Après la Mort, la Vie Continue

Rwanda is beautiful.

The Country of a Thousand Hillsides – Le Pays des Milles Collines – it gives the impression of a rumpled blanket, covering the fitful sleep of a slow unseen giant. The countryside is a patchwork of sloping banana tree fields and vegetable patches, dropping down into tea plantation valleys. The wispy clouds above are complimented by the green of the tea leaves below, a deep, pleasant, and relaxing colour. It’s almost enough to make one forget the nauseating stop and start of the curves in the road, and the steep unforgiving drop just a short driver’s error away to the left.

Just across the Ugandan border, the road provides its own stern warning: the charred skeleton of a petrol truck, lying at the bottom of a hundred-foot black scar. The smoke has mostly cleared as we drive past.

Rwandan Landscape

Our driver continues obliviously onward, treating the speedometer like a bungee cord as he bounces between sixty and thirty kilometers per hour at every bend. The speedometer is likely broken anyway. It has been my experience that in poor countries, they always are. Exhausted from several days of travel, I curl up in my seat, resigned to whatever fate has in store.

I am in Rwanda at the invitation of my friend Aska, a Polish medical student I met in Cambodia last year. She is on an International Federation of Medical Students exchange at the University of Butare in the south of the country.

Arriving in the capital after a ten hour bus ride I am soon informed that the last bus to Butare has already left. I find an alternative route on public transport. Four hours and several dozen stops later, I saunter into a restaurant in Butare, a dusty mess with a large backpack. Thankfully, Aska is there waiting with friends. She’s already entertained them with the story of how we met, traveling on the roof of a pickup in Cambodia. My ragged entrance seems appropriate.

They invite me to join them at a dance club. Émanuel, a Rwandan medical student in his final year of studies, is warm and friendly. He seems to take a special delight in looking after foreign visitors. As the girls gyrate their way to distant corners of the club, he stays behind to make sure that Laurent, a French student, and I are both comfortable. We’ve both been awkwardly practicing our respective versions of the white man shuffle. Surrounded by the kind of booty-shaking that can only be seen in Africa, our lack of rhythm draws attention.

We are soon joined by other enthusiastic Rwandans, men and women who are happy to offer words of encouragement, "No, no. Don’t worry so much. Relax! Have fun! Just feel the music. … Much better!"

This is Rwanda. At first glance, it is a country beautiful, friendly, and open. Old men pass the time playing Igisoro, a subtly complex game of sixty-four stones in thirty-two piles. Women sidestep around puddles and people, carrying snack trays for sale. Children shout "Bonjour Mzungu!" at passing foreigners. An exception amongst poor countries, the government passes progressive laws, and the people actually follow them. Every motorcyclist wears a helmet. Taxis even carry an extra one for their passengers. Every major road is paved with barely a pothole in sight. Plastic bags have been replaced by environmentally friendly paper ones. In the hospitals, volunteers dressed in pink clean and tend the grounds.

"Il y a un esprit de développement ici." – "There is a feeling of progress here," I told a Rwandan named Émile when he asked what I thought of his country. He had just been telling me about the genocide. Émile is a Tutsi. He survived by moving from one hiding place to the next. Several members of his family weren’t so lucky. "Après la mort, la vie continue" – "After death, life continues," he replied.

That is also Rwanda, a country littered with genocide memorials and mass graves, a country in which only twelve years ago, men, women, and children butchered men, women, and children.

After World War II, European civilians could claim they were unaware of the genocide in their midst. In Rwanda, there is no such option. With the limited resources of a poor country, the Hutu massacred the Tutsi with whatever was ready to hand: machetes, hoes, and clubs. For a hundred days, people murdered from sunrise to sunset, stopping only for food and rest. It was hard work. Those Hutu who refused to help were often massacred alongside the Tutsi. Unable to escape, victims were gathered in groups to watch and await their turn.

The volunteers in pink do not work voluntarily. They are génocidaires, former participants in the genocide. With limited resources and countless accused, Rwanda relies on traditional courts. Every week, businesses close so that the population can convene to hear evidence. The guilty are usually sentenced to public service. It has been twelve years since the genocide ended. The lists of accused are still long.

