"The Peace Corps Returns" -- by Josh Ruxin

In 1994, the Peace Corps officially closed its office here in Rwanda. The horrors that followed kept the Peace Corps at a distance until last year when the office was reopened. That return is very welcome, and I'll explain why in a moment.

While the Peace Corps was out-of-sight in Rwanda, it was also scarcely in the spotlight in America over the past eight years. During that time, U.S. presence in the world was defined by two wars and often less-than-collaborative diplomatic relations with other nations. In the din caused by those wars, most of us Americans could be forgiven for having failed to notice that the Peace Corps has quietly continued to perform its important mission of promoting world peace and friendship across the globe. Now, at a time when we are trying to rebuild bridges and heal wounds, that mission couldn't be more important.

The result of stressing defense over true diplomacy or development has been a supreme failure in American prestige abroad. I've seen that clearly in the places I've visited and worked over the last several years and that's why it's heartening to have 35 fresh Peace Corps volunteers here in Rwanda at the commencement of President Obama's administration.

The Peace Corps was founded in 1961 by President John F. Kennedy to meet several goals. Foremost among these are imparting our expertise to people in other nations, working to understand their culture, and helping them to understand ours. These are simple, but revolutionary objectives, as they count knowledge and friendship as their currency. Much of the work my teams are doing here in Rwanda through the Access Project and Rwanda Community Works is in line with a Peace Corps-style approach. I'm very excited now because we have been informed that we will be receiving three Peace Corps volunteers in the next several weeks to work on one of our most ambitious projects: to improve health care management in six districts. We don't yet know who will be sent our way, but we know that their skill sets will compliment the important work we are undertaking to build prosperity and health care infrastructure.

Though the Peace Corps was founded nearly 50 years ago, the program is still extraordinarily vital, and the need for Peace Corps volunteers is greater today than ever before. In my work in Rwanda, my teams have collaborated with corporate fellows, government aid workers, and business partners to build capacity. Adding Peace Corps volunteers to the equation will build expertise among Rwandans and provide the lucky American volunteers with the chance to see why Rwanda is one of the most exciting countries in Africa today.

Not since the election of the Peace Corp's founder John F. Kennedy has the wider world reacted so positively to the election of an American president. President Obama has thus far brought a sense of mission to his presidency as well as an optimism that is reminiscent of Kennedy's. Coupled with the messages of Obama's presidency, I think that the presence of Rwanda's Peace Corps volunteers will go a long way towards reinforcing America's place in the world, person-to-person, one-to-one. I also anticipate that the Rwandan people will confirm for the new American contingent what I have already seen. They don't need America's charity or hand outs, but rather its perennial optimism, its ideas, its expertise, and its friendship.

Dr. Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. This posting if from the Huffington Post

"A Killer and a Cure" -- by Dr. Josh Ruxin

This December 1st marked the 20th commemoration of World AIDS Day. The international commemoration has perennially been accompanied by new, bleak reports, and bureaucratic hand-wringing over the invariable failure of supply – in the form of drugs, management and financing – to keep up with the needs of the desperately ill around the world. However, this year, there’s actually some rather interesting news.

A new study just released by Harvard shows that President Mbeki has now topped the charts as one of the world’s top killers of all time. His outrageous ignorance and deadly policies resulted in excess deaths of at least 350,000 South Africans. The study does not include the lives lost in other countries, particularly in sub-Saharan Africa where South Africa’s perspectives are deeply influential. Quantifying the toll of Mbeki’s malfeasance is an important step toward rectifying the challenges in Africa: leadership in the fight against AIDS does make a difference and those who choose not to lead must be identified as collaborators in the killing.

Meanwhile, for the first time since the advent of anti-retroviral therapy and vaccine trials, hope for a cure has emerged. Through a bone marrow transplant, a German scientist has perhaps cleared the first AIDS patient of the virus – quite possibly the first time in human history that a person with AIDS has been effectively freed of the virus. There is nothing easily replicable about this case, but this breakthrough offers a glimmer of hope for what is essential to bring the pandemic to a halt: a cure. Despite nearly a quarter of a century of treatment and research, over 30 million people are currently afflicted with HIV and close to 2 million die from AIDS each year. Most worrisome is the momentum of the pandemic itself: 2008 registered nearly 3 million new cases of the disease, and only a small proportion of them are likely to receive treatment before perishing.

