Rwanda: The humanitarian’s dilemma

Rwanda is a beautiful example of how even the most devastated country can, with enough support and the right kind of planning, make a stunning recovery and get itself on the path of progress.

On many indicators of health and welfare, as well as economic growth, Rwanda is at the top of the list in Africa and, in some cases, globally. I’ve seen the evidence for this in person, having visited and reported on Rwanda more than a year ago. It is an impressive ‘success story’ – a story that gets repeated over and over and over.

But a bizarre juxtaposition of events that took place this week illustrates, for some anyway, the dilemma that Rwanda poses for the humanitarian community.

An alleged war criminal, Bosco Ntaganda, who many believe was fomenting violence in eastern Congo at the direction of the Rwandan government this week sought refuge in the U.S. embassy in Rwanda’s capital, Kigali. Rwandan officials, who deny any connection to Ntaganda, nevertheless had to promise the U.S. ambassador they’d allow the warlord to be extradited.

Days before that, late last week, Rwanda’s Minister of Health Agnes Binagwaho was celebrated at a big global health meeting in Washington, DC, for her country’s rapid progress against poverty and injustice. Twitter went nuts with people referring to Binagwaho as “inspiring, amazing” – a veritable “rock star” for the aid and development community.

You can argue, as some did with me, that trying to link these two events together is unjustified and misleading.

Yet you could also argue they are fairly difficult to de-link — in that foreign aid is a big reason for Rwanda’s celebrated success in health and threatening to withhold foreign aid is how the US government, the Brits and others have been trying to encourage Rwanda to stop messing around in Congo.

“To really understand what’s happening in Rwanda, you have to pay attention to what’s happening in eastern Congo,” said Laura Seay, an expert on central and east Africa and a political scientist at Morehouse College in Atlanta (who is known to many on Twitter as @texasinafrica).

It may put you at risk of cognitive dissonance, Seay said, but the most accurate view of Rwanda is of an authoritarian police state which is also doing a good job of reducing poverty and disease.

People don’t like cognitive dissonance which is why you seldom see these two narratives in the same story. But is sticking to the simple success story a matter of staying focused or naïve complicity?

“The question I would put to those organizations that want to just talk about Rwanda’s success in public health, and it has been very successful, is to ask if it’s sustainable without accompanying political change,” Seay said.

“Are these gains in health and social stability eventually going to overcome the political problems or will all these gains ultimately collapse because we’re ignoring what’s boiling beneath the surface?”

Rwanda, which ranks highly on many indicators for health system improvements and economic development, is conversely ranked very poorly when it comes to human rights, freedom of speech, press freedom, political opposition and other measures we take for granted as basic to a functioning democracy.

Binagwaho, who I met more than a year ago on a reporting trip to Rwanda, was the star of the show at a big global health conference in DC last week, the Consortium of Universities for Global Health’s annual meeting. Rwanda has been widely praised for its stunning improvements in health and Binagwaho, a no-nonsense and entertaining speaker, basked in the glow.

“Improving health is central to our development agenda,” Binagwaho told me by telephone (I wasn’t at the meeting). “We are focused on reaching everyone, on population health and family care, in an evidence-based way that has given our people great confidence in the system.”

A recent report in the British Medical Journal documented Rwanda’s stunning progress in health and in many social determinants of health: A massive increase in getting people on anti-HIV drugs (thanks to aid projects like the Global Fund and Pepfar) with a consequent drop in AIDS deaths by 80 percent, a decline in maternal and child mortality by 60 percent as well as getting one million Rwandans out of poverty between 2005 and 2010.

“Rwanda has achieved some of the most dramatic improvements and achievements in population health anywhere in the world, certainly in Africa,” said Peter Drobac, director of Rwanda’s branch of Partners in Health, the health aid and advocacy organization founded by renowned physician-activist Paul Farmer and Jim Y. Kim, who is now director of the World Bank.

Most people know about the the 1994 genocide in Rwanda, Drobac said, and so some tend to dismiss these statistics as simply a measure of moving from the gaping chasm of death and destruction left by that catastrophe back to maybe just above the baseline for many parts of Africa. Many Rwandans today remain desperately poor, after all.

“But that neglects the fact that this had long been one of the poorest countries in the world,” Drobac said. The health gains made in this country are hardly a statistical artifact, he said, but are quite real and substantial.

A recent article in The Atlantic entitled Rwanda’s Historic Health Recovery goes over much of the details in the British Medical Journal, in a much less wonky and perhaps more entertaining way.

“We’ve seen some great progress here and have learned some lessons that we think can be applied in many other parts of the world,” said Drobac. He’s not the only one to contend that Rwanda is a model for aid and development, especially on health. Binagwaho, as noted above, is frequently asked to provide others with guidance on how the Rwandan Ministry of Health has made such great strides.

“We are organized and evidence-based,” Binagwaho told me. (‘Evidence-based’ is this year’s buzzword for global health, by the way. ‘Innovation’ is old hat.) “Our focus has been on reaching the entire population so there’s a lot of public confidence in our system.”

That may be, responded Laura Seay, but how would we ever know. The Rwanda public is not really allowed to express its lack of confidence in the government, she said. While the reported health gains may be very real and impressive, Seay thinks it’s ‘dangerous’ to push Rwanda’s approach as the model for global health, for aid and development, if the humanitarian community remains unwilling to even discuss the somewhat more troubling political side to all this.

“The aid and development community wants to turn a blind eye to all that and just focus on the positive outcomes in health, and economics perhaps,” Seay said. “But China and Cuba have done great work on health as well and that doesn’t stop us from talking about problems of human rights, democracy and politics.”

The media and political narrative on Rwanda is becoming a bit strained with this wilful ignorance of reality, she said, just as many believe the well-documented authoritarian and oppressive policies of President Paul Kagame’s government is perhaps bringing the disenfranchised segment of Rwandan society to a dangerous, if still beneath the surface, boiling point.

“Rwanda has made great strides and, frankly, most people probably value health and stability more than they do their political freedoms,” Seay said. But if history is any guide, she said, it seems clear that even if you give everyone basic health care and make the trains run on time lack of basic freedoms will erode public support.

“The question for the aid and development community is if these gains will last if we continue to ignore the politics,” Seay said.

MONDAY: I ignore the politics and take a closer look at one of the most critical, and perhaps neglected, features of Rwanda’s successful health strategy – community health workers. More from Peter Drobac at Partners in Health as well as an interview with renowned development economist Jeffrey Sachs.