Kigali Convention Center

"We die of hunger while they build this....place." -Serafine

From my limited experience here, I have learned that Kigali is a city of facades.  Tall fancy hotels, paved roads with hand-painted curbs and colorful murals line wazungu-ridden areas.  The nightlife is booming (and expensive).  The coffeeshops come in multiples as one asks "Which Bourbon are you going to? Which Camellia?"

However, for many of Kigali's residents, the fancy facades may only remind them of the extreme dicotomy of their lives and the ones that swirl around them, spending more on a meal than they may make in a month.  When Lizzy and I first walked to the Genocide Memorial, we passed down some of the first streets that I'd seen in Kigali with dirt, deep divets and dingy signage.  This was the East Africa that I knew.  Where you buy detergent in "one-serving" little packages hanging inside a small shop.  Where the storefronts and inside counters are decked with clear plastic containers packed with fried balls of dough (mandazi) and sambusas.  Where the children look like they've worn the same pants for a month and they stare at you bug eyed as their fear prevents them from exclaming "Mzungu!"  Or perhaps it doesn't and you are ushered past to a sing-song choir of "Hello mzungu!"  While this isn't all of Kigali or even Rwanda, it feels more real than the $2 take-away latte that I buy across from my work.  And, while it may not be the most attractive by Westernized standards, I find these streets gorgeous.  There is color.  There is slow conversation.  There is phsyical activity.  There is life.  What is more beautiful than real life?

This shrouded side is easy found and plenty visible outside the bustling city.  However, espeically in Kigali, there are sad developmental undertones.  Many of the houses that we pass are covered with a red "X" spray painted haphazardly onto their front.  This "X" symbolizes that the house is not up to the modern standards which the Rwandan government set for the "beauty" of Kigali's future.  Therefore, the house will be destroyed in the upcoming years.  You have to make room for more fancy hotels after all.  

One shining example of this dichotomized society is the newest, hyped addition to the Kigali skyline: the Kigali Convention Center (pictured above).  While trying to make Rwanda a site for regional and international conferences isn't bad, the fact that the government is pouring billions of dollars into building a fancy-ass building while people still struggle to provide basic needs for their family is more than sickening.  Guess which roads are the quickestly paved in Tanzania and Rwanda? The ones that tourists and the President use most often.  It's not all that different from when the bike lanes in Chicago feed mainly into Oak Park and Lincoln Park, basically ignoring the poorer, minority neighborhoods.  In this disgustingly condescending video, you can see how Rwanda is being portrayed to investors and foreignors alike.  

In calling Rwanda "unafrican" by being clean and economically viable, it insults every stereotype that African countries are trying to fight against.  When Westerners assume Africa is only poor, disorganized and dirty, the are denying Africans the respect and dignity that they deserve, seeing them only as people that need to be "helped."  

This is why campaigns like "Africa is Not a Country" have been started.  They want to showcase the amazing range and depth of talent that is not shown enough in our perceptions of this continent.

"Africa is Not a Country" Campaign image.

Stigma and Suicide

Why should we investigate stigma among Rwandan youth at boarding school?

Despite stigma reduction campaigns in Rwanda, the stigma of HIV is still highly prevalent and affects the patients at WE-ACTx For Hope clinic in Kigali.  Stigma can reduce HIV medication adherence if patients are unable to hide their ARV’s, can’t find private locations or times to take their medications or have no one to provide support for their adherence.  One particularly vulnerable population is youth in public boarding schools.  Due to the close quarters, the tightly monitored environment and strict school schedule, it can be difficult for students to remain adherent while away at boarding school.  Additionally, in Rwandan culture, if classmates saw someone taking medication, they would be more likely to openly inquire about it or request to use some themselves.  Shirking answers or denying to share medication can be construed as disrespectful and interfere with personal relationships between fellow students in boarding school. 

The primary indicator of adherence rate is viral load and at WE-ACTx only 70% of patients aged 13-24 are virally suppressed compared to 84% viral suppression within the entire clinic population.  In order to investigate this trend and discover methods in which current youth are battling stigma, we organized focus groups of students who were either on break from boarding school or had previously been in boarding school.

There was another account that reinforced our idea to investigate this specific area within HIV treatment when the WE-ACTx research team came in contact with a student who experienced stigma while in boarding school.  One patient’s story, relayed by her mother, started when she was accused by her classmates of stealing money.  The girl’s teacher demanded to search her belongings and began rummaging through her things in front of her classmates.  While she was searching, the teacher accidentally pulled out the girl’s HIV medication and the tablets spilled all over the ground, scattering everywhere.  Her classmates knew the purpose of the medication and the girl was mortified.  After a few days, because of her embarrassment and the stigma that she felt, she decided that she wanted to commit suicide.  In the meantime, one of the girl’s classmates who was also HIV positive and taking ARV’s, began monitoring her for any indications of self-harm.  When her classmate saw her trying to commit suicide, she stopped her and showed her own ARVs, telling her that it was okay and that her life was valuable.  The girl changed her mind and is currently alive and in contact with WE-ACTx.

