Tour of an Urban Clinic in Gitega

I learned so much today while touring a local urban health center, where to begin? There are so many aspects about how HIV prevention has been addressed in Rwanda that are incredibly impressive, on a world-wide scale. We had some visitors from Guyana visiting today (through this week), and they were discussing the problems which they are having in establishing similar couples counseling and testing sites as well as prevention of mother-to-child-transmission (PMTCT) clinics in their country and it really put into perspective how incredibly progressive Rwanda is. The biggest problem they seem to be having is a lack of male-partner involvement in health awareness. Men there do not seem to want to be HIV-tested, come in for regular health visits, or be involved in the family planning necessary for prevention of mother to child transmission. Amazingly in Rwanda's HIV health centers, I've been told the partner involvement is >85%, largely due to President Kagame's nationwide speech advocating the importance of HIV prevention and couples counseling in 2003. When we asked some of the male patients at a local urban clinic what made them want to come into clinic with their wife, they were really matter of fact about how they want to know their own HIV-serostatus and that of their partner in order to prevent transmission to their future children. (I guess we would tend to think that's a pretty obvious reason, but I think globally from what I've heard it really isn't yet.) One gentleman explained how marriage is a partnership and he knows that his health affects his spouse's, and how that idea must start at the family/community level in order to make an impact. I think the Guyanan visitors wanted to put him in their pocket and fly him home to Guyana. :)

The key to Rwanda's success seems to be the genuine partnership between local communities and health centers, outside sponsors/NGOs and most importantly the Rwandan government, which I've learned is really quite involved with improving HIV prevention and education. Antiretroviral medication is available freely for all HIV-infected persons in need from urban health centers (without the need for any health insurance). Rwanda does have the option of a national health plan which costs $2/year (of which ~90% Rwandese possess). The insurance covers some medical costs, but not all. Our clinic offers that national health plan to all enrolled patients as well as general medical care and long-term contraceptives. Due to logistics and funding issues, the clinic is able to refer the patient back to the original health clinic that they visited initially in order to receive the free ARTs, but we are not able to provide that treatment on site. The government has a 5-year plan to eliminate MTCT transmission. In speaking with an NGO here that works closely with the government-run health centers, he also said that they are working on advocating male circumcision for all males using a new plastic device (currently being developed in Israel, as I recall) that actually kills the foreskin cells and can be removed one week later. Not totally sure on the details of how it works, but it sounds interesting as a non-surgical approach for male circumcision, which has proven to be an effective method of prevention.

And they have this really neat program of accountability called Rwanda Performance Based Financing in which the government (in conjunction with USAID and other groups), establishes certain goals and indicators (in all a lot of non-health fields as well, including education and agriculture) with hospitals and other facilities to reach within a year. For example within our field, at an urban health center, there may be a goal to HIV-test X number of couples within a year. If the goal is met, the clinic will receive Y Rwandan Francs/couple tested, and that money feeds back to the facility itself to expand operations. If you don't achieve the goal, the finances allotted to the establishment is proportional to the success of the indicator. There is a QC process where a health director from another province would come to your province and evaluate the success of the goal, and vis-versa. This idea of setting goals (I've been told) is even present at the community grassroots level where communities will establish common indicators of health (# bednets distributed, # couples tested, agriculture needs). There is a sense of competition between regions on meeting these quality of life indicators and annually, community leaders meet to discuss and identify problems they are having and ask other local regions if they have similar problems and if so, how they were able to resolve them. Pretty neat! Needless to say President Kagame is quite popular amongst the people, and has definitely made it a priority to implement accountability at all levels to improve the quality of life here in Rwanda. Anyway, there's much more I could say, but I need to get home before another terrential downpour. Forgot my raincoat at home, so it's going to be a sloppy jog home!

Good Times, Bad Times

Quite a lot has happened in the last couple days, so I'll try to keep this post somewhat bullet-pointed...