Treatment is an area of notable success in spite of its failure to reach a high proportion of those in need. In 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria was born and the dream of billions for fighting the pandemic became a reality. In 2003, President Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR) to combat global HIV/AIDS – the largest commitment by any nation to combat a single disease in human history. In 2003, approximately 50,000 people in all of Sub-Saharan Africa were receiving anti-retroviral treatment. Today, the Global Fund and PEPFAR support anti-retroviral treatment for nearly 1.7 million people in the region – and tens of thousands more around the world, from Asia to Eastern Europe. Unfortunately, that is still not enough. In June of this past year, a joint WHO/UN Aids report showed that nearly three million people are now receiving anti-retroviral drugs in the developing world, but this is less than a third of the estimated 9.7 million people who need them today (what isn’t stated is those 2/3rds in need will likely die in the next 24 months). We must reach more people and we must do it quickly.

As we see a world-wide recession take root, we have to redouble efforts to raise money for treatment and research. Global surges in poverty are a recipe for increases in diseases like AIDS. Short-term budgetary cuts can have massive and multiplied effect in the public health world: now is the time to increase, not decrease expenditures. For example, we have made remarkable advances in the fight against malaria over the past few years, so much so, that deaths can potentially be eliminated over the next few years with the proper infrastructure and funding. The same could be true for AIDS with the right approach and commitment.

The key to fighting AIDS includes a multi-pronged approach for now.

Private donors and for profit organizations should join in the effort as well. Organizations like MAC AIDS Fund and the Gates Foundation have helped the cause dramatically. There are key roles for players of all sizes. Here are some top recommendations taken from the report of the Global HIV Prevention Working Group:

• National political and public health leaders should develop and implement AIDS strategies and operational plans tailored to the particular dynamics of national epidemics; integrate prevention and treatment services; and increase prevention interventions sufficiently to have measurable impact. Countries scaling-up adult male circumcision – and any other biomedical strategy that proves effective – should combine these efforts with complementary behavior modification campaigns to decrease the risk behavior that can occur when new strategies or tools are introduced.

• International donors should commit to rapidly funding these tailored national HIV prevention programs. Additionally they should make available by 2010 at least $11.9 billion U.S. annually to support scale-up of evidence-based HIV prevention programs as part of a comprehensive response to HIV. Donors should ensure robust financing for community-driven responses that build local civil society capacity and leadership.

• Multilateral and other technical agencies should develop mechanisms to assess the soundness of national HIV prevention strategies, identifying instances where national plans conflict with available evidence about the dynamics of HIV incidence, or where selected prevention strategies are not based on evidence of what is effective with particular populations.

• AIDS activists and other civil society groups should strongly advocate for the simultaneous scaling up of HIV prevention and treatment.

President Bush has committed significant U.S. funds to combat AIDS, and over the next four years, President-elect Obama should dedicate as much, if not more, of the country’s resources to this fight. He should also give due consideration to what worked well in the Bush Administration’s approach and what could have been done more effectively with the same resources. If we’re found simply debating whether we have the means to win the battle, we will find that we have already lost it.

Dr. Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"The Best Buy in Public Health" -- by Dr. Josh Ruxin

During this time of appallingly bad buys in the stock market, I thought it might be worth taking a look at an area where there are still colossally good buys to be had. A study published this month examines the impact of the World Health Organization’s “Global Programme to Eliminate Lymphatic Filariasis.” Amazingly, 20 percent of the world’s residents (1.3 billion people) are at risk from the disease, which is transmitted through mosquito bites. Nearly 120 million are currently infected and 40 million are seriously debilitated by the disease. In the past seven years, the WHO program saved an astonishing 32 million DALYs (Disability Adjusted Life Years – the gold standard for a public health intervention). That includes 6.6 million children who never got the disease thanks to treatment and another 9.5 million infected patients spared from its more debilitating effects. You can therefore imagine why lymphatic filariasis treatment and prevention has been called a best buy in public health.

Don’t feel too bad if you don’t know what lymphatic filariasis is. Commonly known as elephantitis, it is one of a suite of lesser-known ailments that includes schistosomiasis, trachoma, leprosy, and soil-transmitted helminths, which affect billions of people in South America, Africa, India and Southeast Asia. Elephantitis is among the most grotesque and terrifying of the diseases, though relatively easy to treat and prevent.

Though massively widespread, the neglected tropical diseases can be defeated with a more modest investment than it takes to fight pandemics like AIDS and tuberculosis. Ironically, because they are less well-known and potentially easier to fight than more well-publicized scourges, they have always been shunted off to the side of the global public health agenda – so much so that this has given them their name: neglected tropical diseases.