Génocidaires at the Hospital in Butare

I gave a talk in January at a synagogue, contrasting the Cambodian Genocide with the Jewish Holocaust. "How can you begin to compare such atrocities?" I was asked. Here I didn’t have to. The Kigali Genocide Memorial Museum had already done so, with displays of the mandatory identity cards that labeled Tutsis, the propaganda that dehumanized them, and the tools that killed them.

The Hutu Ten Commandments, a document widely circulated by the Hutu Power movement before the genocide, exhorts all Hutu: "Show no mercy to the Tutsi!" It forbids marrying Tutsi, frequenting Tutsi businesses, or showing kindness even to Tutsi within one’s own family. Substitute Jew for Tutsi and the commandments provide a good summary of the Nuremberg laws of Nazi Germany.

The museum contains displays of other genocides from the Armenians to Nazi Europe, from Cambodia to Yugoslavia. The Children’s Memorial in the basement is a darkened room in which the names of children are recited in an overwhelming seemingly endless list. If it were filled with the lights of flickering candles, it would be a perfect replica of the Children’s Memorial at Yad Vashem in Jerusalem. There is even a hallway paying tribute to righteous Hutus who risked their lives to save Tutsi. At its centre is a quote from the Talmud in English, French, and Kinyarwanda, "He who saves one life, it is as if he had saved the world."

There is an eery feeling in the museum, a sense that though we know nearly nothing of the history of these people, they know us and ours well. That feeling is confirmed by a glass plaque in the final display, the museum’s central unspoken message:

"When they said ‘Never again’ after the Holocaust, was it meant for some people and not for others?"
     –Apollon Kabahizi

It’s a valid question. While Interahamwe militias manned roadblocks, scouring throughout the country for Tutsi to kill, the United States government actively blocked the United Nations from sending troops to intervene. Until the bodies were piled so high that dump trucks were required to remove them, US officials refused to use the word "genocide." Under international law, that word would have required them to do something to stop it.

France was worse. President Mitterrand was so closely linked to the Hutu Power movement, its leaders referred to him affectionately as Mitterahamwe. Before the genocide, French troops helped in identifying Tutsi. As the genocidal government collapsed, France unilaterally created its own UN mission under the banner of humanitarianism. New French soldiers arrived enthusiastically, expecting to save lives. Many quickly became disillusioned as they provided a safe retreat for fleeing génocidaires.

After publishing One Boy at the start of this month, I was asked, "It’s great to say you should care but practically what action can you take?"

It’s a difficult question. I spent much of my time in Rwanda thinking on it. Here is my answer: Care actively. Become interested enough in the injustices you hear about at home and abroad to learn about them.

We are active in the things we care about. Governments act on the issues of greatest concern to voters. Corporations act on the needs and demands of consumers and shareholders. We are voters, consumers, and shareholders. When we care as much about an injustice as we do about the environment, health care, and gas prices, corporations and governments will take notice.

We want a simple solution, a path that has already been laid for us: Click a link. Sign a petition. Buy a product. The small solutions are good but they don’t absolve us of the need to educate ourselves. Learn. Don’t stop because a practical direction is unclear. The first step is understanding. Solutions won’t immediately follow but the next step will.

Lt. General Romeo Dallaire, a Canadian who led the United Nations Peacekeeping force during the genocide, has said repeatedly that with only four thousand troops he could have ended the slaughter. Subsequent military analysts have agreed with him. No country was willing to send those troops. We in Canada had the resources to help. We chose not to do so. The Belgians, who composed most of the troops in the UN mission, withdrew days after the killings began.

"Riskless warfare in pursuit of human rights is a moral contradiction. The concept of human rights assumes that all human life is of equal value. Risk-free warfare presumes that our lives matter more than those we are intervening to save."
     – Michael Ignatieff

Four thousand troops could have saved eight hundred-thousand dead.

I met two Australian UN workers this week. They were on leave in Kampala from Southern Sudan. I asked them about the situation under the current peace agreement.

"Peace agreement?! There’s no peace and no agreement. Most of the groups didn’t sign it. Many of the remaining groups, Janjiweed and others, might as well be working for the government. No worries though. There will be peace in Sudan. It’s coming just as soon as they’ve eliminated or pushed all the undesirables across the border."

