Some helpful resources

Since arriving here, I've read a lot. Here are a few of the books I recommend:

We Wish to Inform You that Tomorrow We Will be Killed with Our Families by Philip Gourevitch (spelling? sorry I don't have the book in front of me...my roommate stole it...)

Left to Tell: Discovering God Amidst the Rwandan Holocaust, the personal survival story of Immaculee Ilibagiza as told by herself.

Useful websites:

Of course the WE-ACTx website!: http://www.we-actx.org/

A favorite video of mine by Sarah McLachlan for some thought with a bit of great music:
http://www.youtube.com/watch?v=6SkdyRcK9KM


The UNAIDS website, while the UN has their critics, pros and cons, effectiveness debated, it's a good source for getting some general ideas of what's going on
http://www.unaids.org/en/

Some stats from the World Health Organization:
http://www.who.int/hiv/countries/en/index.html

I'll try to add sources as I remember them!

Concerns from the clinic

I thought I'd post some of my notes from a meeting I went to last week about HIV+ teens a long with a few of my other thoughts. Dr. Donna Futterman is a dear friend of Mardge and she gave an excellent talk.

Some basic stats about HIV and transmission according to Dr. Futterman

• For every 4 HIV+ people, 2 of them contracted the virus as teens/young adults

• The average age of infection of girls is 5 years younger than boys--due to the tendency for girls to have male partners that are older than them and not being able to negotiate condom use in their sexual relationships
  
• The average age at first sexual encounter in Rwanda is 13 years old
• It is also easier to become infected via sexual transmission when younger

The majority of children in WE-ACTx have been positive since birth from mothers infected through genocidal rape. Ok, so they've been dealing with this since their first day of life. Not true for many of our teens. The heartbreaking dilemma of when to tell kids is something Rwandan mothers have been struggling with for years. Turns out, they're not so good at it...
The story, common to many Rwandan teens, is one of a struggle to reach the age of five. Battling malaria, TB, dysentery, malnutrition, poverty. Then a struggle to find money to go to school. Finally, they have hopes of more than basic survival...a family, a job, love and a home. Until their mothers announce to them they are HIV+. That's right, many Rwandan teens find out they are positive as teens, through no fault of their own. How do you cope with that?

HIV patients are heavily stigmatized all over the world and their situation is no different in Rwanda. Worst case scenario: death at the hands of the misinformed, scared community members; at best, social rejection well past being the odd duck or the black sheep of the family. I say family, because many people don't tell anyone outside of immediate family due to fear of abandonment. I say abandonment because that is truly what happens. These people are left to fend completely for themselves and often physically and geographically pushed out of their village or town because no one will hire them for work, no one will sell food to them, no one will help them get milk or clean water. Simply, they are seen as walking disease bags. Trash. To be stepped over.

Finding out their positive status as teens is devastating and often causes them to act out against their parents. There is definitely a blame game going on here. The question being is it temporary or will the teens be angry, pushing their parents away forever? The sad truth is that they can't afford to stay angry for long, not at their parents. These may end up being the only people who will support them if the community were to find out their status. The counselors at the meeting attested to stories of teens turning to drugs and alcohol and engaging in many reckless sexual encounters as a reaction to their new label. An increasing number of children are taking ARVs, which has much better success rates of medication compliance when they grow up on medication because they are used to it. It is part of their daily routine. Like a Flintstone vitamin if you will. However, when teens are striving to be like their peers, to fit in, to be accepted, introducing something as small as a pill each morning and night, can have a great effect. Throughout my stay here I have often heard ARVs are a daily reminder of the genocide and of it's direct or indirect consequences. For the young people of Rwanda who find out later they are positive, they are no longer one of the lucky ones. They are a statistic. Support services need to be in place to help them recover from the shock, work through their anger, and find hope in a future that is entirely possible.

I have attended the children's and adolescent support groups. I have spoken with many teen girls who need someone to share with and I am honored and privileged to have been chosen. This about sums up their worries: what will I do? The support groups here, for all age groups are truly the most striking feature of WE-ACTx and definitely a much needed service. The people, at any age, who attend their respective groups are able to find friends to confide in, extended family that shares their worries, shares in their burden. At every meeting I have been to, participants express the most sincere gratitude for the existence of the support groups. This, along with peer education has been life changing according to these patients. It is amazing to sit in a circle with young men and watch them open up about their fears and to see them comforted in each other.

So I suppose the question on everyone's mind, well at least mine, is what can I do about it? Yes, I'm finally here, in the middle of this new place, but still an outsider make no mistake. What will I do when I come home? What can people who are feeling incredibly ordinary do? It will take more than giving money. Giving money doesn't give hope. Giving money doesn't show love. There is a world of difference between charity and justice. So stepping down off my soap box, I say to you, educate yourself. I have come here to learn first. No one can act without first understanding.

Before I came I realized how truly confused many people are about HIV, transmission, and treatment. I was asked how I would avoid getting AIDS. My immediate reaction to this question was pure sarcasm...so I'll leave that to your imagination...But the more I thought about friends and family reaction to this trip, the fear of international travel was nothing compared to the fear of working with AIDS patients. And that's exactly it...that's the answer...the job waiting for me at home...Education. I have not been afraid, not for an instant, while being here. I am not afraid because I am educated. I have sat in a circle with older women and talked about domestic violence, HIV transmission through breast feeding, and their options for safe sexual encounters. I have sat with prostitutes, orphans, substance abusers, victims, thieves, and the lonely. The best learning experience of my life has been spent listening to the outcasts. Lessons learned: 1) listen...It is so hard for some to speak, but the voices of the people I have been working with need to be heard. It is out of respect at the least and love at the most. Simply listening makes all the difference to the Rwandan people. I heard this, straight from many mouths, while I was listening.
and 2) question...It is hard for us to ask questions partly because we don't want to admit to not knowing the answer, but partly because we are afraid of what the answer might be. My hope for my writings is that someone reads them and hears the stories of the people in Rwanda and the world's poor, wherever they are, and are truly shaken. I hope to challenge the fundamental beliefs of our community in such a way as to stir up our way of life. I don't think that anyone can begin to help without first evaluating their own lifestyle and making a conscience effort to include the poor in it.

Some stuff from this week

I spent most of my time this week working in the WE-ACTx town clinic doing the study. Patients were scheduled for Monday when I was supposed to be at Nyacungu and it was my turn to stay. The study is going well and progressing along at quite a rapid pace so hopefully we won't be away from the shadowing/clinical experience and support groups for much longer.

Tuesday I went to Icyuzuzo with Dr. JMV. We had an interesting day as we found out the local private pharmacy is scamming WE-ACTx and the patients. The Icyuzuzo clinic and WE-ACTx town clinic are partner associations. When Icyuzuzo doesn't have the medications the patients need, they are sent to the WE-ACTx town clinic. If the town clinic doesn't have it, they are sent to a private pharmacy in the area that is under contract with both associations to provide meds up front to patients. WE-ACTx pays by prescription each month and the patients still get their meds without having to pay. The patients were being turned away, told to come back each day for months at a time because the private pharmacy told them they ran out of their meds. They'd hand them a card stamped by their business with the date and medication written on it. Then, they'd turn in the original prescription and get paid by WE-ACTx as if they had given out the meds. The only way WE-ACTx finds this out is when patients come back to the doctor and tell their story. A trip that they can typically only make once a month. The man who told us about this came to the clinic for his July ARV meds and was still waiting from the private pharmacy for his May and June ARVs! To properly stress the significance of this--ARVs are saving his life...without them he will progress to AIDS and die. Period.