Fighting these diseases is a challenge, but it also represents an enormous opportunity, one that we can’t afford to miss. Gains made against AIDS and TB are often made “uphill.” We can get medication and treatment to those suffering from HIV/AIDS, but what good is that if patients are suffering from other disorders that reduce the effectiveness of that medical attention? Further, the treatment of these diseases requires more follow-up and attention than the fight against neglected tropical diseases.

Both the World Health Organization and the Centers for Disease Control and Prevention identified these diseases as “targets of opportunity” in the battle to improve global health. Thankfully, efforts against some of these diseases are not just gearing up, they are gaining significant traction.

This success is the product of what’s been called the most rapid scale-up of a drug program in the history of public health. It could also become the largest program of its kind in public health history: so far, over 1.9 billion drug treatments have been administered to more than 570 million people in 48 countries.

This program shows what’s possible when the funding needed to fight these neglected-though-conquerable diseases is put into the hands of organizations that have the will to use it effectively. This kind of program is vitally important, because it’s so unlike what we’re used to seeing. This isn’t an effort to mitigate the effects of a disease, and it isn’t finding the cause of a disease. If followed through to completion, it is nothing less than the complete eradication of a disease. Lymphatic filariasis could go from being a threat to more than a billion people to being simply an interesting epidemiological footnote in a few years.

Given the success against this one neglected tropical disease, we shouldn’t hesitate taking on the rest. Beating these diseases is within our grasp, and it could be the most cost-effective investment we’ll ever make in global public health.

Dr. Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"The Future President" -- by Josh Ruxin

Last month, former President Bill Clinton arrived in Rwanda, the latest in a slew of political figures to visit the country. Several weeks ago, Cindy McCain, Tom Daschle, Bill Frist and others toured the country as part of the ONE Vote '08 mission to draw bipartisan attention to poverty issues. These visits, unlikely even a decade ago, are clear evidence of how much more invested the United States has become in Africa's future. There is a growing recognition in government that Africa's fight against crippling poverty and disease is a battle that can be won with America's involvement.

Many would agree that President Bush has done more for Africa than any President before him, and in the process, has turned many Africans into Republicans. Since 2003, his programs -- such as PEPFAR (the Presidential Emergency Plan for AIDS Relief) -- have dedicated nearly $19 billion to African aid, addressing health care, economic development and prosperity building; nearly half of the $10 billion in Global AIDS spending this year will come from the United States. Bush's dedication has drawn increased attention to Africa and concerted action, but will this momentum continue with the next President?

While I am hopeful that the candidates will seriously address the future of America's involvement in Africa, most of their foreign policy discussions have thus far focused on Iraq and Iran. Africa must not be forgotten. The next administration should closely examine America's political and investment policies and lay out an improved plan of action, a prescription they can put into practice throughout that supports the positive change already underway.

Focusing on Africa is not only the right thing to do, but it's also the smartest. Growth on the continent represents an expansion of global markets for U.S. goods and new producers for cheap inputs, decreasing our dependence on Asian producers. Currently, China has overtaken America as the dominant actor in many parts of Africa and without more comprehensive involvement, America's standing in this region will continue to decline.

Maintaining a flat commitment to African development is not enough. While aid programs are necessary to meet emergency needs, focusing too much on aid often leads to delivering resources only to flashpoint areas and undercuts areas of stability, which also need support. Central to the next President's African policy should be a push for increased investment in business development and the creation of sustainable industries. We must continue to help with microfinance programs and encourage American business investment in Africa. Programs that foster economic growth will help Africans advance out of poverty into a healthier, more prosperous future.

For those skeptical of investment in Africa, remember not that long ago that investors doubted business opportunities in BRIC (Brazil, Russia, India, and China). Today, investments in those countries are among some of the most lucrative in the world, and companies such as Brazil's Embraear and India's Unisys are creating a burgeoning middle class in those nations. Trade drives economies from which large groups of workers benefit, whether they are in the industries being promoted, or in supporting businesses and services. So, while aid programs are an essential safety net for those lacking the most basic needs, aid cannot sustainably help people to feed, clothe, and educate themselves the way investment in small and medium-sized businesses can.