Therefore, the realities of stigma are all too real and can take situations that are challenging yet manageable and make them seem hopeless.  This is why we wanted to investigate how we could further support the youth as they faced these issues and what mechanisms they already had in place to remain adherent and confident in the face of stigma at boarding school.

Focus Groups Update

After looking at the data from the 181 patients surveyed during the Family Needs Assessment that focused on children under 18, we discovered that 1/3 of the patients never reported their viral load during the survey.  This meant that we would not be able to correlate their health outcomes to their management of HIV since ARV adherence is determined via viral load per the most recent WHO guidelines (2015).  Therefore, I compiled a list of patient names and our data analyst helped me to search the national EMR and WE-ACTx for Hope's paper records to fill in the gaps.  While about 1/4 of them were not on ARV's as of yet, the addition of this data was still important.  Now, instead of 67% response rate, we have an 85% rate of data that we could correlate to ARV adherence.

Another concern was the duplication of one patient name on the list in addition to not all the survey results being translated into English.  Therefore, I sat down with one of our bilingual employees that assists our data analyst and spent several hours finished translating.  Initially we were translating from Kinyarwanda and conversing in English, but when we discovered that Swahili was a better method of understanding each other, we switched to that.  He would translate the Kinyarwanda written responses into Swahili and then I'd write them in collouqial English.  Additionally, we discovered while doing this that many of the "Comments" sections which were filled in were not done so in legible Kinyarwanda.  Therefore, some of the results still remain in Kinyarwanda since they weren't legible to a native speaker.  Alas!

After these strides, we planned to sit down on Thursday with the doctor and one of the trauma counselors to discuss the details of our next steps: organizing Focus Groups.  We needed to determine things such as which age groups we'd group together, how many children would be in each focus group and how to supportively word the questions to encourage responses.  While at the Nyacyonga clinic with Edmund, we discussed his impressions of the focus group draft of questions.  He pointed out that he wasn't clear on what a focus group was since he's never done one before.  I explained that focus group sessions would allow for more specific information and for us to ask more questions and hone in on responses as to what and why these factors are affecting HIV adherence.

10 Fast Facts about Rwanda

1. Plastic bags are banned here.  They will even search your bags at the border and make you remove any that you try to bring into the country.

2. You can walk alone at night.  Kigali is relatively safer than its East African capital counterparts (Kampala, Nairobi, Dar) where I would never attempt to walk alone after the sun goes down.  

3. French is more widely spoken and written then English.  Thank you, Belgium.

4. The coffee is phenomenal.  Full stop.

5.  Tea is only drunk in the morning with breakfast.  No mid-day chai break here.

6. When trying to get your attention, Rwandans will "hiss" at you. No joke.

7.  Overcrowding is rarer on buses.  In Kigali, traffic police actually police the streets, especially around rush hour, and pull buses over if there is even one person more than there are seats.  Even the bus conductor, the guy collecting the money and hollaring out the bus's destination, must have a seat to himself.

8. While health insurance isn't mandatory, however, the government provides cost-effective, subsidized plans (called "Mutuelle de Sante," or "Mutuelle" for short) that range from free to $6/year and upwards, based on Income Level Category.

9.  Rwanda is in the UTC +2 time zone, or Central African Time.  Daylight savings time is not observed.

10.  Rwandas tell time in the "African way", adding or subtracting 6 to the time, depending on the hour.  Eg. 10am would be said as 4 o'clock in the morning in Kinyarwanda/Swahili while 12am would be said as 6 o'clock at night.

Umuganda

Saturday, June 25th, was my first (and only) Umuganda day in Rwanda.  Umuganda is a national-wide morning of community service that occurs on the last Saturday of every month.  You can read about the fascinating history and meaning of Umuganda here. 

John, our gardener, woke us up with his booming voice and fervent gestures that morning, insisting that we join in the work being done.  Happy to see another side of Kigali, I threw on clothes and harassed Lizzy and Kerrlene into coming with (just kidding, they actually volunteered quite readily).  We hiked down the winding road for 15 minutes, led by two Rwandans John had arranged for us, before encountering a group of 20+ Rwandans and wazungu lined up along a brightly painted wall outside a coop and one of our favourite cafes.  The wall was being painted with a massive with the more complicated portions already sketched or painted in.  We picked up plastic cups full of varying colors of paint and washed off some paintbrushes.  After a few hours of painting triangles, rhombuses and frilly swooshes, in addition to a plethora of conversations in Swahili, we hiked back up to the house.  In other places of Rwanda, people were picking up trash, shoveling clay and trimming bushes.

From about 8am until 11am on Umuganda, all buses cease running in addition to any form of transportion.  If you are caught on the road without a valid reason, such as catching a flight, you will be stopped and fined.  The city was mysteriously quiet as people either wandered down the road in search of work to do, or hid in their houses and performed the Umuganda for themselves and their families.

Lizzy, Kerrlene and I next to a mural that we didn't actually paint.
Our colorful, albeit basic, additions are further down the wall.