Global Health Solidarity at a Crossroads

On 5 July 2012, I published an op-ed in Project Syndicate about the importance of fully funding The Global Fund to Fight AIDS, Tuberculosis, and Malaria. You can read the full text below, or access the piece on Project Syndicate's website here.

Global Health Solidarity at a Crossroads

05 July 2012

KIGALI – A decade ago, the global community stood together to declare that where people live should not determine whether they live or die when confronted by the scourge of AIDS, tuberculosis, or malaria.

This act of solidarity – unprecedented in human experience – led to revolutionary advances in promoting health care as a human right. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, along with the United States President’s Emergency Plan for AIDS Relief (PEPFAR), quite literally changed the course of history. Programs directly supported by the Global Fund have saved nearly eight million lives since 2002 – an average of more than 4,400 lives every day.

But, while much has been accomplished, much more remains to be done – and the Global Fund needs at least $2 billion to reverse a funding freeze that is in place through 2014. So the world now plays a waiting game to see whether governments will step up and fill the gap.

To be blunt, many of the world’s largest economies are not fulfilling their financial pledges to the Fund. Their politicians cite budget constraints and the need to prioritize domestic programs over fighting diseases that disproportionately kill the world’s poorest.

My country, Rwanda, has been a recipient of Global Fund grants since 2002. Just 18 years ago, our society was torn apart by a brutal genocide that killed more than one million people. Today, Rwanda is a peaceful country full of promise and hope, with one of the world’s fastest-growing economies.

With Global Fund support for our national institutions, we have achieved universal access to lifesaving antiretroviral therapy for people living with HIV, and we have stabilized HIV prevalence at around 3% of the population. Similarly, Rwanda’s tuberculosis program has become a model for Africa, and all Rwandan families now have access to insecticide-treated bed nets to prevent malaria, contributing to an 87% drop in cases during the last seven years.

Integration of services for infectious diseases and primary care has contributed to some of the steepest declines in child and maternal mortality ever observed. And, as life expectancy in Rwanda continues to climb (from below 30 in 1995 to 55 in 2010), we are now taking action against non-communicable diseases such as heart disease, cancer, and diabetes. The flexible, country-owned support provided by the Global Fund has been crucial to our success.

My country is living proof that investing in health is not only the right thing to do, but that it can also create virtuous cycles that promote security and development. In fact, after receiving Global Fund support for years, Rwanda recently made its first donation of $1 million to the Fund.

Unfortunately, infectious diseases are far from under control around the world. Less than a quarter of the world’s children living with HIV have access to treatment, and up to a million people still die of malaria each year. And, alarmingly, only one in six patients with drug-resistant tuberculosis currently receives proper treatment. Moreover, reports of “totally drug-resistant tuberculosis” have recently emerged from India.

Policymakers would do well to remember that it only takes one airplane flight for such a pathogen to go global. Infectious diseases neither respect national borders nor conveniently follow economies into recession. History has shown that retreating from the fight against an epidemic can lead to a renewed plague that is immune to our best drugs, requiring far more expensive measures to control.

Our choice could not be clearer: either we resolve to answer the call of history and provide the Global Fund with the resources that it needs, or we allow political lassitude to undermine a decade of progress and consign untold thousands to preventable deaths. Investing now, on the other hand, would pay off in the long term: just $6 billion more per year for the AIDS response today would save more than $40 billion in averted treatment costs alone over the next decade.

Today, the Global Fund stands at a crossroads. The international community’s regard for the health of the world’s poorest in the face of financial uncertainty will be a standard by which history measures not only our ability to stand together in weathering economic upheaval, but also our capacity for justice.

Now is the time for donor countries, including middle- and low-income countries, to rise to the challenge and ensure that the Global Fund has the resources needed to accept new grant applications as soon as possible. The costs of inaction are morally – and economically – untenable.

Video for Global Health Corps Orientation 2012

This video talk was recorded for the 2012 Orientation for Global Health Corps, an organization that twins young professionals from America with young professionals around the world (including Rwanda) in the framework of health equity and career development.

You can also watch this video by clicking here.

Rebuilding Confidence in Rwanda's Future

My latest article in Rwanda's New Times is below. To visit the website where the article is printed, click here. 

On all levels of a health care system, it is critical that there is real trust. This is true for the patient-provider relationship on a case-by-case basis, and between colleagues but also true on a larger scale. The population of a country must be assured that they can trust their health sector to make choices that are in the best interest of the people, and to avail technologies and services equitably and safely. The only way to gain this trust is by actually providing the promised services and technologies guided by the principle of equity as is written in our constitution.

When I returned to Rwanda in the mid-1990s to work as a pediatrician in Centre Hospitalier Universitaire de Kigali (CHUK), alongside all the team of clinicians, we struggled day-to-day to keep children alive and healthy despite the lack of equipment and supplies to apply the best clinical practice. We saw so many unnecessary deaths during those years - we knew what it would take to save a life, but simply did not have the health professionals, the drugs, nor the technologies available to us to do so.

During my first week at CHUK, I saw more avoidable deaths than I had seen unavoidable deaths over the course of the five previous years when I was working in a pediatric ward in Europe. It is no wonder, then, that the population did not trust the health sector. To lose a child results in unbridled pain for the parents - and this is what was happening in Rwanda every day, unnecessarily, for so many parents.

