Each day here in Kigali begins, invariably, with a walk uphill. Rwanda has the nickname “Le Pays de Milles Collines” (the land of a thousand hills) for a reason. Those thousand hills are packed into an area the size of Vermont, along with almost 10 million people, making it the most densely populated country in Africa. It is an extraordinarily beautiful place, one that has made great strides in overcoming its extraordinarily ugly recent history – the 1994 genocide that left close to a million people dead.
In the intervening sixteen years, Rwanda has become something of a success story; the economy is strong, the government is (relatively) free of corruption, and life expectancy has risen dramatically thanks to free universal health care and massive amounts of foreign aid. Yet like every other sub-Saharan African country there are still extensive health problems in Rwanda, with HIV/AIDS being one of the most pressing.
Which is how I’ve come to be here, working for the International Center for AIDS Treatment and Care Program (ICAP) in Rwanda’s capital, Kigali. ICAP is affiliated with Columbia University’s Mailman School of Public Health and has been supporting the government of Rwanda in implementing high quality HIV- related services since 2002. We currently support 56 health facilities that provide care to almost 45,000 patients, approximately 25,000 of whom receive life-saving antiretroviral medications. So I can honestly say I feel good about the work I do as I walk to the office every morning…even if that walk is more of a climb.
This uphill commute is appropriate, given that the program I’ve spent the majority of my time on here is something of an uphill battle.
Although the HIV prevalence of approximately 3% is high when compared to the U.S., it’s relatively low when contrasted with neighboring countries in East Africa. For this reason the national health authorities in Rwanda have chosen to focus much of their prevention and treatment efforts on most at risk populations (MARPs), particularly commercial sex workers and men who have sex with men (MSM).
ICAP has been tasked with developing a program that ensures MSM have access to high quality clinical services. This is complicated by the fact that MSM face a high level of stigma here in Rwanda. For a variety of cultural and religious reasons, many people, including health care providers, feel that homosexuality either does not exist in Rwanda or that those who practice that lifestyle are deviants and should be denied basic rights. ICAP’s role is not to get involved in issues of morality, but simply to support the government of Rwanda in providing health services to all citizens.
Many countries in the developing world are recognizing the need to focus on populations that are at high risk for HIV, including MSM. These programs usually involve the creation or designation of one particular health facility as being exclusively for MSM. These “standalone” sites can be effective, but can also lead to increased stigma. The government of Rwanda has chosen to integrate care for MSM into all of its health facilities, the first program of its kind in sub-Saharan Africa. My responsibilities are to assist ICAP staff in designing and implementing this program.
So, after a day spent in meetings with government officials, or designing a survey of health provider attitudes towards sexuality, or assisting in the planning of a peer educator training – I walk home, watching the sun slip behind one of the many beautiful hills of Kigali. Although I’m excited to return to New York, and the A train is an express and all…I have to say, I will certainly miss (among many other things) my effortless commute home here in Rwanda.