"Après la mort, la vie continue."

Unfortunately, neglect, apathy, and genocide do too.

As for the Rwandans, the government while coping with the same problems of poverty faced by its neighbours, has done a miraculous job of keeping both sides living peacefully side by side. Artwork in national galleries more often than not has titles like "Reconciliation," "Peace," "Compassion."

Rwandan Art

The Tutsi still remember the murder of their families. The Hutu still mistrust and fear the Tutsi. Witnesses set to appear before the traditional courts still disappear. So do former génocidaires. Nevertheless, the Rwandans are moving forward. As Émile told me, "Most génocidaires were poor and angry. They were told to kill, coerced to kill, and they killed. They did not know what they were doing. If one of these now understands his actions and wants forgiveness, we must forgive." After all, what alternative is there?

"The only conclusion I can reach is that we are in desperate need of a transfusion of humanity. If we believe that all humans are human, then how are we going to prove it? It can only be proved through our actions. Through the dollars we are prepared to expend to improve conditions in the Third World, through the time and energy we devote to solving devastating problems like AIDS, through the lives of our soldiers, which we are prepared to sacrifice for the sake of humanity."
     –Lt. General Romeo Dallaire, Shake Hands with the Devil

Life in Kampala

Providing a break from heavier subjects, the lighter side of life in Kampala.

Mobile Phone

Ladies and gentlemen, as seen on countless Kampala street corners, the world’s most mobile phone:

World’s most Mobile Phone

It’s even got wheels.

The Equator

“Hey Australia! Which way does the water in your toilet drain?”
&tab;–Bart Simpson

Thanks to the valuable scientific knowledge in The Simpsons, many of us learned that while water drains counter-clockwise in our Northern Hemisphere, it drains clockwise in the Southern one.

So, I’ve been asking myself ever since, what does it do at the equator?

About a ninety-minute drive from Kampala, there are three small water basins set up at the equator where one can try the experiment oneself. The first basin is about ten meters into the Northern Hemisphere, the next directly on the equator, and the last about ten metres into the Southern Hemisphere.

At the exorbitant charge of nearly three dollars, I opted not to try the experiment.

Standing at the Equator

Luckily for science, weeks of staring at my bathtub drain, which according to the GPS unit I borrowed from the Injury Control Centre at 0º 20.63’ North latitude is pretty near the equator, have yielded the following result:

Counter-clockwise about half the time, clockwise the rest.

Purchasing Pants

Arriving for our first day at Mulago hospital, Amna and I immediately noticed a problem. We were underdressed. Luckily, with much haggling, used clothes are available here at very reasonable prices. This is part of a general trend throughout Africa. When second hand clothes dealers in rich countries are overstocked, they ship in bulk to Africa at discounted rates. These clothes are so cheap that local manufacturers are often unable to compete, effectively destroying domestic garment production in many countries. It’s a twisted irony. Clothes that were donated to help the poor rob them of employment.

I’ve been told that in some places these shipments are called “Dead white men’s clothes.” The logic is that no one in their right mind would give away perfectly good clothes for nothing. When nearly everyone is poor, fashion is a non-issue. Besides, 1970s polyester dries more quickly in the sun than cotton blends do.

About a week before my departure I had been telling a friend about this problem. “Really?” she’d responded. “I don’t want to donate clothes just to have them cause problems overseas. Which groups are responsible?”

It was an astute question. “I’m ignorant,” I replied. I’ve heard of the trend but I don’t know if it’s Goodwill, the Salvation Army, or what. Once the local clothing manufacturers are wiped out, I’m not even sure if the process could be stopped without leaving whole countries without clothing. I haven’t done the research.”

Back in Kampala, Amna, some friends, and I investigated Owino market, an amorphous heap of wooden and tin stalls stretching endlessly through the downtown core. It is a place so full of pickpockets that even local Ugandans dare not bring more than a few small bills with them inside. The sight of three potentially rich foreigners started a ripple through the shopkeepers. As the word, “pants,” escaped my lips, I was surrounded by eager men with measuring tapes, proffering me endless pairs of Khakis.

One of them had a green Value Village tag on the waist.

Value Village, j’accuse.

Pants Shopping at Owino

Shylocke?