Another report this week was from a patient who came back from the private pharmacy with the wrong meds. They charged WE-ACTx for the expensive, top of the line meds (in Rwanda) and provided the patient with a cheaper drug that wasn't even the same type of medication. Unbelievable. Dr. JMV asked me to pass the message along to Mardge and now WE-ACTx has another issue to add to their list of concerns.

On Thursday at the clinic, I met a nurse who has been on leave named Christine, who spoke quite a bit of English. I told her that was my mother's name and she jumped out of her chair, hugged me, kissed me and we've been family ever since. Don't worry Mom, she told me to tell you that since you're so far away she'll be my Rwandan mother and I am now one of her girls. She said she will keep me safe, and make sure I'm eating well...It was as if my mother had teleported into this Rwandan clinic exam room...hahaha. She is bringing me a picture of her family as a gift, 'so you will know your new Rwandan family'. I need to find a picture of my family in return for her, which should be interesting since I don't have one on me, nor do I have any still left on my sim card in my camera, or have access to a printer...hmmm...

Every time this woman left the room she'd slap my cheeks...it's tough love all the way here... and when she left for the day she hugged and kissed me again and gave me a flower she'd brought to brighten up her office that day. The people here continue to amaze me. Something as simple as having the same name makes you family here. True, there are many Rwandans who are extremely interested in mazungos as it is a sign of privilege to have white friends, but today it was clearly beyond that.

Candida's Fabulous Biscuits

Today Margot and I made dessert biscuits with Candida, our friend who works at the WE-ACTx house we're staying in. She's fabulous and so this recipe is all thanks to her and her fabulousness. It makes a lot...

Ingredients:
8 eggs 8 tablespoons flour 2 limes (trust me on this one) 8 tablespoons sugar
1 tablespoon baking powder oil for frying

Grate both limes (rinds only--for zest) with the finest side of the cheese grater. Set aside.
Add all 8 eggs and 8 tablespoons of sugar into bowl and mix well.
Add 2 tablespoons of grated lime rinds to bowl and mix again.
Add 8 tablespoons flour to bowl and mix well.
Add 1 tablespoon baking powder, mix.
Add more flour if necessary to make the consistency of pancake batter (We ended up with 10 tablespoons of flour total in our batter). Mix it up again.
Add the rest of lime and mix it.
Fill a shallow pan halfway with oil and turn on low/medium heat.
Put some oil in a small bowl (not in batter).
Coat hands in oil (we did all the scooping by hand). Dip tablespoon in oil and use to drop batter into pan with oil once oil is heated. The batter is going to be fried so heat the oil appropriately and be careful.
Drop about 1/2 teaspoons of batter into oil and fill pan. Dip tablespoon in oil when batter starts getting stuck and hard to drop into pan. The batter should drop fairly quickly otherwise it (like my first few) ends up stringy, but tastes great anyway so I suppose it doesn't matter.
Use a strainer spoon to turn over each biscuit when the top of the biscuit bubbles (like pancakes). Each side should be lightly browned, then take out and put in strainer.
Make sure to use strainer spoon and put in a strainer to drain any excess oil before eating.
Tada! Eat and enjoy!

I'm really bad at updating

People were telling me that promising to post everyday is quite a lofty goal and I turned up my nose at them saying, 'Pish. I'm on top of my stuff.' I lied. Sue me.

Last Saturday was day of the African Child. MOST FUN EVER!!! I started off my day at the futball field welcoming some kids and then made my way over to the crafty activities. No, I did not participate in the futball fun.

I worked at the mask making station and all of our supplies were jacked by the kids before I even got there. Poor Nina...she never saw the stampede coming...The kids were incredibly creative with a few stickers each and some garland. Note to Rebecca: All of your stickers were snatched up and considered a very hot item! I have a picture of a little boy wearing some. I tied masks on little heads for about two hours. The kids took pictures with my camera and while most of them turned out with people missing body parts, they still look great! Pictures are difficult to post on my blog because the internet takes a very long time to load them here so I will be adding an online photo album soon.

After masks I was mobbed at the face painting station. Being one who isn't known for artistic abilities, my lizards looked like bloated turtles, flowers looked like blobs, and cars were unrecognizable. Good thing there weren't any mirrors.

Lunch followed craft time. Fanta's all around. Fanta is a strange fad here. It's a very coveted treat and unfortunately is cheaper than clean water here. I find this to be absolutely ridiculous. Especially since I've yet to see a dentist anywhere here and tooth decay is clearly an extensive problem for this population...can't blame it on the food, they don't get a lot to eat...For lunch we had some meat, wedge french fries, and a really good roll/cake thing. The little girl in the photos I posted with the yellow hat and red coat sat on my lap while she ate and I felt very much at home, like Thanksgiving dinner, cutting up food and helping to control the milk spillage situation. The girl on my lap and the little boy next to me kept sneaking pieces of my meat, so by the time I started eating I didn't actually get to taste any of it. Everything else was delicious though!

The kids danced and sang...I've got video and audio recordings that sound amazing. After the festivities concluded, the other interns and I broke into a spontaneous dance party and I must say, my dance skills were quite good. I danced with a lot of the kids who just really enjoyed the attention and the fun time in such a safe and welcoming place.

Sunday was definitely a day of rest and relaxation. The perfect end to a fabulous week!

How to Ride a Minibus in Kigali

Coauthored by Margot R. Moinester
1. Is the Minibus Right for You?

When arriving at the bus stop you will see a variety of modes of transportation. There will be mottos which look like adult dirt bikes and private taxis which are all white with an orange stripe down the side. Lacking in seatbelts, these vehicles are also quite expensive. Lastly there are the minibuses. These are large, white conversion vans with more windows and incredibly funky upholstery. There are four rows of seats including the most coveted spots next to the driver. Squish in because everyone’s family in Rwanda! If you are at all claustrophobic, be wary. If you are highly talkative and enjoy close interaction with those around you…this ride’s for you.

In addition, it’s the cheapest mode of transportation in Kigali. Enough said.

2. Choosing the Appropriate Bus

It is key, when traveling, to pick the correct mode of transportation as well as the correct route. A happy trip starts with heading in the right direction, geographically speaking; no one likes to start off being lost. However there are often complications for even the savviest traveler. Be sure to speak directly to the driver, though this position may vary as the driver seems to switch at almost every stop. Be wary of the money man. He just wants your money and will tell you any lie to get you on his bus. More about the money man to follow.

On occasion the final destination of that particular bus is written on the back of it. If you have a poor sense of direction or are in any way less than an expert on the layout of Kigali, the final destination does not assist you in any way on successfully getting to your desired location, but simply exists to further complicate your life. We suggest ignoring it completely unless, conveniently, that’s where you’re going.

