Understanding Rwanda- Written Wednesday, August 29, 2007

“To understand Rwanda, you have to understand genocide,” Michael Arietti, our Ambassador told me as we left the airport.  “I want you to see the Kigali Genocide Memorial first.  It will give your entire visit context.”

He was right.

Scenes of genocide are not new to me.  I have been to sights of the Holocaust and to the killing chambers of the Khmer Rouge in Cambodia.  These are dark places that left my spirit sober and cold.

Once again, I found myself without words to describe the horror and a clear sense that I am insufficient to feel the magnitude of sorrow brought on by what happened in Rwanda during a hundred days of 1994 when more than 800,000 people died in a manner so grotesque I choose to avoid any attempt at describing. (www.kigalimemorialcentre.org)

There was a difference for me in this visit. It was the faces of survivors who stood with me as I viewed the images.  The Memorial’s director, a quiet man with imperfect but sufficient English lead me from display to display. He had escaped by hiding in western Rwanda. As we viewed a video of a woman describing the unthinkable barbarism her family fell victim to, a young woman who works for CDC in Rwanda pointed to our guide and whispered: “that is his sister.”

We walked into a darkened room where thousand of photos of victims hung in memorial. Everyone intuitively speaks in whispers. I said to our guide, “I’m told your family was directly affected by this; I’m so sorry.”  He acknowledged my condolence by pointing to one of the pictures, “Yes, this is my mother.”

The CDC employee, and the same person who had whispered earlier to me about the memorial guide, was herself an example of how millions of Rwandans’ were affected.  An attractive woman in her mid 30’s now, she works as a receptionist at our office in Kigali.  In 1994 she was in her early twenties and living in a bordering country.  When news of the atrocities came to her, she courageously worked her way back to Kigali only to find both her parents and several siblings had been killed, leaving only the four youngest. Like so many other young people, she became the head of household and nurtured her sisters and a cousin who was orphaned into young adulthood, forfeiting the education she aspired to.

It was not just those two.  Everyone in Rwanda has a story.  It was the Health Minister who was a medical student returning to treat the wounded in northern Rwanda.  It was the two drivers who both lost parents and numerous brothers and sisters.  It was the woman in a market whose story is told by the ugly machete scar across her forehead. It was the bullet holes and bullet marks on the walls of churches and schools where people were killed by the thousands. 

Yes, the Ambassador is right.  While I never expect to understand genocide, knowing more about it gave me context for what I saw in Rwanda -- and for that matter a lot of other things too.

President Kagame

In 2003 Rwanda elected President Paul Kagame.  Within a couple of weeks of his election, I attended a gathering of corporate and government leaders in Aspen, Colorado where he spoke. Though my recollection of the specifics of the speech is incomplete, I remember his remarks as profound in two ways. The first was his call for reconciliation, healing and forgiveness and the second was how his soft spoken and gentle manner gave his speech power. 

In essence on that day, President Kagame said, Rwandans have to live together and rebuild our country and that can’t happen unless a way is found to heal. The President described a process that had been used historically in the Rwandan traditional court system called Gacaca. It is a process of confession, contrition, compensation and forgiveness -- neighbor to neighbor, victim to offender. Since there could potentially be hundreds of thousand of people involved, there is no way the normal court and correctional system could handle it. Besides, something other than an adversarial system was needed. (An article I found on it: http://findarticles.com/p/articles/mi_m1141/is_25_40/ai_n6019514/pg_3)

I remember at the time wondering during President Kagame’s Aspen speech if it could ever work.  Visiting Rwanda four years later I saw evidence it is working. I watched a short video of perpetrators, dressed in pink, confessing to the victim’s families and others what they had done.  Apparently, the tribunal’s judgment is tempered by the completeness of the confession and contriteness of the offender.  Each of the victims is given a penalty which can range from public service to jail time.  Driving around Rwanda, I saw groups of people, dressed in pink working on a mountainside, apparently doing their compensation. I’m sure the system is highly imperfect but the country appears to be pursuing a solution and positioning itself to move forward.   

The second thing that impressed me about President Kagame’s Aspen remarks was his soft spoken and gentle tone. Being in Rwanda gave me the impression this may be a characteristic of the culture there. I found most Rwandan’s I spoke with to be graciously polite, gentle and soft spoken. I have no way of knowing how universal it is or for how long it has been that way and I must confess, I don’t know how to square that with the profound brutality the genocide period produced.