Over the past few years, Rwanda has become one of the most stable countries in Africa. Its government is among the least corrupt and the economy is steady, making it an ideal place for investment. Nonetheless, it has been a struggle for the government to attract direct foreign investment. Potential investors may still be spooked by the 1994 genocide, put off by Rwanda's landlocked geography, or perhaps unimpressed by its workforce. Addressing those issues would be a superb use of U.S. assets and influence. Uganda and Tanzania, among neighboring nations, also have the infrastructure and socio-political environment necessary to support foreign investments and have thus far been more effective in attracting it. With the right opportunities, attention, and assistance, East Africa could be the next BRIC.

At present, however, the immediate needs of Africans must still be met. With just 0.16% of US income spent on development assistance, the lowest percentage of any developed country, and though it's having a hugely beneficial effect, it is simply not enough. The next President must consider his long-term strategy for development and overall economic growth. It's through these next-level programs -- not aid -- that long term improvements will be affected. I urge John McCain and Barack Obama to visit Rwanda and to see for themselves how international investments will make all the difference in the lives of ordinary Africans, while benefiting Americans, too.

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"It's time to grow locally -- even in Africa" -- by Dr. Josh Ruxin

On the outskirts of Kigali, Rwanda’s biggest open air food market is bustling today and full of foodstuffs. There’s no shortage, but prices — particularly of maize flour — have climbed by as much as fifty percent in the last six months. While it’s easy to place the blame on oil prices, which have driven up transport and fertilizer costs and thus the price of food imports, the oil spike alone is not the cause. What the average Rwandan might not realize is that America’s thirst for energy is partly to blame for the increase in their cost of living.

Last week, lawmakers in the Senate and House began a bipartisan re-examination of their commitment to ethanol. The current spike in food prices has caused them to reconsider the validity of the idea that corn-based ethanol production provided the best short-term prospect for bolstering America’s energy independence. The facts are quickly becoming clear to Congress — including senators and representatives from corn-producing states — that ethanol is not the magic bullet it promised to be as recently as last year.

Far from it: With 25 percent of all U.S. corn production going to ethanol production, it has turned out to be the catalyst that’s helped transform the crisis in gas prices into a full-blown food crisis. This has been a disaster for the world’s working poor, but hopefully, our leaders’ eyes have been opened to the problem and the opportunities that exist for solving it.

One powerful long-term solution that needs our support is the suite of agriculture programs aimed at helping the world’s poor grow drought- and pest-resistant crops. As Keith Bradsher and Andrew Martin reported in the New York Times on May 18th, we have lost many of these programs to budget cuts due to our government’s and trade experts’ having been lulled by the plenty that American agriculture has always delivered. They outline how the U.S. is currently slashing, by as much as 75 percent, its $59.5 million annual budget for supporting global research focused on improving crops vital to agricultural commodities in poor countries such as rice, maize, and soy.

Despite the administration’s request for $770 million in emergency food aid, cuts continue to be pushed through. The World Bank, a longtime supporter of agriculture programs, has also dropped its commitment to crop research and development significantly over the past few years. This is terribly unwise. Global leaders now appear on notice that agriculture must be put back at the top of policy priorities. The UN just completed a conference yesterday loaded with recommendations that have long been known to policy wonks. Donald Kaberuka, the president of the African Development Bank and Rwanda’s former minister of finance pragmatically noted, “The test will be in implementing the solutions.”

Programs that allow the world’s poor to be self sufficient are smart on many levels. They allow more stability — indeed, those parts of the world with good agriculture programs have been less susceptible to the food rioting we’ve seen recently in the world’s poorer urban areas. Such programs are also more cost effective for American taxpayers since they cost less than emergency food aid. Most importantly, when they allow small farmers in Rwanda or Tanzania to grow hardy crops bred to be drought- and pest-resistant, these programs help the poor feed themselves.

They can also help local subsistence farmers make money and climb up from poverty into prosperity. Small farmers who work to meet local and regional demand end up putting more acreage into profitable cultivation, and the income they receive even allows them to invest in crops like pomegranates — a high-demand niche product for which wholesalers and food production companies will pay a premium.

The fruits of agricultural research projects — drought- and pest-resistant crops — cost less because they require less gasoline and other petroleum inputs, such as fertilizer, herbicides and pesticides, to produce. Locally grown crops can therefore provide cash-poor consumers with an inexpensive alternative to the now unaffordable crops being flown and shipped in from all over the world. It’s time for an African Green Revolution — improved seeds and practices that will increase productivity, self-sufficiency, and therefore, security. An African Green Revolution will not be as straightforward as Asia’s Green Revolution since there are new challenges — decreased rainfall due to environmental change, overpopulation, small farm size, and the AIDS pandemic — which Asia did not face. Nonetheless, helping farmers accustomed to living on the edge of starvation to be productive does not require heroic or financially untenable efforts. The Millennium Villages Project in Rwanda, for example, helped a community of several thousand farm families move from producing approximately 300 kilograms of food to 5 metric tons in the course of one season. All that was required was community leadership, advanced seeds, and good management. That’s a package of interventions that should be provided world-wide.