Ugandans are a religious lot. Muslims drive taxis with Bismillah emblazoned on the front. Christians pepper their buildings with biblical references. For the New Testament Scholars there are frequent Agape Health Clinics. For those who prefer Hebrew, there are The Haggai Nursery School, The El-Shaddai Guest House, and the Shekhinah Prayer Centre. In my opinion though, there is one Hebraic business here that inadvertently tops the list:

Shalom Moneychanger

Yes fellow Israelites, you read correctly. Despite all our hard work to move beyond the stereotype, he changes money at a business called Shalom.

The World Cup Downtown

"Which team are you supporting?"

Right after "How are you?" and "Where are you from?" it’s the most common question I’ve been asked here. Wandering the streets of downtown Kampala after sunset, one often feels like a fish swimming between human islands that stand thirty men deep. The focus is always the same, a single small television screen resting in a shop window, above a restaurant counter, or even someone’s flat. The men trail out as if queuing in a bread line, never moving, always waiting and attentive. Often the TV is muted, as someone in the crowd has brought a radio from which the commentary can be heard in Luganda.

The rule here is solidarity. Though Uganda did not qualify for the World Cup, the teams to support are all African.

"Ivory Coast but they didn’t do so well. Now they are out," I responded one day in surgery, "What about you?"

"What about me?!" was the laughing response, "My skin is black, I support Ghana!"

By this time, with an impressive win over the United States, Ghana was the only African team left. Riding a matatu as the sun set this evening, I was perplexed. The van had stopped short. It was turning away from its usual route.

"Conductor, stage!" I called, asking to be let out. Amna and I exited, strolling around the ever denser downtown television islands as we approached the core. It soon became clear why the matatu had stopped. People filled the city’s central artery, shoulder to shoulder on Kampala Road. They stood calmly, expectantly, staring upwards into the distance.

We followed their gaze up to a large billboard, advertising the greatest public service I had yet seen in Uganda. It was broadcasting the World Cup game. In the streets of Kampala, thousands of Ugandans stood side by side, silently cheering the Ghanaians as they struggled with Brazil.

Already late for our dinner meeting, we stopped. I can not describe the energy of that moment, thousands of people together in the heart of a major city, happy, expectant, and hopeful.
The game was nearly done.

"Hey Mzungu!" someone called from the side of the road, "Who do you support?"

"Ghana!!" Amna shouted with a smile, "I am in Africa! Who else?"

Ghana lost that night. Still I wish that I could have bottled that moment. Never have I seen so many strangers so happily united, stoic in a single hope.

One Boy

I noticed him on the first day in Loubugumou. To the dozens of children not in school, the sight of two white people with clipboards was the most exciting event in months. They let us know by gathering round, asking us endless questions in Luganda that we could not understand. We answered with English that was equally incomprehensible to them. Together we made a game, a vain attempt to start them on the road to literacy, calling out letters printed on the bottom of a water bottle or scratched in the dirt.

Letters in the Dirt

One boy had come with the others to pay his respects. He looked to be about ten years old, leading a group of two or three younger children for whom he had decided to be responsible. He was unlike the others. When he saw what my digital camera could do, he made no attempt to see endless pictures of himself. Instead, he hurried to find a young girl of about four, carrying her back so that she could join in the fun.

He stayed longer than the others, smiling, drawing doodles in the dirt that covered our pickup, and raising his shirt to reveal a protruding lump the size of a small fist where his belly button should have been.

I stopped watching the passing motorists. "Amna," I called out, in my calmest possible voice, "I know I’m not qualified to tell but does that look like an umbilical herniation to you?" Translated into English, umbilical herniation means "Intestine pushing its way out through the belly button."

"Oh yeah. It’s easily treatable. We used to see them at the clinic in Ghana all the time."

"You’ve seen these before?" I asked, "So, without treatment, what’s the likely outcome?"

There followed a look that spoke with silent finality.

In theory, every Ugandan has access to universal health coverage. It remains only a theory though. Coverage extends to those able to afford travel to the hospital, medications that are almost forever out of stock in the public wards, and lost time helping to support their families.