Choose a bus that is primarily full because you are now on Rwandan time and the money man will not signal to the driver to leave until the bus is completely full. There is no sense of urgency here; and yelling at the driver about strict time commitments will not make the bus start moving any sooner. Therefore we advise you to choose your bus wisely!

3. How to choose a seat

This only applies to nearly empty buses.

If you’re getting out early in the route, sit closest to the sliding door on the right side of the van. This will allow you to trample and inconvenience the least amount of people on your way out.

However, we are often the first on the bus and therefore have some advice about which seat to choose. You can always wait until the bus fills up more, but you run the risk of losing a seat and being stuck on the outside, having to get up every stop to allow other passengers to exit. This can be quite cumbersome, especially when carrying any bags. Authors’ note: we recommend not carrying anything with you that is not absolutely necessary because it will be residing on your lap the entire trip.

Seats are not clearly demarcated on the minibus. This means the number of people riding in each row, depends solely on the size of each person and the money man. If he says move, you’d better move in because more people are going to join you. Don’t forget that there are two seats on each bus that fold out from the inside rows, closest to the door. Avoid getting stuck between the folding seat and the main row, as this is an incredibly uncomfortable position which will leave you with a pole in your butt.

Authors’ choice: the window seat, on the left side of the bus, is the way to go as it provides a nice breeze and a place to lean as well as allowing you the comfort of not having to get up with each passing passenger.

4. The Money Man

The money man is an integral player in every bus ride. Obviously, he takes your money and assures that every passenger pays, but his job extends far beyond fare collection. He is a recruiter and advertiser, a cheerleader of sorts. He will run to other buses and try to steal passengers to fill his own bus. If it’s a slow day, a persuasive money man can make your trip begin a lot sooner.

Side note: if the bus starts moving and you’re looking around, thinking, “where did the money man go?” No worries. Look out the window, as he’s probably running alongside the bus. Money men are dedicated and will sacrifice their own seat for another 100 francs from an additional passenger. Look forward to cheering on an out of breath money man at the next stop. The whole bus will share a laugh at this entertainment.

5. Bus etiquette

Move over, move over, move over. You must fill every nook and cranny in the bus and the driver won’t leave if you’re taking up enough room to fit in an additional passenger. Don’t be offended if someone actually sits on you. Just hope they move over a bit.

The upholstery is unexplainable and can serve as entertainment. Enjoy.

While you may be pleased to recognize US ‘90s pop music blasting on the radio, don’t sing too loud. You will get looks from the passengers around you.

When you are ready to exit, you must signal the money man who will get the driver’s attention to stop the bus. This is done by knocking loudly on the wall or roof of the bus. The money man, hearing this, will collect your money and make sure the driver knows to stop.

Authors’ note: it is common that you will have no idea where to get off the bus. As Rwandans don’t use street signs, it is best to be aware of major landmarks. If you are sitting in the middle of a row, it might be difficult to see out of the windows so attempt to alert the money man of your final destination before getting on the bus. If you look lost, he may take pity on you and alert you to exit the bus at the appropriate time. Otherwise, Good luck.

Pictures from Day of the African Child

Let's Play Pretend Again

It's officially last Thursday...

I arrived early at the clinic to await a ride to Icyuzuzo and sat down at a table on the balcony where the women wait to be seen. I decided to put my headphones in and listen to some music while I was cutting out more of those eyeholes for the paper plate masks. At first I was alone. Being engrossed in my own musical world, I continued to feel alone and ended up singing loudly. I look up as I feel eyes watching me to find that I was no longer alone...a few women had filed out onto the porch and as I looked up, began laughing hysterically at me. I continued to sing, and playing the fool, started to dance. It was great, and I'd like to think everyone was entertained. These are the little moments that make my day here.

I also played with another cute baby that was crawling around on the floor by her mother. She kept watching me out of the corner of her eye and I was really hoping this wouldn't end up a repeat of the sobbing toddler incident from the day before. After a few minutes she wandered over to me, stuck out her chubby hands, and pulled herself up. Within a few short minutes, she was on my lap giggling and cooing in that special way that only little ones do. All the women seemed to let me in after that and became very smiley and talkative. Fabulous start to my day!

The WE-ACTx clinic in town (our home base if you will) accidentally scheduled patients for our arterial stiffness experiment/project, so I went to the Icyuzuzo clinic and Nina, awesome as she is, graciously volunteered to stay behind and work with these patients. At the clinic I began my ARV (anti-retroviral) non-compliance study with Dr. JMV. We're asking patients what kinds of things effect their ability to take their medication correctly each day.

Another little boy came in today. He looked to be about 3 years old, but appearances are very deceiving here with respect to age. Many people look far younger than they are. Anyways, little peanut walked in stuck out his hand, which I took to shake and, with lightening speed, was settling into my lap. (I swear, I've held more kids in my two weeks here than I have my entire life in the US.) He snuggled with me and had an intense desire to hold my hands. He was sitting on me, laying his head on my chest, and yet that wasn't enough. Every time I moved my hands, his fingers found mine and he just wanted that special attention. I was goofing around with him, looking at him, then away, little kids are excited by the simplest things! Then, out of the corner of my eye, I see a tiny finger sneaking up to the side of my nose and he started talking to me. Dr. JMV told me the little boy noticed my nose piercing and thought it was pretty (ha! mom, some people do like it!).

Dr. JMV continued, by telling me the young boy that had clearly worked his way into my heart with lightening quickness was here to start ARV therapy. His CD4 count was 246. Under 200 is AIDS defining. This child was very sick, though you'd never know it. (CD4 is a receptor found on the surface of white blood cells that alert the immune system of a need to mount an immune response when you're sick. HIV strips the cells of these receptors and so your body is not able to get its shit together to mount a successful immune response. Hence the severity of the disease and the commonness of opportunistic infections, such as TB, herpes, etc. The more severe the stage of HIV, the less CD4 receptors-->the worse the immune system functions.)

This is the epitome of my experience in Rwanda. Powerful, loving interactions that leave me feeling drained and heart broken. Everyone's story has a twist...it's never good. I knew that this would be a hard place to spend the summer. But I never expected to see such hopeful, loving people here. This is what makes it hard. I feel jerked around emotionally, even in this short time, because I build up hope that the patient in front of me will be different. Something will be positive for them. It is uplifting to interact with them, and crushing to hear their story. How can people so loving, have such terrible lives?

I'm really learning a great deal about Paul Farmer's theory of structural violence here. The idea that social structures act in ways to keep the poor, poor. More on these thoughts later, I'm sure.

Friday:
Masks, Masks, Masks. I saw patients at the WE-ACTx clinic for our study then worked on those damn masks all day. They're finally done! We had awesome pizza for dinner and had a mask making party. I don't know how I always seem to volunteer for the most time consuming stuff. I can't wait to see the kids decorate them. That'll make it all worth it!

Tuesday and Wednesday Ongoings

Tuesday:
Nina and I spent all day working to get the machine ready to gather our arterial stiffness data for a project examining ARVs and their effects on blood flow. Stupid piece of crap...enough said.
After all day pulling out our hair at the clinic, I went home to cut 300 paper plates in half to make 600 masks for Day of the African Child and cut 600 nose notches. Thrilling.

