Progress is more plausibly judged by the reduction of deprivation than by the further enrichment of the opulent. We cannot really have an adequate understanding of the future without some view about how well the lives of the poor can be expected to go.

Amartya Sen, “Will There Be Any Hope for the Poor?”

It’s been two or three weeks since I last wrote. Amazing to me how the first few weeks I was here, things seemed to go quite slowly, I woke up every morning and wrote, either to my journal or to the blog, but now the time escapes me, and I don’t even know where July went. Part of it I know went to the two big visits we just had here. Saturday before last was Bill Clinton and the next day was Bill and Melinda Gates. Clinton’s visit was the first time he actually stepped into the depths of Rwanda, so I heard. The first time he came to Rwanda it was just to the airport, the next I think he might have gone to a hotel. This time, he was here at Rwinkwavu Hospital. The Bill Gates visit was the next day - a smaller quieter affair although equivalently important. There is a lot of preparation that goes into a visit like this. It’s like having dinner guests come over for Thanksgiving and you’re really trying to go all out; everything gets an extra polish. Except with house guests, you’re usually just trying to impress just to impress, or you go the extra mile to make them feel at home and comfortable. In this case, impressing could have huge rewards for the poorest of the poor here, so it’s worth taking the time to buff up a few extra windows and clean a few extra mosquito nets over patients’ beds. It was reassuring to see though, that in lieu of all the pomp and circumstance of the Clinton and Gates visit, PIH is always and will always be an advocate for the poorest of the poor. It is an organization that will never have the majority of its staff located in a capital city, shipping Muzungo’s into the countryside on an occasional once a month affair, discussing policy of the poor far away from the realities of the population suffering most from a world economy that so far does not trickle down. Yes, we may have made every effort to show our best side to Bill, Melinda, and Clinton, but we were, that whole weekend, advocates for the patients.

It is so clear to me that being here in the thick of things is the only way to see the 11 year old girl with a facial tumor so large it has distorted the features of her mouth and cheek. The whole pediatric ward smelled like rancid meat because of that tumor. And after asking, we came to understand that this tumor grew over a matter of 6 months. The young girl had been to one or two health centers over the past few months and she was treated with medicines we don’t know the name of that didn’t help her situation. The father and daughter ended up walking here from the other side of the country because they heard we had free care. And so we did an x-ray of the tumor and although some thought it would be deeply involved with the bone and virtually untreatable without access to chemotherapy in this country, we came to find the other day, the tumor does not penetrate the bone. We may actually be able to treat her here. She may be able to become better with surgery and antibiotics.

And this is another thing that has been the most meaningful to me these past couple of days: I like it here. The sunsets at 6:30pm are magestic. God like. The children who get better from malnutrition as wonderful and darling as any child can possibly be. My efforts may be little by little, one person at a time, one family at a time, but there is always someone. I may not be able to help all the kids, or save a child who basically starves to death, or give every person who wants it gifts. But I can do something daily. I can be present to the moments at hand.

I did a home visit on Tuesday and the family there had a 4 month old that was admitted to the malnutrition ward at 1.5 kg. That’s the size of a premature infant in the U.S. The baby was discharged at 2.6kg/ 5 months old because she was gaining weight consistently over a couple of weeks as, surprise surprise, we gave her food. And when I went to visit this child on Tuesday, the mother lived with her husband. They are subsistence farmers with 5 children. Refugees to Burundi during the war. Returned to Rwanda with nothing, not a pot to cook in. Now live in a mud hut like the one I have shown in photos here and I could see their struggle. I could see them struggling to be able to have all school age children of theirs in school. It was a priority for them and they had done it. I saw them talk about how they are struggling to pay their rent because they can’t afford to own their mud hut, they have to rent it. I could see a sensitive and intelligent father who wanted to learn how to make the baby formula just as much as the mother, so he could help, since the mother was not producing enough breast milk to keep the child alive. I could see a man who studied to be an artisan but couldn’t get a leg up in life because he was just trying to keep them all fed and rent paid with small little jobs here that weren’t permanent. Making bricks for awhile here. Finding another small job there. Odds and end things. He wanted to work consistently somewhere, but nothing near for him. And so I asked him how much to buy a house like this one they were living in. They called in a neighbor who would know better. The neighbor looked into the air, upward, as if doing the calculation in the sky, then said, “30,000.” So I’m thinking, “That’s 60$. 60$ to buy a house for someone.” But I also know that if I just continually pass out 60$ to all the families I see, I won’t have money left either, I would like a more durable solution (I do have $80K of school loans to pay back), but in truth, there is not a person here who I am not in a position to help. I also want there to be some pride for this proud man. I don’t want him to think it’s just a hand-out. I don’t want him to think that his ability to care for him and his family is dependent upon what I or some other outsider provides. I’d like to give a sense of responsibility, that with some work he can own this place, I’ll make it easy for him. Right now they are hand to mouth – dependent on personal health, good rains, access to water and no bugs eating their plants. So I asked him if I gave him 30,000 could he build a house for his family. He discussed this with not only his wife, but the other Rwandan PIH people I was there with, the other nurse, the nutrition educator, the driver, who was sitting in this mud hut with us, giving encouragement to the father too. And the father turned to me and said, “It would be better to buy this house.” His life was there, the children were settled, it had a nice patch of land to grow food that he was already cultivating. If he got 30,000 he said he’d buy it from the man who rents it to him. So I said OK. I’d like to buy the house for him. But I said I wanted the rent that he now gives to the man to instead go to me, but he doesn’t have to give it to me now, or this month or next month. I have no intentions of being a slum lord. I want to help. That I’d rather have him buy what he needs for his family over the next couple of months with his hard earned money, put a tin roof on his house rather than banana leaves, take time to find a good consistent job without having to worry about the rent for the week, and he can pay the rent at the end of the year. 1200 francs which is what he was paying for rent now x 5months = 6000 Rwandan francs at the end of the year was what I asked for. $12 for me.