Making deep cuts to restore fiscal sanity in government makes sense, but great care must be applied when choosing which programs to cut, and which to keep. Just last week, John McCain spoke at length to an audience about pork barrel programs that needed to be cut: He mentioned agricultural research programs among those that must go. The presidential candidates need to consider the long-term costs to America in emergency-food-aid allocations and global security, and should think carefully before slashing. Divesting from agricultural programs while staring down the barrel of a global food crisis would be a decision certain to rank highly in the annals of poor public policy practices.

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts (including this one) can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project

"Doctors Without Orders" -- by Dr. Josh Ruxin

To improve global health, what we need isn’t just Bill Gates’ billions, but Microsoft's managers.

Two years ago, I saw a line of 30 people waiting for services at Nyamata Hospital in Bugesera, a rural region in southern Rwanda. Its approximately 300,000 residents live clustered around small villages. It was the epicenter of the 1994 genocide and remains one of the poorest districts in the nation.

The hospital is on a charming plot of land, and its infrastructure is welcoming, impressive, and modern. It has some 60 professional staff and half a dozen doctors, an adequate number of personnel for a district facility. But while a line of 30 people seems long to Americans, it’s not to Rwandans. I was surprised to find so few lined up for the sort of high-quality care that this hospital promised, on the surface, to deliver.

When my team asked why so few patients were there, the staff, the patients, and the community all pointed to the same cause: a malfeasant and incompetent director. "People go to that hospital to die because the director doesn’t care," they told us. Apparently, his attitude and style was such that it seeped into the rest of the staff. No one else cared either, even with state-of-the-art equipment and new facilities.

I wasn’t fully convinced of how poisonous the culture had become until two incidents a few weeks later. A nurse, who worked for one of my projects and volunteered at the hospital, told me she was appalled by the shoddy and rancid-smelling mattresses in the patient rooms. After pushing the issue with the staff, she learned that brand-new mattresses had been in a storage room awaiting use for years. Soon after, I bumped into an extremely poor woman who had recently had an emergency caesarean delivery at the hospital. When I asked her when she was returning home, she explained that she had been ready for four days, but that the hospital director insisted on her paying for the ambulance to travel the 30 kilometers to her home. The price demanded was higher than her monthly income, and no one at the hospital seemed willing to figure out how to resolve the dilemma.

Not surprisingly, performance and opinions changed rapidly when a new director arrived. This new manager cleaned up the hospital’s accounting, queried staff on major management and resource needs, fired incompetent and corrupt employees, and figured out how to respond in a timely, thoughtful manner to key challenges. Within two months, there were working X-ray machines for the first time in two years. Staff morale improved dramatically. Today the hospital sees more than 100 patients a day, and the community views it as a center for healing, not dying.

The lesson? In public health, just as in any other collective endeavor, management matters. It seems like an obvious point, and yet at the heart of some of the world’s worst public health crisis zones, it is one that has yet to sink in–with dire consequences for millions.

The history of public health in the twentieth century can be characterized as a losing battle for resources against a rising tide of epidemics and pandemics. In spite of some breakthrough solutions to massive problems like childhood disease and pandemics like polio, the failure to construct viable public health systems in the developing world has helped create the conditions for the pandemics of today: tuberculosis, AIDS, and cardiovascular disease, among many others. To make things worse, massive health problems predating these remain, from extraordinarily high maternal mortality rates to the scourge of malaria. The numbers are so breathtaking that they obscure the heartbreaking stories each represents. Globally, there are still an estimated 500 million episodes of malaria every year that claim at least one million lives, and in Africa more than 250,000 women die in childbirth annually. Over the past two decades, these grim statistics have scarcely budged, and in many countries, they have worsened.

If public health planners were business people objectively examining the sector’s progress today–particularly in sub-Saharan Africa, where average life expectancy is now 46 years, versus 67 in the rest of the world–the answer would clearly point to a change of strategy. Many international public health programs are so poorly run–or at least achieve such poor results–that they resemble the management quality of a local lemonade stand rather than an Apple or Google.