Wednesday:
Nina and I worked all day at the clinic running the first round of testing with the women. We didn't have a translator, which made for an interesting revelation/confirmation. We have to place electrodes for an EKG on the women and measure the distance between the two pulse point we're using and the top EKG lead, then place a tonometer that gives us a reading of blood flow (velocity) at each point. Very Frankenstienish feeling. We were stuck in a tiny office with dim lighting that reminded me of horror film portrayals of mental institution...essentially, we were only missing the weird smells and the dripping water you see in every scene. My interactions with the women were completely different from what I had experienced every other day I was here. Medical sterilization at its best. I had to fight to keep the humanity I'm fond of in the room. At one point I was taking blood pressure measurements and Nina whipped out the tape measure and began taking the pulse point distance measurements. Immediately I felt uneasy, pulled my stethoscope out of my ears, took the cuff off and stood there staring into the eyes of the woman we were prodding. Instantly, I realized the uncomfortable feeling in the room...how very Tuskegee Institute. My mind flashed to the racist scientific experiments that measured head circumference, nose size and made bold, degrading, and downright ignorant statements to oppress those of African decent in our own country.

What bothered me the most, was that Nina didn't seem to notice. She continued measuring, continued rushing around both of us without lifting her head to really see the woman, without noticing the feeling of the room. I cannot conduct any work this way. I simply refuse. But in reestablishing that human connection with the woman, the tension was relieved with a smile and a touch--this is the importance of hand holding, of human contact.

It was in this instant that I understood a piece of Rwanda, and it's people, that I made a significant connection. The genocide started with systematic measurements that were used to divide people in to ethnic groups based on physical characteristics, many years before the 94 genocide. The Hutus and Tutsis were divided up long before the world turned its eyes to this tiny country (I still find it sad that my first education on Rwanda was through a mainstream movie, ten years after the devastation). Our behavior in the clinic that day was a parallel to that. Something that, clearly, I never intended, but seen too commonly in medicine and science in general. I strongly believe that this is not the inevitable fate of medicine. Not every interaction needs to be this way, so sterile, so mechanical, and I was happy to find that today I confirmed this idea in a smile. Again, it comes down to De Mello and his life changing idea of truly seeing people.

So, how do I do that in this experiment situation? I don't care if I look like the biggest nut alive, I talk to every patient. I use all the Kinyarwanda words I know. I'm awesome at miming. I show the women on myself where I will place leads. I show them every step on myself. I touch the tonometer to my skin and I watch their faces. I may be slower in getting done with each woman, but I will gladly sacrifice my time for maintaining the humanity and respect that these people have a right to. I am glad that I have figured out a way to connect again, in such a difficult setting. I extra glad I'm not a culturally incompetent moron, which was definitely the road I was heading down with this project.

Last Monday Cont'd

I've finally recovered from the week and ready to blog again...
So continuing with the rural clinic work...
I attended a meeting for two hours with Mardge, Nina, Dr. JMV, the clinic director, and a woman named Aren who does something...she doesn't speak much english and Mardge was a little too busy for some explanations. Anyway, our meeting was to address the HIV+ pregnant population of Nycungu (spelling?) and their breast feeding practice. (Vertical) Transmission can occur at birth when mom and baby's blood can mix, but there are prophylactic pills that can be given to the mother and baby to reduce the risk a great deal. The other method of transmission is through breast feeding, which harbors a 10% risk for the first 6 months. All risk for all modes depends on viral count of the infected person--the more copies of the virus, the more chance of transmitting HIV. Here's the problem: the women don't have clean water for formula and dysentery is, I believe, the top cause of mortality in children under the age of 5 in most African countries. Mothers know that dirty water = death. The other problem is that the babies won't be getting mom's antibodies for certain diseases, which translates to generally weaker immune systems and poorer health. Bottom line is kids will be sick one way or another here. There have also been new studies out of South Africa that show mixing breast feeding and formula for the first 6 months increases not only the incidence of poverty related disease: malaria, TB, dysentery, but also the risk of HIV transmission.

The debate now becomes, how do we keep them safe from diseases and get these women milk/clean water for formula--for 6 months? This was the topic of the day. Two hours, six of us in a crowded office, Kinyarwanda and French with very little English translation. I am amazed by the ability to understand and communicate without speaking the language. This is what I took away from the meeting:

The rural clinic of Nycungu serves 28,000 people, most of whom travel a great distance through the mountains to make it for a visit. (One grandmother walks two hours through the mountains to pick up ARVs for her grandkids once a month.) We are dealing with an estimated 96 HIV+ pregnant women each year. Not only is there a need to increase efforts for bringing these women into clinics and hospitals to deliver (to receive prophylaxis as mentioned above), but fresh milk and water needs to find its way into their homes. The proposed idea is to raise two dairy cows at the clinic and each day boil fresh milk and water to mix for each woman to come and get 1-2 liters to replace their breast feeding. Problems: too far to travel each day...
So, give each village or neighborhood a cow. Problems: not enough milk to share with people who aren't pregnant and you know everyone will want some. Still have to boil milk and water--water's not commonly boiled now. Run the risk of dividing milk up and the women are so poor they might still breast feed to save the cow milk for other children who are typically getting one meal a day.
This debate was obviously not settled.

We left the meeting to tour the rest of the simple, yet elegant facilities. (True beauty in extreme simplicity.) Nina and I were waiting for Mardge when I saw a toddler in the waiting room. The room was extremely crowded and everyone was looking at the Mzungo's standing around. The toddler takes one look at me and starts balling. I generally don't have this reaction from children, so I was slightly surprised. Everyone in the waiting room was pointing and laughing at me...I imagine "Oh silly mzungo! Hahaha" Every time she saw me, crying. Not just quiet sobbing or clinging to mom, but down right horrendous screaming. I looked at the women, threw up my hands, shrugged, and we all laughed.

I am impressed by this aspect of human nature: the uncanny ability to share thoughts and feelings that overcome the language barrier. Every day I have these encounters, especially with the children, where I feel connected to others, who seemingly live in a totally different world, yet there is a strong, stunning something that links us all. I know this sounds like a Lion King song, but it is entirely true. It is humbling and awe-some, in the truest sense of the word, to be welcomed in this way and to feel a universal, innate bond, true love, I suppose. It always makes me wonder, How would these people be received in the US? Why have I never felt this connection with strangers I meet in my daily life back home? After all, we speak the same language. I think it's because language often colors our world and attitude in such a way as to distract us from this feeling. I often find myself losing my patience with those around me and thinking negative things after my interactions with many other people. This all comes back to the Anthony de Mello quote I posted earlier. I suppose, I am not truly seeing those around me at home. It is sad in many ways that it takes something as extreme as a trip to another continent to come to this realization. Better late than never. I am anxiously awaiting the search for this connection when I return.