Fun things that have happened:

- Had dinner and sang karaoke (mostly back-up singing, due to the uninspired and incredibly random assortment of pop songs available) with a certain Scandinavian ambassador and his extremely quirky wife on Friday evening. They happened to be a friend of a friend of my roommate's. Still recovering from what a random experience that was! Interestingly, neither was a typical Scandinavian, both dark-skinned with dark eyes born from developing countries. The ambassador's wife was hilariously blunt and tried to lend me what she felt was genuinely critical forewarning about arranged marriages. Hah.

- I can say without a shadow of a doubt that being in our lab has prepared me for many things professionally, academically, and even socially -- one of which is the ability to stay out late dancing in clubs to music that is sometimes very poorly mixed and even occasionally, seemingly undanceable. This ability proved to be useful Friday night when my roomies took me to this club in downtown Kigali called Planet Club. I was enticed to go to the club by the prospect of a live band (little did I know it was the UN Band, comprised of UN workers stationed in Kigali). However, by the time we got to the club, the band was on their last song, Jimi Hendrix's classic single "Hey Joe!" What a tease. :/ Oh well, it was nice while it lasted!

- I've noticed that there are at least three ways to physically greet each other here, with a combination of hugs, handshakes, and arm grabs. It is kind of interesting. The most complicated combination I think is one which involves a triple hug (right side, left side, right side, I think), and then is followed by a handshake. The closeness of the relationship between the people is proportionate to the complexity of the greeting, I think. ;) So far, as I am new, I've gotten a lot of handshakes and arm grabs. Hope I'm upgraded to hugs by the time I leave! :)

- Another random shopping update: huge avocados are amazingly cheap (due to their high accessibility) - $0.16/each! Guacamole galore. And there is a LOT of gouda produced in Rwanda, and as most of you know, I do love gouda.

- Was just thinking about the interesting mix of ex-pats that I've met either en route to Kigali or here in the city itself. I guess it's your typical mix of well-travelled, progressive types: UN volunteers, Peace Corps volunteers, Infectious Disease MDs working for the CDC or Ministry of Health, 20/30-somethings working on starting up NGOs or teaching English abroad. We hung out with a lot of ex-pats last night at another friend of a friend's birthday party. Again, the karaoke machine was involved, and this time when "Hey Jude" was suggested as the next song up, I felt I could not sit back and watch it crumble. Although I've sang the song probably 1000 times, what I forgot at the time of impulse in taking the microphone was that it is incredibly LONG. Good God. And we were being scored...so regretfully by the 7th or 8th "Da-da-da-da-da-da-da, da-da-da-da, Hey Jude" towards the end, we were all pretty well spent. Hah.

- Things are going really well at the lab/clinic. Just spent the last few days of the week training the lab director at the site, and I think he's really got the technique that I was training on, and was so happy about it (as was I)! Still getting along well with my roommates and love everyone at work. My Kinyarwanda is improving daily, so that's "meza" (good) too.

Reality Check:
Obviously, coming here to Kigali, I had emotionally prepared myself for confronting remnants of Rwanda's heart-wrenching past. It's hard to believe that it's been 17 years already since the genocide. It is clear in talking to some of the ex-pats that have lived here for some period of time that residual elements of the tragedy are still very much an unspoken part of daily life here for Rwandese residents. Kigali does seem incredibly safe for foreigners, but even after a few days here, I can tell that there is still an air of instability and tension in the country itself. Grenade attacks are not uncommon, there is still a clear military presence in the streets, I've been told it's best to stay off of public transportation, and I've heard too many second-hand stories about the genocide itself. It has been really difficult for me to balance the regular conversations here with some of the ex-pats that have lived here for a while. Suddenly, conversations will jump from talking about the playoffs and UB40 to talking about evacuation plans and bodies found in house lofts. I haven't quite been able to adjust to the rapid change of topics.