To the best of my knowledge, eighty percent of Ugandans work in subsistence agriculture. With luck and hard work, they grow what they need to feed their families, with a little remaining to buy clothes and tools. With poor luck, transport costs, and unexpected hospital bills the average Ugandan family will begin to lose what little they have.

I looked over at our guide, Jerome.

"Amna, do me a favour," I asked with forced casualness, "Ask Jerome what would happen if we told the boy’s parents that his problem is both potentially dangerous and easily treated."

She returned a moment later. "He says the problem is common here. The parents will expect you to transport and treat him yourself."

Here was my dilemma: Similar things happen every day. It wasn’t a revelation to me. I had known the statistics for a long time. Thirty thousand people die every day from hunger and preventable illness. Every day. Six thousand are children. Though I knew this indirectly, until that moment those children had always seemed like someone else’s responsibility. There I stood, a budding health professional with the resources and connections to whisk this boy away to the side of a well-trained surgeon and back again.

Was it my responsibility this time?

I continued counting motorcyclists, trying to decide what to do. I opted to wait for an opportunity to check with some of the doctors from whom I’ve been learning in Kampala.

The response came during rounds of the hospital the following day. "It’s quite common here," I was told, "Generally, you don’t need to worry about it unless the bowel becomes twisted or the blood supply is interrupted. Then it’s serious. Actually often the larger hernias are safer than the little ones."

"Oh good," I said, feeling both surreal and relieved.

On the drive back to Loubugumou, I considered this re sponse. The boy was in no immediate danger. I had dodged the responsibility. There was nothing I needed to do. Still, I had not dodged the question.

Between malnutrition, unsafe water, and poor sanitation, these children have far more than umbilical herniations with which to contend and no reliable access to health care with which to do so. In a country with supposedly universal health coverage, they are the rule not the exception.

What if the boy had needed treatment urgently? What difference if I poured my resources into treating this one child? Did he deserve it more than the others?

Worst of all, what kind of a system would prompt me to ask such a question?

The resources exist to protect all of these children. In Canada alone, we spend more each year on ice cream than we do combating global poverty. If the numbers were reversed, proper nutrition, safe water, and actual health care could be made available to every one of them, not only in Uganda, but also in several other countries as well. I’ve read it before. Somehow though, when I reach a Baskin Robbins or the frozen foods section of a Loblaws, it always seems so distant.

Having had two weeks to think about it, I’ve come to some conclusions. The resources exist. We have the power to make them available. That boy is no more my responsibility now for having been right in front of me than he was before.

He was always my responsibility.

The trade, economic, and political imbalances that lead to extreme poverty are subjects wide enough for several books but the central point is this:

There is a global system that allows for this kind of poverty. Canada is powerful enough to help change that system. We can influence our government to represent the causes in which we believe – We have the power to change that system. "It’s not my fault," "It’s not my responsibility," and "I’m only one person," are about as valid an excuse for apathy as "I was only following orders."

When we arrived in Loubugumou the following day, the children were there, happy to see us. We began our observations as they laughingly clambered over the pickup truck, shouting and joking in Luganda. Several of them were running around without shirts nearby in the tropical heat. This time, I noticed what I had not seen before: countless umbilical herniations, only smaller.

"All that is needed for evil to prevail is for good men to do nothing."
  –Edmund Burke

Cracking Heads?

Passing under towering Mukavu trees, our driver eases gently along the dirt roads of Mukono district. In front of us, a flat-bed overloaded with firewood teeters dangerously on top of a mound of dirt. The mound is one in a regular series. This is a country in which SUV drivers have an excuse.

Before our arrival in Uganda, we had proposed a study to measure how often motorcyclists here used helmets. A law was recently passed requiring that drivers, but not passengers, wear them. No one here seems to know why. As motorcyclists in Kampala try to save the twenty dollars needed to buy proper headgear, one sees everything from construction hardhats to equestrian caps bobbing through the traffic flows.

Mukavu Tree

When we first arrived in Kampala, we learned that our study had become redundant. The Injury Control Centre of Uganda (ICCU), where we now work, was recently contracted by the World Health Organization (WHO) to perform the same study on a far grander scale. So, we adapted. We altered our plans to complement the larger study. We decided to leave Kampala, to learn the effect the new law is having outside city limits.