The Rural Clinic

Today (Monday, honestly you should probably assume I'm writing a day behind) I spent the day with Nina, Mardge, and Dr. JMV at the Nycungu clinic, not sure how to spell that one. The drive was interesting and beautiful. We drove through the east end of Kigali and around a bunch of hills to the south. Personally, I was shocked I didn't have to get out and push the car. At one point the car rocked back and forth as we teetered on the verge of rolling back down the dirt road we came up on. The clinic is halfway up a hill and the roads are far from paved. I loved being able to look out the window on the way there and see the houses and the roadside change as the trip progressed. The homes reflected a much poorer community as did the far more ragged clothes. The houses were made in a lean-to style with large sheets of crimped metal for the roof. The entire way to the clinic we saw people selling things like fresh fruit, lone pairs of pants, and water. Young boys have cardboard boxes filled with candy and travel packages of kleenex. Very strange combinations of goods are being sold here. The roadside is incredibly interesting. When I say 'lone pair of pants' I mean one person holding up a pair of pants and trying to sell it to everyone walking by.


So I'm temporarily suspending the blog until Sunday. Sat. is day of the African Child! and so, I'm super busy after work getting everything ready for tomorrow. What are you doing, you might ask? Well, I'll tell you. I cut 300 paper plates in half to make 600 paper plate masks, then cut 600 nose notches, and 1200 eye holes, then tied a string on each mask...they're finally done, but tonight I have a pre-celebration meeting...so hang in there 'til Sunday!

Grrr...Blogging is hard

So once again please use your imagination and pretend today is Sunday. I'm already getting bad
with updates...

Today was by far the most fun I've had in a very long time. It was children's support group day!! I sat in a group for men 18-25 and we talked about what happens when they isolate themselves from the community. I suggested journal writing and role models who could come speak at the support group and the guys wanted to try writing. We had lunch and a treat, orange Fanta, and then off to the children's group.

The group is held at a mosque in Nyamirambo and we took a very crowded minibus to get there. All of us from the morning support group got out and walked to the playground and soccer fields in the back...you could hear the voices of tons of kids...Then, when we stepped into view about 200 kids shared a collective moment of silence before the stampede.

I didn't even get to put my bag down before I had children swarming me from four years old to ten. Boys and girls. Two little girls one about seven and another about four ran up to me and held my hands. This is a reaction kids give mazungo's a lot here and they're incredibly desperate for some sort of contact. The kids were fighting over who got to hold my hand. There was pushing. There was shoving. We were one step from complete and utter chaos. (Hear that Brandon, some people enjoy holding my hand in public...) anyways these kids were adorable.

When I finally made my way to the picnic shelter area, a group of girls were dancing. I walked over to see them and they taught me to dance. Not too bad, dancing in less than five minutes. Then we played relay games. There were two lines of kids and each sent one runner with a stick starting from opposite ends to run around in a big circle and they tried to touch the other runner with the stick. When you got back to where you started, you passed the stick. The kids were slightly losing interest and the other adult facilitators were trying to keep them playing so I kicked off my shoes, hiked up my skirt and hauled some major ass. I could just hear laughing and the occasional shouts of "mazungo" (I imagine there was some pointing as well...) The kids were cheering me on and I was trying not to trip or get caught by the seven year old behind me. My team lost, but the important thing is that I did not lose my dignity to a first grader. Almost, but not quite.
After playtime we sat under the picnic area. We finally wrangled 200 kids and then I busted out the camera...I have a new found appreciation for the professional photographers that take the class photos in elementary school...Eventually the group shots were done, but I made the mistake of trying to take pictures of smaller groups and more natural shots of the kids which turned into an act of mob violence eliciting an exhibition of major police force. Well, 200 screaming kids crowding me reaching for my camera, pulling on my clothes and yelling at me is just as serious. They were great though. It was truly an enjoyable day and I'll let my pictures tell the rest of the story. All of these kids are HIV+.

A day behind

Yesterday I went with Nina to the genocide memorial in Kigali. I bought a book from the exhibit because I truly have no words.


I did get a chance later to check out the craft market...

At night we all went to Republica to have a celebratory good bye tea for another intern Rebecca who's leaving tomorrow.

That was pretty much it, very depressing.

The big day, with relatively little activity

So I just finished yesterday's post and it still listed it as a Thursday post, so the first couple sentences about pretending it's still Thursday makes me look stupid. Whatever, such is life. (At least I don't look as dumb as mom in that turkey hat...hahaha, Just kidding mom, great hat.)
I say today was a big day because I had my project meeting with Mardge. Or Dr. Mardge as she's commonly called here. We've decided on two projects. One being an ARV non-compliance issue. We're going to ask the women, while we're gathering medical data for a project for something else, questions about what makes it hard to take their medication. Very light, very conversational, very relaxed. We, Nina and I will also be asking these questions at the Icyuzuzo clinic and the more rural clinic we will be traveling to on Mondays. Our other project is a little bit trickier and we're looking to address the issue of disclosure. Who do these women tell about their positive status? Why do they disclose, why not? How do they feel afterwards? What reaction do they get? One teen girl reported that her grandmother found out her positive status, told her whole town, and then no one would play with her. I'm finding that many people don't tell anyone outside of their immediate family. It should be interesting to see what everyone says.
Nina and I also did a little shopping today and I discovered my hidden talent for haggling. Originally, the saleswoman wanted to sell me a pair of sandals for 8,000Francs which is $16US and I told her nope, walked away and ended up with them for 3,000F ($6). I truly have a shoe shopping gift. (Don't worry Grandma, I only bought one pair to replace the painful pair.) I came home and we had the second awesomest pizza ever (I heart Lou's!). Which is saying a lot, since I have high pizza standards being from Chicago and all...
Other than that, I spent the night writing two days worth of blogs, reflecting a lot on yesterday, and reading for fun. Tomorrow it's a sobering trip to the genocide memorial in Kigali and possibly the memorial at a rural church.

The True Thursday Events

Ok, so I started a whopping one sentence of Thursday's actual events and then fell asleep. So just pretend it's still Thursday. Also, I've heard that a few people have tried to post comments and were unable to do so. Good news! I changed the settings and you can feel free to comment, question, or critique as you like. Please let me know what you think and what you're wondering.

So much happened at Icyuzuzo today that I may have to split this all up! I'll keep it brief, I promise...hahaha. I spent the day following Dr. JMV. Nina and I sat in his office and saw patients with him. Phenomenal experience! A car drove us to the clinic and we went immediately into Dr. JMV's office to wait for him. On the way to the WE-ACTx clinic in Santra-Ville, my shoes were bugging me and I ended up with a bunch of blisters on my feet. I asked for band-aids at both clinics and was informed that neither clinic had any. Let me repeat that, no band-aids. Ok, again for those of you struggling to fit your head around that one (much like my initial reaction, so you're not alone!) NO BAND-AIDS. A clinic that performs routine blood draws on HIV+ patients and sees people who end up with skin lesions...doesn't...have...band-aids...Insane? Yes. Shocking? Not so much. These clinics are lucky to be staffed with physicians and have supplies of ARVs so band-aids aren't really a priority. Close your eyes and imagine being that poor.

Nina and I sat all day with Dr. JMV from about 9am to 2:30pm. This experience was absolutely amazing and I'd like to split my thoughts into two areas: the physician-patient relationship and patient issues.

