Reflections on the Genocide Commemoration Week

Health Sector commemorates 1994 Genocide against the Tutsi, 2012
Photo from: http://www.rbc.gov.rw/spip.php?article276#

I published the following piece in The New Times on Monday, 16 April 2012

On Saturday, April 7, I was fully moved by the atmosphere in the Amahoro stadium during the opening of the 18th anniversary of the Genocide against the Tutsi. The ceremony was a mix of events: somber music; a testimony of a young, bright man left for dead during the Genocide when he was a little boy, but currently living with a handicap that has not diminished his enthusiasm for life.

Then the reminder of the importance of ownership during the speech by President Paul Kagame, where he reminded us that we need to stand and refuse the double standards of the countries in the North and West, that protect major actors of the 1994 Genocide against the Tutsi.

He also declared that the history of Rwanda belongs to Rwandans above all, and that our history has taught us that we must fight to ensure that there is not one chance in a million that Rwanda will return to the horror of the 100 days.

During this event, all morning, in the circle of the stadium, mournful, deep, lamenting cries rose continuously, so palpable that I felt as if I could touch them. Sometimes the cries were in high tones, sometimes they were low, but they were always audible and communicated the suffering of memories of traumatised souls. All of these experiences together set the tone for my week - one of deep emotion, and intense reflection on how to take the negative energy from this sombre part of our history and transform it into positive energy towards our bright future.

Later, I had an exchange with four American students about their views of the 1994 Genocide against Tutsi. My discussion with them gave me the hope that the history of Rwanda is taking hold globally to encourage all people across the world to fight against genocide so that it never happens again.

On Sunday inhabitants of my Umudugudu (neighbourhood) came together just as was done last week in each Umugudugu across the country, and, together, we commemorated the victims of the Genocide against Tutsi. Neighbours shared testimonies on their day-to-day life in Kigali before and during the Genocide.

On Monday, April 9, I accompanied my family and the American students to see an interesting play in Cambodian and Kinyarwanda called "Breaking the Silence". The actors were so good that I felt as if I understood Cambodian simply from their emotionally expressive acting. The play explained the Cambodian Genocide with a melancholy rhythm of songs, testimonies, drumming and guitar strumming. Two Rwandan actors interacted with their Cambodian colleagues and helped the audience to understand and question the driving factors and consequences of genocide. The play displayed the story of two countries with a lot of similarities and illustrated how the consequences of genocide are the same across cultures and civilisations, which increased my resolve to fight against it. The difference between the two countries is that, in Rwanda, the RPA stopped the Genocide and is a pillar of our current development. In Cambodia, on the contrary, an army, the "Khmer Rouge", led the horror.

Throughout the week, while at work and also outside of work, I felt sadness deep within me over what happened in 1994. This feeling culminated on Thursday, April 12, when we commemorated the workers of the health sector who were killed during the 1994 Genocide.

We started the day by visiting the Kigali memorial, it was not the first time I had visited it, but it was the first time I was interviewed right afterwards. I was incapable of talking; my throat felt stuck and I was on the verge of tears. In the afternoon, we did a walk in memory of our fallen colleagues.

Every step I took during this walk punctuated the memory of those colleagues who I never got to know because their lives were cut short. I thought about the heroes who continued to work valiantly during the 1994 Genocide to provide health care for Rwandans and paid for that with their own lives. I also thought, with immense fury, about all the murderers who used their positions in the hospital to kill vulnerable, sick people, instead of giving them the health care they were trained to provide.

This year, we commemorated the Genocide with our Development Partners in the health sector, and we also remembered those among them who were killed because they decided to stay in Rwanda in solidarity with our people. In memory of the Genocide victims, I lit a candle as a continuation of all the candles that have been set alight this week, starting with President Paul Kagame at the opening ceremony. The fire from my candle was passed throughout the people present. The glow from the flames reminded me of the Genocide victims within our health sector, but also of the optimism I have for our country's future. As a family, Rwandans and international partners, we supported the relatives of those who died during the Genocide. It was a very moving sight.

On Friday, April 13, we closed this week of commemoration in Rebero, where I took time to think about victims of the Genocide who were politicians. We remembered that across several political parties, courageous Rwandan politicians died so that Tutsis could retain their right to life.

This event closed a week rich in emotion: pain, compassion, rage, sadness, but most importantly hope.

At the end of the week, as I reflect on the lessons learned from the courage of brave Rwandans, both dead and alive, I feel stronger and more motivated than ever to better contribute towards our country's bright future.

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You can access this article here, too

Health, Human Rights, and Democracy in Rwanda

Below is my piece in the New Times published on 11 December 2011. You can click here to read the article on the New Times website. 

