as Prince and the shopkeeper, Savemana, immediately created a medical file for Jule like those I had made for the other kids. Savemana brought me the growth chart he had created for Jule. “Is this right? Like you showed us?” he asked.
I proudly told him it was.
As I left the orphanage to return to the U.S., I twisted my body on the back of my moto to keep the cluster of cheerful hilltop houses in sight for as long as possible. I strained for a last look long after we were out of range.
I spent my last weekend in Africa in the most African place I knew – in the Congo. Ignoring travel warnings issued by the U.S. State Department because of escalating rebel activity in the area, I returned to Goma with Katelin, Scoot and Jeff, two other Americans from her micro-finance NGO. We figured we would really get to know the country by spending a few nights there.
I don’t remember who decided we should try to visit one of the refugee camps, but we enthusiastically agreed when a soldier outside one of the camps asked us if we would like to go in for a tour. The misery in the camp overwhelmed. Small tents pitched on the sharp lava rock housed entire families in 10 square feet of squalor. The children wore rags so tattered that they were barely recognizable as clothing. Sickness was widespread and none of the kids had been to school in over a year of living at the camp. The conditions distracted me so that I barely noticed the scene at the gate. Soldiers and police officers gestured at us and yelled at each other.
“Oh God,” Scott said in alarm. “I think we’re in some trouble. They’re not going to let us leave.”
Sure enough, five hours later, the police still held us in a small building near the entrance to the camp.
“Why would you enter a refugee camp without permission?” an officer kept asking us. “What would make you think that the military had jurisdiction? What is your real purpose here?”
Our interrogator wore a garish African shirt with a weeping Virgin Mary on one panel and a crucifixion scene on the other. He had confiscated our cell phones and refused to let us try to reach someone from the American consulate. He believed none of our answers. Before he loaded us into the back of an SUV with a soldier gripping a machine gun in the front seat, he required us to sign interrogation papers, ignoring our complaints of being under duress.
A Congolese UN colonel met us at our hotel. He refused to let me use the bathroom while he and his armed guard searched our rooms, looking under the mattress and through our bags. The two of them wrote down our passport information and strongly advised us to get out of the country when the border opened at 8 the next morning. Then, the colonel delivered a scathing lecture about our utter stupidity and irresponsible behavior in a war-torn country.
“Who do you think you are going into refugee camps for fun?” he yelled. “Angelina Jolie?”
After a few months back in Colorado, I have once again gotten used to daily showers, a fridge full of food and traveling without suffering multiple bruises in the back of a minibus. But I’m already itching to return to Africa. The oppressive loneliness and discouragement that set in after my first month alone at the orphanage is already a distant memory. Instead, I think fondly of all the time I had for reading – 15 books – and self-reflection. The ringworm on my forearm that I’m having a hard time shaking is less a nuisance than a badge of honor. “Something I picked up in a Congolese refugee camp,” I can say casually. The biggest surprise for me about my time in Africa was the magnitude of the adventure of global health. That, along with the choked up feeling I get every time I look at a picture of the gorgeous kids of L’Esperance, is why I will try to continue in this career path – maybe even finding a way to that elusive sustainability.
Kathryn Burge Clair grew up in Fort Collins and studied history at Boston College. She worked in New York at Vogue and Teen Vogue magazines before coming back to Colorado to take care of her mother, who was ill. Burge Clair took pre-med classes and enrolled at the University of Colorado Denver School of Medicine in 2007. She hopes to be a pediatrician.