It’s not that public health workers don’t have their hearts in their work. It’s that the global public health workforce has long had to make do with small initiatives that were perpetually under-funded and training that valued a flair for squeezing results out of miniscule funding. However, we live in an age when immense public and private resources are suddenly available. From major programs like the Global Fund to Fight AIDS, Tuberculosis and Malaria to bilateral ones like the U.S. President’s Emergency Plan for AIDS Relief, along with major efforts led by nonprofits like the Bill and Melinda Gates Foundation, global public health is now discussed for the first time in history as a venture warranting and receiving billions.

With so much money being committed and so many lives at stake, it’s time to revolutionize global public health. We need less do-goodism, and more do-it-rightism; we need more managers, not more doctors. The billions of dollars in new funds must propel an infusion of new management talent and practices based on private sector experience. We must upgrade the entire health system in countries–and in poor countries with few doctors, that means taking medical doctors out of management positions and replacing them with professional managers. It means encouraging nongovernmental organizations (NGOs) to cast their nets wider when recruiting public health workers in order to pull leaders from the private sector rather than the public sector, and teaching the management of health delivery to soon-to-be minted public health graduates. And it means building new initiatives like we would a business, with rational accounting and delivery systems, while likewise reforming existing efforts.

This is not a popular position; it is, to be blunt, easier to treat the disease than the cause. For instance, programs for childhood health and family planning, which could revolutionize African public health, have been dwarfed by spending on HIV/AIDS, in spite of the far greater complexity and cost of rolling out such programs. This is not to argue that we should return to the days of limiting interventions based on appallingly small public resources: On the contrary, to fight AIDS effectively, improve maternal and child health, and meet all the other deep-seated public health challenges, we must build out health systems in poor countries. But relying on traditional public health workers will fail. It’s time to shake up the public health establishment and do nothing less than completely reinvent it.

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Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"Germany, Congo, Darfur, Rwanda" -- by Dr. Josh Ruxin

April 7, 2008, was the 14th anniversary of the commencement of Rwanda’s genocide. With periodic massacres that date back to 1959, Rwanda’s genocide did not happen overnight. Its climax, however, began April 7, 1994. It was a few days later that 36-year-old Epafrodite Rugengamanzi was murdered. From what his sister, Josepha, has gathered, he was chased into the yard of the house where we now live, brutally killed, and buried. Her brother’s killer confessed to the murder during gacaca — the traditional court process for genocide suspects — and brought her to his burial spot.

The disinterment of Epafrodite Rugengamanzi

Josepha came to our house Wednesday with other family members and dug up her brother’s skeleton. The orchestrated process took several hours. Once they were sure that all of his bones had been collected, they carefully cleaned them. Josepha then asked me and my family to come over and listen to their testimony (and asked us to share it with others). Josepha was smiling and told us how lucky she felt to have found her brother’s bones and to be able to re-bury them shortly at Gisozi, the national genocide museum and burial ground.

Epafrodite Rugengamanzi

Josh Ruxin with Josepha

Epafrodite’s murder was avoidable, since the UN had the power to prevent it. Ultimately it was not an international team of peacekeepers who brought Rwanda’s genocide to a close, but rather, the Rwanda Patriotic Army, a disciplined military force drawn from Rwanda’s diaspora. After years of fighting, the Rwanda Patriotic Army on July 4, 1994, brought stability to the country. Human Rights Watch, a French judge, and a Spanish judge allege, however, that the Rwanda Patriotic Army carried out thousands of reprisal killings and crimes against humanity during and after the genocide. President Kagame publicly bristled this past week over the recent Spanish indictment.

A close look at the complexities of Rwanda’s genocide would remind China’s leader Hu Jintao, President Bush and others of the path history can take, yet does not have to. Darfur is at least beginning to take on some of the dimensions of Rwanda: a gradual genocide in a region still lacking an adequate peacekeeping force and the political commitment to bring it to an end. The carnage there continues and now a new genocide threatens in Southern Sudan. While hope has so far proven elusive for Sudan, it is even harder to imagine that its people will get themselves on Rwanda’s track to peace and prosperity anytime in the next few decades. Rwanda’s resilience and approach are exceptional.