I am left to wonder if the universal hardship and sorrow experienced by the people of this nation has produced a special kind of humility that allows forgiveness and moving forward. Genocide and hardship has nearly eliminated an entire generation.  Forty two percent of the population is under 14 years old.  Less than 3% of the population is over 65 years old.  Is it possible that the new generation and those who survived will have different values and behaviors than before?

Changing government in a nation can be done by a majority vote or revolution. Changing the collective hearts of a nation is harder than both.

Changing Hearts

Actually, the question of how hearts are changed has been on my mind through out this African trip. The entire continent of Africa is being ravaged by another kind of brutality: disease. In all four countries I visited, the HIV-AIDS virus is waging war, systematically and venomously destroying families, communities and ultimately nations.

I’ve been to the front lines and seen the evidence of caring people from all over the world, rallying to help.  I’ve seen researchers who left the comfort of their university lab to live at the epicenter of the epidemic pursuing every lead on how to defeat the heartless killer. I’ve seen health workers organize clinics to administer medicine. I’ve seen caring people struggle to meet the needs millions of orphans left in the wake of this disease.

I see our nation and others with us, sending tens of billions of dollars to fuel this effort. There has never been a more noble humanitarian effort made to stand between mankind and disease -- and yet, we are losing. While we succeed in treating the sick and providing life and hope for millions, new cases are growing faster than our ability to treat them.

Whether it is in the outback of Africa or the streets of American cities, we cannot treat our way out of this epidemic. Prevention is the only way to succeed.  Prevention requires change of behavior.  Changes in behavior happen only when there is change of heart.

Visit with Students

In Kigali, I visited what in the United States would be considered a public high school. Ironically, I learned later, great brutality took place at this school during the Genocide.  I watched a student body assembly where students performed a dramatization teaching abstinence and the importance of being tested to know your status.

The program portrayed in the frankest of terms a situation between a male and female student regarding sex.  They had been dating for some length of time and the male student was pleading with the female to have a sexual relationship with him. The interaction featured an empowered female refusing to subject herself to the risks of AIDS or unwanted pregnancy.  It included candid conversation between teens about the need to be tested.

Outside, after the program, tents had been set up where students could engage in smaller group conversations.  In addition there were medical workers able to test the students and provide counseling for those who needed it. The program officials told me they will ultimately test over 80% of the students.  Only ½ of 1% will test positive. The Minister of Health told me he aspires to have it expanded to all schools.

I went to the Kigali Institute a medical school.  The Minister of Education in introducing me, said, “Mr. Secretary, our goal at this Institute is to be AIDS free.” The students applauded. No one has illusions about how hard this is but AIDS is a vicious indiscriminate killer and it will only be interrupted and defeated by changing the hearts of the people, especially the coming generation.

The condom use part of our ABC policy (Abstinence before marriage; Be faithful in marriage and consistent Condom use in high risk behavior) is important because it recognizes the realities of human behavior but here’s another reality: In a world saturated with AIDS, any society that counts on the C (Condoms) part of ABC to facilitate a continued practice of males routinely having multiple and concurrent sexual partners will be overrun by AIDS and its harsh economic, social and health consequences. 

President Kagame was out of town so I met with Rwanda’s Prime Minister Bernard Makuza.  He made an important observation in our meeting. He feels while many people think of health as a compassion issue, to him it is also an economic issue. (http://allafrica.com/stories/200708280261.html)

He’s got it right in my judgment.  Failure on AIDS will bring about the type of social and economic instability that inspires further human tragedies.

President Bush has proposed Congress double funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) over the next five years to $30 billion.  Throughout Africa, I asked those working with HHS and our partners to provide suggestions how the reauthorization of PEPFAR should be structured to drive prevention.  If five years out, all we have accomplished is the perpetuation of treatment of millions more people but infection rates are outstripping our capacity to provide treatment; we will have done a compassionate thing, but Africa will still be on a pathway to failure.  We need to organize our efforts so they result in a change in behavior.

Comments

Mr Leavitt,

While I'm not sure that I get your point about condom use, let me thank you for at least bringing this up for discussion. I'm not so naive as to believe that condoms alone will solve the problem, just that abstinence is mostly a lost cause unless other more powerful changes are happening in these societies.

Many things matter. Female education - over and over in developing countries ravaged by poverty and disease, the single most important factor for improving the lives of communities is keeping girls in school for as long as possible. When that happens, they are empowered to make decisions about their lives and those of their children, especially their daughters, which perpetuates the benefits.