Dr. JMV saw about 15 patients with yesterday being a slow day. The nurses also handled a lot of routine, HIV negative patients while we were with him. My focus question going into this shadowing experience was: How does he maintain the physician-patient relationship while seeing so many patients? It didn't take long to see what made him special. He is sitting when the patient enters and shakes their hand, says hello, and gets down to business, but he is never rushed. His questioning style is one that is both deliberate and detailed, but also slow and intimate. He never wrote a word while the patients were speaking. He never interpreted or explained while the patients were talking to him. If a patient started talking again while he was writing his notes, he immediately put his pen down and sat back to face the patient. Each patient sat in the seat right next to his desk where the barriers were broken down. He never slouched, but leaned in to be closer and hear better. The Rwandan people are very stoic and quiet. They often talk without looking at you. The tone and volume of his voice matched that of each individual patient and he never forced eye contact. His focus was intense and it was clear that he was both physically and mentally present. For that time, as far as he was concerned, Nina and I were not in the room. After he wrote his notes, he explained the patient's complaints as well as the purpose of each medication. For every single patient.

The patient that I see when I close my eyes and think of that day was a young boy probably about nine or ten years old. Old white Nike gym shoes stained brown by the dry red dirt, long yellow shorts with the three familiar green stripes of ADIDAS running along the side, and a dirty gray t-shirt. He came to the clinic alone and I never asked where mom or dad were, there was really no need. This young boy spoke softly and looked down at his hands as he answered Dr. JMV's questions. This physician was patient and kind. He prodded the boy and leaned in to lock his eyes and ask his questions. This boy was going to begin ARV therapy and needed a few other medications for a cough. Dr. JMV wrote the script and then did something I've never seen a physician do for a child: he carefully, one by one, explained each medication by name. Directions and all and asked the boy questions to make sure he understood. I had to go to the doctor a few days before my trip and my mom still asks me if I need her to come along. I'm 23. He was about nine. Hmmm... I know that he is alone because of necessity, but this speaks to the ability of understanding treatment in pediatric patients. As a future physician specifically interested in children's Infectious Disease, I am greatly concerned with the doctor-patient relationship. Too often I see physicians talk over and around children directly to the parent while never truly acknowledging the actual patient. And we, as a medical community, are wanting to see children feel comfortable with trips to see the doctor to grow into adults who trust us and come to see physicians when necessary. Do we expect this relationship based on trust and understanding to happen via magic beans and fairy dust? This boy came in and was able to describe his symptoms in his own words, expressing himself in a very poised and eloquent way. Many people do not hold the expression of a child equal with that of an adult, but this is to do them a great injustice. This is not to say children are capable of the same maturity or level of understanding as an adult, but their voice and the words it speaks are important. Just as important as that of the parent. This is something I will encourage in my own patients. In fact, for the first five minutes, I would love to cover the parent's mouth with duct tape and only hear from the child. So many adults feel uncomfortable in the presence of the physician, enough so to deter them from going. I feel this is an attitude that must be changed, and even better, never developed. It comes from years of talking to the doctor, finding their voice and the right words to explain their problems. How can a mother or a father know if a child's pain is sharp or dull, pulsating or steady? They, themselves are not feeling it, they must be told. If parents are encouraging their children to speak to them about illness, why not encourage them to speak to the person responsible for treating them as well?
The patients feel so comfortable as children and adults seeing Dr. JMV that I was surprised at the ease with which shirts came flying off! A little boy came in with his mother had a very severe and painfully swollen case of shingles (think Brandon... sunburned...100 times worse). Truthfully, I've never seen a human being that shade of red before. And the whole area was covered with tiny, painful blister-like spots. Dr. JMV asked him what he was in for today and before I knew it, we were looking at a bare back and a little kid butt crack. Just like that. He never appeared embarrassed and he was never prompted to drop trow, but there he was, quite matter-of-factly. I see London, I see France...I saw a lot today.
While it's true that the Rwandan people are very serious in appearance, with little show of emotion this is not usually true at Dr. JMV's office nor at the WE-ACTx clinic. In these places pain is not hidden. Physical weakness is not covered. Concern is intensely expressed. Is this due to feeling relaxed in the physician's office? Partly. Dr. JMV is comforting, attentive. They let down their guard with him because he is respectful of their vulnerability. It has nothing to do with physical exposure. It has everything to do with emotional exposure. He moves and speaks slowly. He asks questions that can be difficult or stigmatizing to answer, but he does it in such a way, with such an emotional tenderness, that shows each patient he or she is loved. Unfortunately, this cannot be taught to medical students. Too often, this relationship is taken for granted or never cultivated to the level of trust and true partnership that it should be. When one has the opportunity to witness an encounter of such quality between a physician and a patient, it is truly both inspiring and humbling.
So, what's the other part? Simply stated, desire. Necessity. These people are very sick and very poor which makes for the most deadly combination. I love hearing people use the phrase, "Oh that's the worst. I hate that." Poverty and illness, whether it's malaria, dysentery, HIV, or TB, that's the worst; I hate that. No higher, I call. Patients know that, especially in resource poor settings, they have very limited time to spend with the doctor and that the waiting room is often overflowing with people just as sick as themselves, waiting to be seen. They are always waiting. To see the physician, to feel better, to find their next meal, to find work, to get their test results. Once inside the physician's office, Rwandans no longer wait. The second the doctor asks the first question, many patients speak with a fiery quickness, voices raised, emotional faces. They have come to see the doctor and there is no confusion about why they are there. Many patients don't acknowledge Nina and I. The ones who do, shake our hands, sit, and don't look at us until Dr. JMV begins to write. They are finished, and now, again have time to wait.

Back tracking a bit

This is actually what my day was like on Wednesday, but I was up pretty late and too tired to get everything posted yesterday. Not a lot happened yesterday. Nina, my partner, and I went to visit the clinic, Icyuzuzo, in the Nyamirambo district of Kigali that serves a much poorer area of Rwanda. Hard to imagine being any more below the poverty line.
We toured the clinic which consists of two main buildings. One for HIV testing and counseling that also houses a meeting room for large groups. The WE-ACTx clinics are part of an association that all work together to coordinate care along with the national TRAC program. TRAC is the government's agency that focuses on HIV treatment for all Rwandans. The offices were created from one large stone building with sheets of plywood acting as office walls and doors. We then walked past a grassy area where the kids play while they wait and an outdoor toilet, that as far as i can tell is a wall that people walk behind to go to the bathroom. We went into the clinic and met a lot of staff. The women have and outdoor education area that begins a new health related education session each morning at 7/7:30 which lasts about an hour and the patients really seem to like it. They also have a comment/suggestion book that lets the women ask for certain topics to be addressed each day.
There is one doctor for this clinic and three nurses, along with a lab technician (one microscope and some test tubes and blood draw tubes), a pharmacy tech, and many trauma counselors. Too often, the trauma counselors outnumber the rest of the staff. The clinic is clean and nicely organized. The doctor sees patients with difficult cases, those that need prescriptions and referrals, and anyone starting Antiretrovirals (ARVs) for HIV. The nursing staff is given a lot of opportunity to treat patients in a way that physicians do. This clinic truly would not survive without the fabulous nursing staff! On a busy day 80 patients are seen and no one is ever turned away. Dr. JMV sees every patient that comes to the clinic each day. It is even open on Mondays when he is at a rural clinic in the association, and on Wednesday and Friday mornings when he is at meetings for TB and pediatrics cases in the mornings. He is such a nice man and I look forward to talking with him and learning from him. Odette is by far my favorite staff member because she greeted us with hugs and kisses on the cheek. (How very French indeed!)
After our tour, Nina and I went back to the clinic and went fabric shopping with the other interns. I bought some fabulous fabrics, including very lightweight Tanzanian cloth. All of the colors are so bright! I think the clothes I'm having made will turn out very nice.
Later Nina and I worked on finishing our ARV survey and focus group stuff and just relaxed a little. Truthfully, we were pretty psyched about our new fabric and spent about an hour planning clothes. We do get to have some playtime here.
So I feel I should say a word about the food here, seeing as that is the first question my mother asks me each conversation I have with her online. Seriously. Every time. We have excellent cooks at the WE-ACTx house, Seraphine and Candida. There is a lot of rice and potatoes. Our main dishes include fish and tofu, which actually does taste just like chicken if prepared correctly. I really can't describe the sauces except to say they're nothing like I've ever tasted before and incredibly yummy. Each night also includes a vegetable mix with sauce. For lunch it's peanut butter sandwiches all the way with the best PB I've ever had! Breakfast is usually toast or oats, which are good too, like bigger pieces of oatmeal. I'm going to attempt eggs for breakfast this weekend and hopefully I'll learn how to make crepes. We also have delicious spinach/broccoli soup puree and homemade french fries! The hills are a rough climb so I'm sure I'll come back a little lighter.
P.S. Dad I ate my vegetables, now go get your damn colonoscopy. I'm holding you to the deal!