My friend and head of Orphans of Rwanda, Jean Baptiste Ntakirutimana, wrote me the other day about his meeting last week with his mother’s killer: “I inquired first about his life in prison, his family and his state of mind. He said he was expecting that I could kill him, which he thinks was the way of doing justice for having killed my mum. He added that no one dared killing my mum; that she was brought by two militia to her home village and called for people to come and kill her. No one did so besides him who felt he had to kill her. In fact he told us that they were told that no one was allowed to loot from Tutsis before killing all their family members. Since they thought I was already killed from Kigali, where I was residing, the only hindrance to take all the family property was my mum. So she had to be killed. By the time he started explaining how he killed her I partly lost consciousness. I prayed to God to give me His spirit to revive me and give me more strength to continue, as I felt it was His mission I was on. Miraculously I felt warmth from my head to my feet, I felt like a big rock melting from my chest and my head. I felt very refreshed, cleaned up my tears and carried on the conversation tremendously relieved from my whole being. I then told him that I have personally been forgiven all my wrong from God and that it is in the same spirit that I was coming to him offering him pardon myself. Then it was like a huge veil off his face he started smiling with a lot of words of gratitude. He started holding my hands and telling me many other things I couldn’t expect about himself and the reality around the genocide. He agreed to go and see other people for whose family members he killed.”

Fourteen years later, Rwandans are still struggling to reconcile the past. The struggle, however, is proving easier against a backdrop of national stability, economic growth, and a rising national profile. Foreign investment is at a high, there are swank hotels, and tourists are coming by the thousands.

Post-genocide history is mired in enduring civil conflict and instability. Rwandans know firsthand that exports such as peace and stability are far superior to tales of disaster, massacres, and corruption. Rather than provide the object lesson of what can go wrong, Rwanda now embodies quite a different ideal. The nation was one of the first to send peacekeepers to Darfur and today has one of the largest contingents on the ground. Nothing points more clearly to Rwanda’s recovery and resolve.

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts (including this one) can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"Rwanda out front against HIV/AIDS" -- Dr. Josh Ruxin on CNN's Inside Africa

In this clip from CNN's Inside Africa, EGR friend Josh Ruxin explains why Rwanda has such an impressive record in the fight against HIV/AIDS.

"One of the health centers that the Millennium Villages Project is involved in, in Mayange, has done such a great job of improving the quality of health that a woman in the community approached me just last month and said, 'You know, I'm a little bit angry with you. I used to have a job in this community that I don't have anymore.' And I said, 'What exactly is that job?" and she said, "Well I used to coordinate the funerals here, and for the last eight months there hasn't been a single funeral, but just last year I was coordinating three or four funerals every single week."

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"Bush, AIDS, business and Africa" -- by Dr. Josh Ruxin

This month, when President Bush traveled to Ghana, Liberia, Tanzania, Benin and Rwanda - the nations on his African itinerary - he visited more than a few AIDS treatment centers. This makes sense: a big reason for the president’s visit was to see firsthand the progress made by the life-saving initiatives he set in motion through his administration’s programs.

More than $19 billion has been invested in programs to fight AIDS, malaria and other killers. More than one million Africans with AIDS have been put on AIDS drugs, and new programs are aggressively treating and preventing malaria, the biggest killer of children under five on the continent. Though more needs to be done going forward, the Bush years have been a time when a foundation was laid for meaningful global public health interventions, and it’s right for the president to see the real impact of the United States dollars on African lives.

While the medicine and care provided by the Bush Administration is indeed important, it is only part of a larger equation. Providing health care support will treat disease, but it can’t eliminate its roots in poverty. Business development can. The more prosperous people are — whether in the United States or sub-Saharan Africa — the less likely they are to contract AIDS.

Rwanda has taken an approach that includes massive health care improvements alongside extraordinary efforts to build the private sector. This approach makes sense: a recent BBC report showed that economic growth does not necessarily improve health. President Kagame — when not pushing health issues — has recently visited far-flung places like the Consumer Electronics Show to drum up investors in Rwanda.

Several months ago, I wrote on my New York Times blog about the need for technology businesses to invest in countries like Rwanda. Among the comments I’d read in response were a few that wondered why in the world we should be worried about that kind of development when providing food and medicine was an infinitely more immediate issue.

The fact is, between providing aid and encouraging business development, you can’t do either exclusively: you must do both. If you only provide medications and food, you may treat disease, but you’ll have to do it over and over again. Adequate AIDS treatment alone might get us to where we were 25 years ago - but on its own does nothing to cultivate economic productivity. AIDS treatment alone fails to address the root causes of disease. In the community of Mayange, Rwanda, a Columbia University project recently rolled out voluntary counseling and testing for AIDS. While the community quickly took advantage of the new service, it was not exactly the talk of the town. Several weeks later, the basket weaving cooperative in Mayange received a purchase order for $2,000 of coasters and placemats. The community has been talking about that ever since.