Anyway, that's about it for now. Can't believe a third of my stay here in Kigali is already over!! Looking forward to the next two weeks and hopefully getting in a couple of day-trips here or there. I wanted to see the mountain gorillas or go on a wildlife safari, but it is surprisingly difficult to pull together those logistical details fast here. We'll see, but as Dad reminded me, I'll try not to be too disappointed if the excursions don't happen this time because I think this won't be my last time visiting. Hope everyone is doing well Stateside! And congratulations, you've made it through this long post! :)

The Land of a Thousand Hills

Howdy all! I had my main presentation this morning! I think it went pretty darn well considering the fact that I had more than a few technical snafus: could not get the Internet network to connect (meaning I did not have access to the program that I was going to train the lab on, hah), the Mac adaptor available didn't fit my MacBook (meaning I couldn't project what I did have on my computer to the projector screen) and apparently my external hard-drive only works on Macs (of which there are few in our neck of the woods). But that being said, with a little quick improvisation, we made it work! And I think the talk was well-received. Everyone at the clinic is really interested in our research at the Hunter lab, so keep up the good work, guys! :)

Kigali is surprisingly safe. I feel pretty comfortable walking around by myself after 3 days here (minding general caution). Our place is near "downtown" Kigali, so that has been convenient for grocery runs, etc. I have really liked walking around daily (don't get a whole lot of that back in ATL), and with the hills and altitude, it's been a nice leisurely built-in workout. Because the entire staff at the clinic/lab is so well-versed in English and everyone seems very amused with my attempts at Kinyarwanda, regretfully, my French has taken a bit of a back-seat. My roomies have a private French tutor that comes to the house bi-weekly, but despite my crash course in French (via Lonely Planet), I was relatively lost post general greetings and exchange of names :) I'll work on it. On a completely random note, I wish that Dijon mustard was cheaper. It's nearly $6/jar. (Decided to go with the old spicy brown mustard in the fridge instead.) Until next time!

Waking Up in Kigali

Made it to Kigali safely last night with all my luggage! My roomies are really nice (fellow ex-pat interns) and have been really kind in making me feel welcome. My first day of work was pretty great -- just got introduced to everyone at the clinic and in the lab, and spent the rest of the day working to understand the flow of how things work at the clinic starting from the very beginning with recruitment of new HIV-discordant couples. It has been really interesting to learn how the other end of the process works, since our molecular work is so far downstream of those critical preliminary steps. The basic Kinyarwanda that I learned from the SpeakRwanda series has really caused a lot of surprised and delighted faces from co-workers (and a few patients). My first "murakoze" (thank you) generated a very shocked noise from one of our data/IT co-workers. It was pretty funny. :) Surprisingly, some of the more anecdotal notes from the series have come in handy. For example, at the beginning of Lesson 3: Speaking with Children, the narrator makes this hilarious comment about the proper way to wave your hand. Apparently, the right way to wave is like a beauty queen - side to side, not fingers to palm. In my time here, that has been confirmed. I've not had the chance to speak to children, which is good, because that lesson is really hard and I still haven't made it all the way through it. Hah.

Weather is very warm, as anticipated, however I think the BBC weather was a little off with the heavy rainfall predictions for yesterday. The Internet is not that reliable, but if anyone is interested, I do have a cell phone number for which you can use Skype credit or Reliance Global credit to call. If interested in the number, let me know. Otherwise, I'll try to update here when I can. Took some pics of the intern house (amazing) and the outside of the clinic, but I think the Internet is too slow to bother posting it quite yet.

Kigali's Rainy Season

Really?! Other websites have predicted 100% humidity. Yikes. Looks like I'm in for a real "rainy season."

In the Beginning

"All our dreams begin in youth." - Heinrich Harrer, Seven Years in Tibet

1/19/11:
In three fleeting days, I will head out to Africa to start the journey into international research! This dream's been a long time coming, and I can't hardly believe that I'm actually leaving...soon. Really excited about the adventure ahead and, admittedly, a little nervous. Sincere thanks to everyone for your support and encouragement! Will try to post updates, as it seems fit. Until next time!