Health, Human Rights, and Democracy in Rwanda

By Dr. Agnes Binagwaho

Success in Rwanda’s health sector is due to the fact that the Government works as one in pursuit of an integrated and community-driven development process. This past year, I have read and listened to many great newspaper articles and speeches about Rwanda’s social and economic progress since 1994 that highlight the country’s unprecedented achievements but conclude with a single sentence or two that intends to make the reader or listener doubt all of these achievements.

Listening to such reflections on my country has caused me to reflect on a number of trends since my return to Rwanda in 1996. Still much needs to be done and as a nation and as a people, we have pursued with fierce urgency the integration of participatory democratic principles and equitable social policy to ensure that all Rwandans benefit from the process of development. We promote and strengthen our democracy by always engaging our people – Rwanda’s true wealth – in the formulation and implementation of policies for health, education, gender, youth, decentralization, financing, infrastructure and other.

In order to do so, the Government must apply an integrated and collaborative approach across all sectors. His Excellency Paul Kagame, the President of Rwanda, makes this quite clear when responding to a new policy proposal from a member of his Cabinet, asking first without fail: “What will this mean for the people, and how does it link to our poverty reduction and economic development strategy?” The evidence and results of such an approach can be seen at all levels, exemplified by a number of uniquely Rwandan approaches to the empowerment of our citizens.

One fine example of communities working together for national development is the monthly day ofUmuganda, a voluntary work day on the final Saturday of each month. Community members in villages, towns, and cities across Rwanda collaborate on various service projects. Activities are identified and selected through a participatory process, and often include building schools or health centres, planting trees, or clearing areas for the construction of new homes for the community’s most vulnerable families. Umuganda creates momentum for the development of all sectors, as public sector agencies often choose to contribute resources to these projects (and Ministry officials often join in the work around the country). All of these initiatives serve the pursuit of health; even the construction of a school will facilitate increased uptake of health services in the next generation because a well-educated woman is a highly valued member of a family who is well taken care of.

Other national programs similarly fight poverty and promote economic growth in ways that amplify the work of the health sector. For instance, the Ubudehe process of village-level community decision-making that includes “poverty-mapping” (or communal categorization of households into socio-economic categories based on income and needs) allows for better targeting of social services and pro-poor subsidies for items such as our community-based health insurance program, Mutuelles de Santé. In the Ministry of Health, we use Ubudehe and district level data to proportionally allocate our malnutrition interventions (such as the One Cow per Family and kitchen garden programs) towards the most affected areas of the country.

In order to catalyze economic development at the community level, our Government undertakes massive sensitization campaigns around financial savings. Umurenge Savings and Credit Cooperatives (SACCO) were established across Rwanda to increase access to financial services among the rural poor. Today, all of the country’s sectors manage their own SACCO with technical assistance from the central government. These cooperatives are voluntary, and they allow each citizen to contribute what they want to the communal savings pool. With these savings, the community can provide loans (same amount as invested by the citizen) to individuals who agree to reimburse the cooperative for the amount. One district I visited two weeks ago, Burera, has a savings pool of over one billion Rwanda francs. Umurenge SACCO is a very successful program for economic empowerment through the creation of community-owned and directed capital.

The Ministry of Health also uses cooperative savings mechanisms to compensate our 45,000 clinical services providers the community health workers (CHWs) through performance-based financing. Each community elects the CHWs in a participatory and open manner, after which they are trained by the Ministry of Health in prevention, care, and referral of the most common causes of diseases and mortality among communities in Rwanda. As I have written about elsewhere, our massive team of CHWs has contribute to dramatic improvements in health outcomes over the past five years, including a 50% decline in child mortality, a 70% decline in malaria incidence, a 52% increase in the proportion of mothers delivering at health facilities, and a 450% increase in the uptake of modern family planning methods. They serve as the first line of defence against the biggest killers, addressing 80% of the burden of disease through home-based care, but also stand ready to link patients to health centres or district hospitals via ambulances that they contact with their cell phone.

Economic development at the community level is crucial to Rwanda’s long-term vision for the health sector, because we want every Rwandan to be capable of contributing premiums to the Mutuelle de Santé program. When visiting officials from our partners in the United States or Europe ask how we plan to make this vision sustainable, I like to show them a graph of Rwanda’s recent economic growth – about 8% for the past several years, which has contributed to the expansion and flourishing of our poverty reduction programs.

Rwanda has the vision of becoming a middle-income country that is able to self-finance our pro-poor social interventions and guarantee equitable access to high-quality medical care. When I join in for Umuganda or visit a SACCO and see our people’s unwavering commitment to our nation’s vision, I have no doubts that we will make it. To empower Rwandan citizens economically, we promote a spirit of independence to make the best choices for themselves. This is the basis of democracy; when you are dependent and begging, you cannot direct your life.