We are in search of a “rural” town, somewhere not too far from Kampala, so as to save on gas, but not too close, so as to create a reasonable contrast with the city. At the end of a bumpy lane, just down the road from a mud brick kiln, we find Loubugumou. It is a small collection of buildings and fruit stands, full of dust, playing children, and idle men. We place ourselves in front of the “See How God Loves” chapati shop, next door to the “Jesus Cares” barbershop, with a clear view of the road and the “Trust in God Soda Depot and Payphone” across the street.

Loubugumou

Over the next several hours and days we watch the road, ticking off riders and passenger as they glide past. The children entertain themselves with loud shouts of “Mzungu bye!” a semi-accurate mishmash of English and Luganda meant to convey, “Hello white person!” The women mind their fruit stands or pass by on errands. The men sit idly in front of their shops and motorcycles, awaiting a customer. Occasionally one will ride his bike morosely across the street to a fruit stand. Amna and I will debate if this qualifies him to be counted in the study.

At the end of the day the men gather in circles around benches to play board games. One of them offers to teach me to play. The board resembles Sorry! encased in a picture frame. Four men play for a pot worth slightly more than two dollars. It’s more than most earn for a day’s labour. It’s more than they or their families can afford to lose. I ask permission to take a photo. One man agrees on behalf of the group. Another, who speaks no English, is unwilling to be caught on film. He flees at the sight of my camera. I thank them in Luganda and the crowd laughs.

Board Game

At the end of a week, having observed nearly nine-hundred drivers and their passengers, there is neither a construction helmet, nor an equestrian cap in sight. A quick glance at our survey sheets shows that only about one in fifty were wearing any helmet at all. Those locals educated enough to speak English have been happy to explain the cause.

Motorcycle helmets aren’t designed for tropical climates. They’re hot, sticky, and uncomfortable. Motorcycles are often shared between several drivers. To save costs, they also share one helmet. Many are worried about head lice, communicable infections, and sores. For women, who spend a large portion of their limited income styling their hair, a helmet is guaranteed damage on their investment.

More importantly, no one seems clear on why helmets are necessary. It is thus unsurprising that as police presence dwindles outside the capital, so too does helmet usage. Some riders even take to carrying their helmets under one arm, popping them on their heads when they pass a police check and removing them again afterwards.

There has been no public education on the benefits of helmet usage and no precedent in local history to explain them. Some believe that the government passed the law requiring helmets because of pressure from donor countries. Others believe that it was done simply to imitate richer nations. Most are less concerned about the reasons than the inconvenience it causes. One man, who tells us his name is Mr. Ibrahim, explains that though he knows that in our country helmets have been linked to lower rates of injury, no study has ever been done to prove that this is true Uganda.

I flash back to a man I knew in Cambodia, working with the WHO and the Ministry of Health to promote helmet usage amongst motorcycle taxi drivers. “Months of ad campaigns, sit-down sessions, and public education, and when we ask them what their number one reason for wearing a helmet is, do you know what they say?! To keep dust out of their hair! Aargh!!”

I added the “Aargh!!” There were more expletives in the original version.

Seeing that helmets damage local hairstyles, the Ugandans don’t have even this slim motivation. Having visited nearby Kowolo hospital, notorious for treating the most road traffic accidents in the country, I can see their point. The hospital’s logbooks are full of fractured legs, arms, hands, and feet that occurred on the roads. Though many of their most urgent cases are not recorded properly, in the past five months not a single skull or neck fracture has been logged. Ignorant as I am of the statistics proving the benefits of helmet usage, I’m forced to wonder if maybe leg braces or wrist guards might not be a more appropriate measure.

In the meantime, with our data collected, we pull out from in front of the barber shop one last time, waving goodbye to smiling children and thanking the men for their hospitality. Some look up long enough to call out “Goodbye mzungu!” as we pass.

With only two short months in the country, there is little we can do to contribute to the larger question of how useful helmets are. At best our information will show how effective the new law is – the short answer is that outside of Kampala, it isn’t. For my part, I’d be curious to see someone answer Mr. Ibrahim’s challenge to prove that helmet usage prevents injuries in Uganda. In the meantime, without resources to enforce the law, or public education to explain it, to me it seems naïve to expect Ugandans to abide by it.