Rwanda : Reflections from a Safe Distance - By Dr. Vincent Degennaro

http://magazine.nd.edu/news/36205-global-doc-safe-distance/

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Global Doc: Safe distance

BY DR. VINCENT DEGENNARO JR. '02 

PUBLISHED: DECEMBER 12, 2012 POSTED IN: ALUMNI BLOGS AND SOCIETY & CULTURE 

I don't like Rwanda. I never have. It's taken me a long time to admit that, but I'm finally comfortable with it. Of the 40 or so countries I have been to, Rwanda may be the only one I didn't like. To be fair, it is the only country outside the United States where I have ever spent more than three months, and that kind of proximity and intimacy allowed me to get to know the country from many different angles, including the ugly underbelly.

It has nothing to do with living without the creature comforts of hot showers, sleeping in different beds every night or constantly being eaten by bugs. Working in global health for the last 10 years, I've long since become accustomed to living with a different standard than in the United States, and it never really bothered me to begin with. In fact, living in Rwanda is much easier than places like Honduras, where there is a constant worry for personal safety, or Haiti, where you can't rent a decent air- conditioned hotel room no matter how much money you have. Rwanda, especially Kigali, is "developing country lite," a good place to get your feet wet in global health and development work that offers proximity to the poor with most of the comforts of home.

Something about Rwanda struck me as off from when I first arrived, a constant unease, a feeling like wearing an overly starched shirt. There was an immediate sensation of being in Pleasantville, a perfect place on the surface with a dark soul. I initially shrugged it off as a remnant of the genocide, a ghost from the past that still haunted the present. Later, I started chasing the dark spirits down the corridors of the hospital, but they always stayed just out of reach. As more attention focused on my work in treating cancer patients, the spirits stopped hiding in the shadows and eventually started pursuing me.

I like the Rwandan people — honest, generous, and loyal — but a heavy emphasis is placed on race, albeit under the surface. More than any other country of dark-skinned people, Rwanda made me feel odd, like an animal in a zoo. No matter where I went, Rwandans stopped whatever they were doing, stared as I walked by and, without fail, said, mzungu (white person or foreigner). The contrast in skin color is just as great in Haiti and Uganda, but only rarely in those places have I been stared at or greeted with the equivalent of mzungu. There was little, if any, malice behind the singling out of foreigners in Rwanda, and maybe Rwandans were simply more open about their acknowledgement of the differences between us, staring instead of casting sidelong glances, but it was constant, making me feel less welcome, less like they believed in our common humanity.

Rwandans follow orders and procedures to a fault, even if the rules contradict their own self-interest. On some level, the consistency was comforting, knowing that every form must have every box checked, that deadlines would be strictly adhered to. Frequently, however, the inflexibility was maddening and interfered with the care given to patients, as adherence to the procedures and rules trumped a patient's life. As a doctor, I could not stand to watch patients die because of regulations, and my big mouth repeatedly landed me in trouble for speaking my mind.

Rwanda is the darling of the international donor community — progressive, organized and largely devoid of corruption, and most members of the government genuinely care for their people. On the other hand, the government does not tolerate dissent, to the point of paranoia, and they can be capricious in decision-making. Writing that sentence, I'm afraid for my friends with whom I worked that are still in the country, and genuinely worried that the government might react negatively to the organization I worked for. They are obsessed with the outward perception of their performance, and dissonance is not tolerated in Rwandan culture on any level. The Rwandan government doctors statistics on health indicators to impress their donors, and since they generally rank low on the corruption scale, the statistics are often accepted by donors as fact.The New York Times and Boston Globe have called them out for the practice, but they have stuck by their inflated figures, and little has changed.

Recently, rebels in the Democratic Republic of the Congo, supported financially and militarily by the Rwandan government, restarted a campaign of raping and pillaging, largely over disputes of who controls the rights to the diamond and gold mines in the border region. The Rwandan government denies any responsibility, but the international community has condemned their actions and withdrawn some of the financial aid that makes up half of the Rwandan government's budget. As the foreign funding disappeared, the health budgets were cut, resulting in doctor and nurse shortages in the rural areas. Rather than pull back their support for the rebels, the Rwandan government doubled down and started a "solidarity fund" to replace the funds through domestic sources. Officials strongly suggested, stopping just short of an order, that everyone in the country donate 10 percent of their annual salary, more than a month's paycheck, to the fund. The government held charity auctions with the rich and powerful of Rwanda, each trying to demonstrate their patriotic zeal, but really hoping to secure their company's access to business, none of which gets passed without government approval.

Rwanda is in significantly better shape than many of their neighbors because of the singularity of purpose of the government, but at what cost? The feeling of being watched and the permanent unease that enveloped me for 18 months in Rwanda has melted away; I've traded it for feelings of constant insecurity in Haiti. It is entirely possible that I will never be welcomed back in Rwanda if the wrong person reads this diatribe, and I'm finally at peace with that.

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For more information, visit:
BBC, Boston Globe, NY Times

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Vincent DeGennaro is an internal medicine doctor and a global public health specialist in the Department of Global Health and Social Medicine, Harvard Medical School. See his An American Doctor in Rwanda blogs.