Then there is establishment of stable civil society. I've been profoundly touched at various times by stories from Rwanda, when such a gentle people can commit such unspeakable atrocities. There are social scientists who hypothesize that it's not possible to establish stable democratic societies with the rule of law until you have at least 2 generations of high literacy. I don't know whether that case is tested true, but I would submit that reversing the fortunes of failed states is one of the most difficult tasks that humanity faces, and our track record has been poor indeed.

Another component is integration into the world economy. Unless and until more of the African economy can participate in the benefits of globalization, societies will continually fall prey to corruption, violence, and bigotry. The key ingredient is hope: the illiterate HIV widow raising seven grandchildren can be galvanized to work just that little bit harder to keep the children in school if she can see a future for them that promises less drudgery and more dignity.

When people can believe wholeheartedly that they have a future, when an educated middle-class influenced by contact with the rest of the world begin to demand decent living conditions for their communities instead of try to lord over them, when parents campaign to ban female genital mutilation, when young men begin to understand the concept of tomorrow and the possibilities for the next generation, then the incentives to change their behavior, to take responsibility for their actions, will begin to take root.

Before all these changes have happened, simply 'educating' them, telling them to 'just say No', is IMHO unlikely to work. Or at least I haven't seen any data that suggests so, have you?

Posted by: SusanC | August 31, 2007 at 07:56 PM

Dr. Leavitt,

There is little I can add to your post.

My one observation is that people have not given up nor putting their fate in the government's hands. My sister in law and niece have. They feel they do not have to prepare because the officials are taking care of things. That is their job. One puts it all in the lords hands. What can be done? I tell her those who prepare and learn suffer less than those who do not.

Reading your posts about life far worse than what Katrina or Tsunami wrought helps show not only what people can endure but bounce back from.

Testing and counseling - even in a tent. Sadly 1/2 of 1% will test positive. Hopefully 99.5% will see they are HIV negative and want to stay that way so that years from now very few will test positive. Those who know they are positive, those who know they are negative will not wait for help but take care of themselves and thus take care of others as well. May they also feel empowered to do so.

There are many in the U.S. who have the rescources but do not feel empowered to prepare.

Regards,
Allen
"Few things are harder to put up with than the annoyance of a good example. "
Mark Twain (1835 - 1910), Pudd'nhead Wilson (1894)

Posted by: Allen | September 01, 2007 at 01:32 PM

Secretary Leavitt,

Your eye witness accounts of your travels reveal your humanity.
You wrote:

“I am left to wonder if the universal hardship and sorrow experienced by the people of this nation has produced a special kind of humility that allows forgiveness and moving forward.”

I believe there is more than hardship and sorrow that drives change such as you write. It also requires desire, perseverance, and a sort of innocence. Culture and belief systems would also play a big part.

In today’s world, there is vast chasm between the have’s and have-not’s. Their life is different, but that is what they know. Can sadness & grief guide a country’s character? Maybe…. America has experienced this sort of “coming out” (so to speak)… . With Kennedy’s assignation…… With the end of the Viet Nam war…. With 9/11….

It seems that the character of Nations is shaped by their people. One person at a time….

Keep writing… we are reading.

Posted by: Kim Crady RN | September 02, 2007 at 05:22 PM

Mr. Secretary,

Thank you for your descriptive and moving accounts of Rwanda. I often wonder why more people around the world did not tune into the ghastly events and plight of the people there as the situation was happening.

Hearts must change for HIV/AIDS awareness to occur. The empowerment of females is so essential to the process of change.
It is happening here as well.
Several years ago, my daughter at age 16 announced to me that she was having sexual intercourse with her 16 year old boyfriend. Before I could splutter out a response, she said "Relax, Mom, I took your advice." "and that would be?" I uttered. She replied
"I took charge, went to planned parenthood and got tested and I made my boyfriend do the same. I read the results."
Education at school and especially at home have paid off.
I wish she had listened to the maturity and abstinence parts of my previous discussions but I am glad she learned the parts she did.

Posted by: Teacher | September 02, 2007 at 07:11 PM

Dear Secretary Leavitt,

Thank you for your very moving comments. I had similar reactions on each of three visits this past year, as a psychologist and writer. Like you, as an American I felt an enormous responsibility to convey my respect and admiration for the astonishing recovery and spirit of the Rwandese people. I am trying to get back, to hand deliver (1)a book about the leadership (including Minister Nyaruhurira's story) and (2) a mental health project for the Youth Minister. I would be happy to volunteer my time to your department, just for a chance to return. -Patricia Pasick (patriciapasick.com)

Posted by: Patricia Pasick, Ph.D. | September 03, 2007 at 06:14 AM

Dr Leavitt,

The last line of your comment is the most telling. My nice is on her way back to her last year of college. While she read the avian flu post on the college web site she does not want to think about it.