So we’ll see. I’m going to go back there in a couple weeks with the same Rwandan crew I went with last time and see how it’s going. See if he was able to buy the house. Make sure everything is rolling forward OK.

And who knows. Maybe the family will disappoint me. Go off and spend the money frivolously on who knows what. But I don’t think so. A) there’s not much frivolity in the countryside here. Banana beer maybe. Can’t spend 30K on that. And b) I just felt like they were trustworthy; their concern for their children, the father’s involvement, the mother’s knowledge about which kids had which vaccines. If so, and if I keep doing this at home visits, I’d like to get some micro credit projects going here. There isn’t anything here right now. For all the money I get back, I can put it in a pool to help other families. I need no personal profit from this. I make an adequate salary via the Durant Fellowship. I don’t need to earn any more. I merely want to do it to create a system for them. Infuse it with some money so they can start creating micro credit for themselves. Like I said, he’s the first one. So we’ll see. I hope it does more help than harm. I think there are a lot of good intentioned people in this world whose efforts actually do more harm than good, unbeknownst to them. I may be one of them. Who knows. I think this is particularly true of the NGO community in developing countries. All these great well-intentioned ideas that don’t end up really helping the community in the way they need. And the only way you’ll ever know this is by living here. In it. And better yet, being able to speak the language so that you can directly connect, without a translator (which I am not able to do yet).

But nevertheless, all this is to say, I like being here amongst the rural poor. We are as close to the medical, social, and economic issues of the poorest of the poor as anyone in this country. What I am seeing and feeling as I work in the hospital, and out in the community, is that a basis of medical rights, water rights, land rights, food rights, education rights are tantamount to a fair and just life. With the tragedy of a child or two dying a week, some who die while I’m trying to save them and they go floppy on me with neither heart beating nor breath (these children would not die in the U.S.,Europe, Japan – these deaths are preventable), some who die when I’m not there, is that these people need what I am told Haitians call decent poverty. It’s not freedom of speech, freedom of assembly we’re struggling for here. It’s freedom to water, food, education and medical care. As Richard Gunderman says,

What is medicine about? Is it about maximizing the incomes of physicians or health care organizations? Do patients and their suffering exist in some fundamental sense for the benefit of the physician, the hospital, or the stockholder? Or do physicians and the entire medical enterprise of which they are a part exist for the benefit of the patients and the relief of human suffering?

Medicine and the Pursuit of Wealth (1998)

Here we definitely exist for the poorest of the poor patients and the relief of human suffering. Although we, an NGO, or any organization or church for that matter, do not and will never be able to provide “a right” to a Rwandan, or to all Rwandans for that matter, the government can. Because the reality of our modern world is that the only sector that gives rights to people is the public sector (food, medicine, education for all; freedom of press, freedom of speech; freedom of assembly). It is the government that has to figure out ways to provide the greatest amount of rights to people for the common good. In the meantime, we, PIH, and any other NGO for that matter can help assist in influencing those decisions for the good of the whole while at the same time providing the best medical care we can to one of the poorest areas of the country and that in truth, is the most, an NGO can do I think – relieve human suffering with support, aid, new legislation from the local government of that country. And in that case, the answer to Amartya Sen’s question would be, yes. We can lift things to decent poverty here, and yes, most definitely, despite the hardships that exist everyday, there is hope for the poor. But we have to make it that way.