Day Two: the most amazing day ever, and it's only day two!!

Today I woke up early and went to the clinic. I talked a lot along the way with Mary, a psychologist who works with torture victims seeking political asylum in the US. She's been giving me the ins and outs of Eastern Africa all day today. Trips are in the planning stages...
Anyway, at the clinic I finally met Simon who's the financial director of WE-ACTx and we talked about the project I'm doing with my partner, Nina, who's a med student from Northwestern. We'll be giving out questionnaires and conducting small focus groups with HIV+ women who are eligible to be on medication, most of whom are, but we're looking at medicinal regimen compliance and what factors contribute to why these women might be inconsistent with taking their medications. (minus 2 points for a run-on sentence.) Another project I was encouraged to design/work on is a pilot module for sex ed for adolescent girls and boys and discuss some of the cultural issues that we see happening here. The kids that are enrolled and seen at WE-ACTx are amazing kids that have access to a great deal of staff members who are fabulously kind and generous with their love and time. Part of the problem is that the girls face a much different reality than some of the boys and they don't feel comfortable talking in front of them and some of the male counselors. For example, another intern found out a few weeks ago that many of the adolescent girls are prostituting themselves for money for their families as suggested by their mothers who, at one time, were also prostitutes. These girls also reported very young sexual experiences with their boyfriends and talked about familial sexual abuse. Clearly these girls will not be able to prevent sexual abuse in many cases, but there are things they can do to protect themselves from getting additional strains of the HIV virus. So, I'll be searching (While God's greatest gift was love, google comes in a very close second) for modules that were used elsewhere and then presenting them as a pilot and having it translated to the girls. After the session, we're all going to talk about what can be changed, what they already knew, what questions they would like to see answered in it. We're truly hoping that the young Rwandans will help open up the dialog about sexual practices and HIV in this country, especially with respect to family planning.
This afternoon I went attended a support group for women who have children who are HIV positive. All of the mothers that attend are positive as well, which is how most of the children got it. There was one grandmother there that pulled out a photograph of her and her grandchildren to show us all of them, I think 8 total. Leave it to Grandma's to bust out the pictures! (Hi Grandma!) A couple of topics came up today and everything was translated for the interns so we could comment, ask questions, and contribute. We started with breast feeding and the risk of passing HIV on to the babies, because two mothers had infants with them today (Cutest babies ever!) We talked about their fears, alternative solutions, and other mothers gave advice. The problem with this is that, while many women have access to drugs to reduce the chances of mother-to-child transmission at birth, this does not extend to breast milk after birth. The of HIV infection through breast milk is about 10%, which is very significant. So the easy solution would be to say, stop breast feeding. Well, that's nice but then they'd starve or die of terrible dysentery. The water supply is not clean enough to use to mix with formula and normally children receive antibodies from their mothers during breast feeding and naturally from within their own bodies as they grow. These antibodies help fight off some diseases found in the water and help keep them strong so that they can avoid a serious case. Oftentimes, the water supply is so dirty that cholera and other diseases claim the lives of a large percentage of young children. So again, it comes down to the economics of poverty.
Another woman told us her story and the group leader and herself asked my opinion. She was a prostitute and became HIV+ to support her family when her husband was trying to find work and eventually passed it to her child. She didn't tell him this, but there were rumors in her neighborhood that she was HIV+ along with her child. She is no longer living with her husband and they both love each other and he wants her to stay with him, but she feels ashamed returning to his house, and doesn't want anymore children to be born HIV+. She never told him her serostatus herself and asked me what I thought she should do. She also added that she feared if she told him, he would hurt her and her child, but she doesn't want to lie. Umm......So I told her we should be concerned with her safety and her child's safety first and possibly set up counseling with the husband if she felt she absolutely had to tell him. We're going to discuss the topic of disclosure more next week.
The stories were amazingly difficult. These women also expressed that they were so open to sharing with us because they like the mzungo's connected to WE-ACTx and knew that we loved them and would help them. I felt so small. I looked at them and memorized their faces. They are tired, but still unbelievably strong.
As we were leaving the neighborhood young children probably no more than four years old ran up to us and pulled on my skirt to come play with them. They fought over which one could hold my hands and were giving me high-fives along the way. Looking around these people have nothing. They are living in shacks built with metal slabs for roofs that just lay over the top of their stone wall house, barely attached. Poverty is such an avalanche for these women. There are so many issues that greatly and deeply affect them that can be prevented, like finding clean water sources by installing wells with simple water purification technologies. There is a lot of listening, talking, and teaching that needs to be done here. The cycle of cultural stoicism needs to be broken down with respect to HIV and people need to feel comfortable talking about it and their sexual health.
I'm only going to post a few of my pictures because the internet here is very slow and hard to get them all on the blog, but I'll be putting them on facebook for all my friends that have it!