Yet, she had strong emotions about building codes. "That after a disaster they upgrade building codes - why don't they just do it before hand."

Sadly the change in behavior that can make people feel it could happen to them and that they can do something about it now is elusive.

People may prepare for one disaster or problem but not another. Freedom of will, freedom of spirit but not what I consider "informed consent" nor the power to say no.

The power to do something else besides what others want you to do.

Each person can be an independent soul doing those things they believe are right. Doing those things that are good for you, your community and your country.

That last line of keeping more sick people alive without stopping or stemming the flow of new cases is potent.

It might be AIDS, it might be new cases TB or disaster victims from hurricanes or lastly H5N1.

I trust my post will be read Tuesday. Have a good Labor day to you and your staff.

Regards,
Allen

Posted by: Allen | September 03, 2007 at 03:28 PM

Dear Secretary Leavitt

I am a Utah native(grew up in Lehi, Utah) now residing in California - I follow the advances in the biotech world closely, as I am getting on in years and may need the advances and I invest in some biotech Cos. I have a question for you:

Why does the FDA always take the full 90 days to "approve" a drug?

Current Example: Testing has shown that the drug Tysabri is probably safer and more effective in many cases of Crohns disease - An advisory panely strongly advised that it be approved - the 90 days is now ticking away - what value added is the FDA contributing during the 90 day + delay? The studies have long ago been done and evaluated - Why don't they just approve/disapprove and move on?

For what its worth, It has been nearly a year since the process started - delay, scheduling an advisory committee and now the 90 + day bureaucratic stall (from my viewpoint)

For patients who are suffering, the time is painful, what is being done during the 90 days? Could you have someone let me know what is done during the 90 days and why it can't be speeded up!

Thanks, William Powell
12020 S El Monte
Los Altos Hills, CA 94022
PH 650 941-1934
email mbpowell@comcast.net

Posted by: William Powell | September 13, 2007 at 04:43 PM

Dear Sir,

There appeared a rather interesting article in our local newspaper, The Virginian Pilot. I am including the URL. I hope that you/staff member will take a look at it.

Thanking you,
John Roughton

http://content.hamptonroads.com/story.cfm?story=132600&ran=151016

Posted by: John Roughton | September 16, 2007 at 07:57 PM

William you are so right, but I guess this is the way it is, time wise it's a nightmare

Posted by: Hair Extensions | September 17, 2007 at 08:32 AM

Wow. That's a hell of a story. You're a natural writer. Will you be putting these stories into a book? Maybe some of the proceeds could go to building something in a Rwandan village? Put me down for one if you do it.

Posted by: Malcolm Lambe | October 03, 2007 at 07:48 PM

What a heart wrenching story. Very insightful. I agree with the other the fellow's comment. Will you be putting these stories into a book?

Posted by: Ms. Water Coolers | October 12, 2007 at 06:48 PM

Dear Secretary Leavitt,

Thank you for taking the time to provide information concerning this topic.

Sincerely,

Rosy Cruz
President
http://www.new-york-document-scanning.com

Posted by: | November 05, 2007 at 05:41 AM

Thank you for taking the time to bring more awareness to the unfortunate situation Rwanda is left to face.

In the 'information age' it is sometimes surprising to me just how uniformed many truly are about countries exposed to similar travesties.

I hope and pray that the youth of Rwanda grow up to help build a better nation - a proud nation.

Posted by: Rick | December 12, 2007 at 04:38 PM

Very usefull blog (posts).
Thanks for that!!!
K.

Posted by: BEZ BIK | January 18, 2008 at 07:14 AM

Dr. Leavitt,

Few people know the historical roots of the rwanda genocide. I want to give some information on. Albeit we know this genocide occur between two rival trib, there are no etnic differrence bewteen Tutsi and Hutu. this section was artificial discrimination invented by colonialist germany in early times of 20th century. It is tragedy that two rival group has same origin.

Posted by: david | February 16, 2008 at 07:02 PM

Dr. Leavitt,

Thanks for the post! I do appreciate your effort to advocate this issue. I am from Costa Rica and I think this is one of the major problems of the country. However, I have seen and observed that Costa Rica has the best AIDS treatment in Central America, with all the latest medication available to sufferers.

Posted by: Costa Rica Real Estate Jack | March 26, 2008 at 07:44 AM