At that time in Rwanda, the impact of the ethnic tensions - planted by the colonial enterprise and exacerbated by the bad governance based on divisionism during the first three decades of independence that ultimately resulted in the 1994 Genocide against the Tutsi - made it even more important that we start a new chapter in terms of providing services to our population in the framework of equity and rights.

When I started to work in CHUK, distrust in health professionals was not only due to the fact that clinicians had limited tools to save lives, but distrust was also due to those that used their position in heath facilities to shorten the lives of Tutsi patients during the 1994 Genocide against Tutsi. Immediately following the Genocide, some patients were afraid of being victims as were their relatives during the 1994 Genocide against Tutsi, and others were afraid of possible revenge. We knew it was absolutely necessary that the public sector's health system change drastically in the framework of development in order to provide good quality care and regain the trust in parents and the entire population.

This difficult working environment almost pushed me to return to Europe, but I decided to stay with my colleagues to be part of the movement to change the medical environment in Rwanda. This was the most important decision I've made thus far in my professional and social life.

The organised, peaceful return home of more than a million Rwandan refugees from the Democratic Republic of Congo had great impact to the peace, and the security process, and has affirmed for ever my trust in the future of my country, as did the Gacaca courts for justice and reconciliation. These decisions, among many others, have aided Rwanda in planning and creating a better world for our children so they can live in peace, security, prosperity, and good health.

Last week was the closing of the Gacaca courts - close to two million people were tried in this homegrown judicial system, compared with the 60 cases tried by the International Criminal Tribunal for Rwanda (ICTR), which shows that it would have taken at least two centuries to process all cases through ICTR.

Gacaca's detractors who claim that there is nothing good in Gacaca offer polemic arguments unsupported by evidence. Gacaca has allowed Rwanda to harness its tradition to reach a grassroots solution to ensuring we can dissolve our fear of insecurity, recover from wounds and pain, collectively hold criminals accountable, give victims reparation, and build a foundation for truth and forgiveness. This has and will continue to allow us to design the roadmap for Rwanda's future together as one nation, and promote a cycle of peace, development, health and wealth, instead of poverty, revenge, crime and distrust.

As President Paul Kagame has said Gacaca is not perfect but no system would be perfect in such an extraordinary situation. Yet those who criticize propose no alternative to it. I have asked myself if those who criticize Gacaca prefer to see a poor and forever destroyed Rwanda without hope in its future instead of our vibrant nation which wants the best of peace and development for its population

In my primary and secondary schooling in Europe, teachers taught us a concept called "enemies hereditaires" and explained it during many history lessons - the concept denotes a relationship wherein you inherit enemies from birth only because you are born in one place. This mindset is dangerous and gives false rationale that enables persistent regional and social divisions. In our new Rwanda, we have gone for the opposite of this term - we have gone for justice, recovery, and development through reconciliation and the understanding that every human being deserves respect and has fundamental rights to be protected, healthy and the right to be educated.

All sectors of Rwanda continue working together in the promotion of this virtuous cycle. We, in the health sector, do so by providing services to our population that can be accessed anywhere in the country and that can be afforded by all. The number of health centres has risen drastically over the past 18 years, to now 438, and soon 476, distributed evenly across the country.

Our trained community health workers (45,000 in total, three per village) provide preventive, diagnostic and curative services for some of the biggest killers equally in each umudugudu (village).

Nearly 70 per cent of new mothers in Rwanda now deliver in health facilities - this also has been facilitated by the confidence in each other, in part rebuilt by the Gacaca justice system, and is proof of a solid foundation of a trusting relationship between patient and provider. If parents wish to choose the size of their families, they must be able to trust that the health system will provide the needed services to keep their children alive. Between 2000 and 2010, uptake of modern family planning methods has increased by over 450 per cent from 10 per cent to more than 45 per cent and we expect within a year to increase access by availing this service in each of our villages. We, in the health sector, would not be able to achieve this in a country struggling with distrust and not focused on development

There are multifaceted processes, systems, policies, and interventions that have enabled Rwanda to be an example to the world. Showing, for example, fast improvement in provision of health services in low-income countries we can also provide hundreds of other examples. I can cite our education sector with the primary and secondary school enrollment increased for both boys and girls, and completion rates that continue to improve. Our country has also been highlighted in newspapers and journals around the world illuminating the fact that the percentage of Rwandans living below the poverty line has decreased from 57 per cent to 45 per cent between 2006 and 2011 - accounting for one million Rwandans who have lifted themselves out of poverty. In this area, Rwanda is one of the world's best achievers.

All this dramatic progress in a country destroyed 18 years ago has been made possible only because of good leadership, good governance, zero tolerance to corruption, a vision focused on the wealth of our people and a spirit of accountability developed through processes including the Gacaca.

The Gacaca courts have directly and indirectly allowed Rwanda to advance as a nation toward prosperity, security, increased wealth and better health. Even though some in the world will criticize Gacaca, I know from being like the millions of us a witness and a part of Rwanda's development, how important reconciliation is to building a public sector that can be trusted to provide services in the best interest of the people. I see a bright future in front of us and I am proud of my country.

Video for Wilton Park Conference 2012: TasP

For presentation at the Wilton Park Conference in Geneva on 27-28 June 2012, titled "The new era in HIV/AIDS treatment and prevention: science, implementation and finance." The Head of the HIV/AIDS, STIs and Other Blood Borne Infections Division in the Rwanda Biomedical Center, Dr. Sabin Nsanzimana and I present Rwanda's country perspective on treatment as prevention for HIV.

You can also watch this video by clicking here.