These are just some shots of Kigali from the balcony of the clinic:

This is the story of how I almost died 8 times

So the legend goes that there was a girl from the midwest that is used to crossing the streets in a large city. She always looks both ways, then does the double look in the first direction she looked just to be sure a car didn't sneak up on her while she was looking in the opposite direction. She's never even been close to being hit by a car, motorcycle, or various mode of transportation...until now...::Flash to the present:: Kigali, the capital city of Rwanda. While traffic drives on the right side of the road, not like the crazies in the rest of the world...::shameless fun poking, don't be alarmed::...anyway, I digress. So the cars and stupid moto's (motor bikes) are zooming everywhere and decide when there are traffic signs, they exist solely as pretty wilderness decorations, nothing to be followed as rules or anything. Most of the streets en route to the clinic don't have lines, so as you can imagine it's a free-for-all. Anyway, I was peacefully walking along today, and yesterday, minding my own business, looking at the million new things there are for me to see, and a bunch of cars almost hit me. Like 8 times. They were going really fast. I actually, honest--this is not a joke or a made up story to make me look good, but I actually pulled a little boy out of the way of a psychotic minibus that would have hit him and me if we didn't move. Surprise, Surprise, motor vehicles hitting pedestrians is a huge problem in Rwanda leading to fatalities, so much so that the government was inspired to put in raised sidewalks. Good idea. Except they're not in by the clinic so it was no help to me as I wandered dangerously close to cars flying around everywhere.
I know what you're thinking, "Melanie, you're supposed to walk opposite the direction of traffic". Thanks. That would be great advice to follow if traffic went in two different directions and stayed in their respective lanes. Something to get used to.
Today I stood on the clinic's balcony and watched. I...watched...everything. The mechanic taking the hub caps off old tires, the woman selling phone cards waived to me, the young man selling women's shoes on the street (none of them matching), and the women carrying babies in a sack on their back. I really think this is the way to go. Never have I seen happier children. The people here are so friendly, but they are a very stoic people. It is said that it is impossible to tell what a Rwandan is thinking. Generally, I've found people to open up to me with just a smile. For me, not being able to speak the language, body language and non-verbal communication have become crucial in bonding with the Rwandan people I meet. Today at the clinic I used the bathroom and started to walk back upstairs when a woman in a bright blue apron stopped me and started speaking French to me. I quickly told her I didn't understand, with the confused look on my face at which point she took me by the hand, guided me back to the areas with the washroom and started to pat her chest. She held up a key for the men's bathroom and made a motion of putting the key in the lock and turning it. Now I know, without one word, that there is in fact a staff bathroom, and that this woman has the key. Amazing. Today was kind of a simple day because my partner didn't arrive until after clinic time and then we hashed out the details of the projects we'll be doing. I will be going back tomorrow and going fabric shopping to have some clothes made for me. I'm also still working on the pictures.

Two Faced

I can't help but write a bit more after talking with another intern, Margot. We talked about how beautiful the country is, how surprisingly normal, how seemingly ordinary. The Rwanda I see when I close my eyes involves screaming, explosions, gun fire, blood soaked machetes. I can hear the scenes from Hotel Rwanda in my head. When I open my eyes, the genocide is gone. I cannot tell a Hutu from a Tutsi, I cannot tell who killed, I cannot tell who fled. I can't even see a reflection of the genocide in the population numbers. The destruction of the poor areas in Kigali looks like the social consequences of being poor, not a result of genocide.
This is what really seeing is all about. The amputees on crutches got their limbs hacked off by machetes. The people with scars across the backs of their ankles, they had their Achilles Tendon slashed to prevent them from fleeing. The Hutus would cut this tendon and then try to get back to kill the wounded later. The wounded Tutsi can only flee as fast as his arms can drag his own bloody body. Many people here have large, disfiguring scars all over their limbs--again, machetes. Where are the people who caused this? The people who killed? Who aided the killers? They're in the big black flat bed trucks wearing the bright pink uniforms. Prisoners who were found guilty for having a role in the genocide. There they are in a truck going down the street. The punishment for these people reflects a desire for the country to heal: the Hutu killers must do volunteer work to build houses for the remaining Tutsis. The pink jumpsuit is their work uniform.
I listened to an excellent PRI (see NPR) special podcast on Rwanda before coming here in which the killers were interviewed about their current thoughts on their deeds and Rwandan officials discussed the punishments chosen for them. Are the Hutu Power individuals truly sorry? Some claim the killers are simply admitting their roles and apologizing because they know they will be given volunteer sentences and pardoned. Rwandan officials are juggling between punishment and forgiveness, hatred and love, justice and revenge. This country craves peace, but how do you reach that goal when no punishment is equal to the taking of all those lives? How do you love your enemy? How do you simply forgive? Tutsis are mixed about this as, many would expect. Some feel a life for a life, others feel there was no sense in the genocide, so there will be no perfect punishment. There will not be peace here until there is forgiveness. There will not be forgiveness until the victims can finally find peace in their own hearts, not until the victims can lay down their anger. I don't know how someone goes about doing that.

Finally Here

I'm here! I slept like a bum in London's airport, laying out on the benches, on my backpack, for 15 hours. The woman checking me in at O'Hare and in London told me to make sure Ethiopia didn't lose my bags, which, I'm delighted to say, they did not! But i was pretty lucky because I had about 20 mins to get to the next flight, so I definitely didn't have the time. But I showed up in Kigali, and so did all my MedSend supplies and my personal stuff, but my ride was late...very late...so late I was in a near panic, as I'm not trained to use the telephone system. The man at the immigration counter chit-chatted with me very politely and wished me luck. The new yellow dufflebags received many compliments throughout the airport and from my new house mates. Back to being temporarily abandoned...I walked past a row of people with name placards...nothing. I go outside and wait. A man walks up to me, well many men walked up to me as one of the only white people there, looking lost, all offering taxi services. A Rwandan police officer walked past, "Hello, sister". This is the way people greet me here. I showed him the address of the WE-ACTx house, which was pointless because no one knew WE-ACTx by that name, and the goal of the house is to keep the community from hounding the staff, so of course this would not be helpful (apparently taxi drivers don't recognize the address system either). He explained to me the nuances of using a phone that required purchasing a great deal of equipment, so needless to say the situation was intense and I was too cheap, so I took a big leap of faith and SURPRISE! Rebecca showed up with our driver, yay!!
Riding back to the house was breathtaking, the hills, the houses, the people.
The interns and I attempted to go to the market and I had my first ride in a minibus. 30 cents a ride. Long story short, market closed, terrace coffee place closed, so we ended up in a streetside bar drinking this awesome African Tea that's very creamy milk with some cane sugar and spices. Very good. Getting home took forever, b/c there's not so much a line at the return minibus stop as there is an angry mob (one that most certainly doesn't like cutters).
And now, for a little more of the less mundane:

The staring hit me the second I got off the plane. It's not as if Rwandan's haven't seen muzungo's (non-africans) before, it's just that we're rare. The last time white people seemed to care about them almost one million Rwandans were wiped out. It's a very intense stare, as if the voyeur were trying to memorize my face. This happens everywhere I go. Everywhere. Put five white girls together and cars start to honk. And they did. And being white here makes it much easier to find a cab too, not shocking after living in Chicago. I don't feel that they're looking at my color so much as my features, the way I dress, and listening to the sound of my voice. Every time I speak they laugh a little. I know what you're thinking, 'what stupid thing did you say to them?' Just ordering tea in the bar/restaurant was an interesting interaction with the staff. The man giggled nervously every time anyone of us said anything. As we sat and drank our tea, we commented on the surprising music choice playing in the background a mixture of 90s pop and current US hits. Shakira is big here. How can one country have such a cultural impact and yet, not act to influence the history of Rwanda?
The history of this country shows in the streets. There is an incredibly large number of amputees walking with the aid of crutches and children follow us every place we go, begging for money, food, or miscellaneous other objects, like pens. They're all wearing American clothes with famous cartoon characters on them, most likely donated by someone in the US. So these kids are clothed, well for now. Essentially, they've been given a band-aid and this of course, will only be a temporary fix. There are so many temporary fixes here, so much charity. Very little justice.