Full civil and political rights are essential to human development and are highly valued in Rwanda, but we can never forget that these must be built upon a foundation of social and economic rights. If a woman fears that her child may die of malaria for want of a 500 Rwandan franc treatment, being able to vote will not serve her in the short term if it is not link with economic growth; if a man does not have enough money to feed his family or send his children to school, the ability to nonviolently express grievances will not fill stomachs or pay school fees. Civil and political rights and social and economic rights can and must be mutually reinforcing; neither is sufficient alone – we must assure them all. This understanding is woven into the very fabric of our nation’s Constitution and each of our major social sector policies; we must never forget it.

I am truly delighted that more and more high-level officials from the Governments of our long-time development partner countries are coming to see firsthand what we are doing in Rwanda. I have the feeling that we are all truly contributing to a revolution that will bring more health and wealth to our people. Our partners deserve to see how we are using the investment in the health and wealth of our population. In the global humanitarian market, the value of money invested in Rwanda is incredibly high due to lack of corruption, our dedication to participatory processes, and our reliance on integrated cross-sectorial approaches to tackling policy challenges. As a public servant, I am so proud to belong to Rwanda, a country that has pro-poor human-focused policies in practice, and to its population, who are the most valuable resource our country will ever have.

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HPV Vaccine in Rwanda: Different Disease, Same Double Standard

Youtube Video: HPV Vaccine Rollout in Rwanda

On December 2, a Correspondence letter that I co-authored was published in The Lancet regarding debates about using and paying for the Human Papillomavirus vaccine in low-income countries: “HPV Vaccine in Rwanda: Different Disease, Same Double Standard.” The text of the letter is copied below, and you can click here to read it on The Lancet website. This Youtube Video was recorded to complement the Letter in the Lancet.

We respond to a group of public health researchers who wrote a piece in July that was critical of Rwanda's program and made several claims which have been echoed in other corners of the international community. We draw parallel between this resistance and that of many debates about providing antiretroviral therapy in Africa last decade.

We have detailed articles on strategy, delivery, and outcomes of Rwanda’s program underway, and will post on my blog once they are published.

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Published in The Lancet on 2 Dec 2011

HPV vaccine in Rwanda: different disease, same double standard

Agnes Binagwaho, Claire M Wagner, Cameron T Nutt

In a Correspondence letter (July 23, p 315) [1] regarding Rwanda's human papillomavirus (HPV) vaccine roll-out, Nobila Ouedraogo and colleagues express “serious doubts that [a national HPV immunisation programme] is in the best interest of the people”. Are the 330 000 Rwandan girls who will be vaccinated against a highly prevalent, oncogenic virus for free during the first phase of this programme not regarded as “the people”?

Ouedraogo and colleagues argue that cervical cancer ranks behind other vaccine-preventable diseases in resource-constrained settings. But for the diseases cited (measles and tetanus), Rwanda has 95% and 96·8% vaccination coverage rates, respectively [2]. Second, Ouedraogo and colleagues state that HPV vaccine effectiveness is unknown. Many studies say otherwise [3]. Third, the cost-effectiveness analysis cited does not account for vaccine market dynamics by presenting assumptions as immutable facts. The initial price of the pneumococcal vaccine provides a helpful lesson, and Merck announced a two-thirds reduction in the price of Gardasil for GAVI-eligible countries (to US$5 per dose) [4] more than a month before Ouedraogo and colleagues published their Correspondence letter. Finally, Ouedraogo and colleagues accuse Merck and Rwanda of conflicts of interest regarding connections to the GAVI Alliance. Actually, Merck representatives are non-voting GAVI observers, and GAVI's website clearly shows Rwanda's board membership terminating on Dec 31, 2011 [5]. GAVI will have no role in the HPV vaccine programme before 2014.

Ouedraogo and colleagues' argument reminds us of nihilistic claims against provision of antiretroviral therapy in Africa. Their argument constitutes but the latest backlash against progressive health policies by African countries. When the possibility of prevention exists, writing off women to die of cancer solely because of where they are born is a violation of human rights.

The opinions expressed in this Correspondence are entirely those of the authors and should not be attributed to Harvard Medical School or Dartmouth College. We declare that we have no conflicts of interest.

References


1) Ouedraogo N, Müller O, Jahn A, Gerhardus A. Human papillomavirus vaccination in Africa. Lancet 2011; 377: 315-316. PubMed
2) Ministry of Health of Rwanda. Demographic and health survey 2010: preliminary report. Kigali: National Institute of Statistics of Rwanda, 2011.
3) Schiffman M, Wacholder S. Success of HPV vaccination is now a matter of coverage. Lancet Oncol 201110.1016/S1470-2045(11)70324-2. published online Nov 9. PubMed
4) Merck . Merck offers further commitment to sustainable vaccine access. http://www.merck.com/newsroom/news-release-archive/corporate-responsibility/2011_0605.html. (accessed Aug 9, 2011).
5) GAVI Alliance. Board members. http://www.gavialliance.org/about/governance/gavi-board/members/. (accessed Aug 9, 2011).