Encouraging local business, urging international development, teaching micro-finance and building cooperatives does something health care can’t accomplish, something that can lift people out of the cycle of disease and despondency. More than “fighting poverty,” which has always seemed to me to be a goal that’s not ambitious enough, these types of programs can create prosperity. Prosperity is the engine that can pull a whole nation up, and could bring AIDS down to levels you’d find in Europe or the U.S.

So, while President Bush looked at AIDS centers, I hope he also took a close look at the business environment, what his programs have helped bring about, and what more can be done to create more opportunities. If it seems counterintuitive to stress business and prosperity, just think how much easier it would be to get ahead of killers like AIDS if the number of new cases goes from a flood to a trickle.

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts (including this one) can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"Removing the N from Neglected Tropical Diseases" by Dr. Josh Ruxin

Last month in Bujumbura, Burundi, a remarkable meeting of medical practitioners and policymakers from that country and Rwanda was held without fanfare or press to examine the results of a two-country initiative to reduce the prevalence of neglected tropical diseases (NTD’s) through the newly-formed Global Network for NTDs. Even though the most infamous NTD’s are scarcely known outside of classrooms and the offices of public health experts, they have a devastating impact on one billion people worldwide.

Schistosomiasis, trachoma, river blindness, elephantiasis, hookworm, soil-transmitted helminths, and other intestinal worm infections wreak havoc and result in death rates that puts them in the epidemiological running with the more popularly known diseases — AIDS, tuberculosis and malaria. Together, the NTD’s produce just as much disability as the better known diseases and are a major reason why the poorest people in Africa cannot escape poverty. The intestinal worms found in most schoolchildren in Rwanda stunt childhood growth, physical fitness and impair intellectual and cognitive development. River blindness has impaired the sight of nearly a million people, 99 percent of whom are in Africa. The great irony is that NTD’s can be effectively treated and controlled for a fraction of the cost of these other diseases. Recently, the Ministry of Health in Rwanda in collaboration with several partners launched a campaign to treat one million children for NTD’s at a cost of about 50 cents per treatment; it costs 300 to 1,200 dollars per year to treat and care for an H.I.V./AIDS patient. Suppressing these diseases is an important goal in itself, but because they increase susceptibility to other diseases, treating them also makes it much easier to treat patients with AIDS, tuberculosis and malaria.

In Rwanda, things are changing for the better. For the first time in decades, news surveys are being conducted to establish baseline data on the prevalence of these nasty and persistent diseases. The results so far are harrowing: nearly 70 percent of school children carry intestinal worms and nearly 30 percent have hookworm. That’s a full-fledged epidemic, but it can rapidly be brought under control. A constellation of political parties in Rwanda are cooperating to do just that.

That’s one country’s approach, but how much longer will NTD’s remain neglected in the rest of the world? AIDS wasn’t a cause for international attention and action until it hit the United States. Perhaps the revelation that an epidemic of NTD’s is possible in the U.S. could have the same effect.

“But wait a moment,” I’ve recently heard. “How could there be an epidemic of neglected tropical diseases here in the United States?” The problem of NTD’s is, in fact, here, and it is quite possibly larger than we know.

In an unusual, recently published article, one of the gurus of neglected tropical disease, Dr. Peter Hotez, postulated that NTD’s, though greatly diminished in America, likely continue to pose a serious public health burden — but one which is completely avoidable. How is this possible in the 21st century and how prevalent are these diseases? Hotez notes that NTD’s disproportionately impact the poor and minorities, and that a lack of epidemiological studies leaves public health experts essentially blind. First to the possibility that a problem exists, and second, to the full scope of the problem.

While new studies are documenting that these diseases are out there in the American population, national surveillance is utterly lacking. So here is the lesson from Rwanda and Burundi for the week: perhaps the U.S. can learn something from health care in Africa (and President Bush should check it out when he visits next month!). The reauthorization for PEPFAR bill — the President’s Emergency Plan for AIDS Relief — is now seeking $30 billion of funding for five years and has called for treating “easily preventable infectious diseases” alongside its HIV/AIDS efforts. NTD’s should fall under this effort. That would be the kind of holistic approach that can dramatically improve health in developing countries. Who knows? In a few years, with improved knowledge and interest, the N may be dropped from the NTD’s.

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

"Kenya isn't Rwanda" - by Dr. Josh Ruxin

Josephine Mujawiyera is traveling this month and is unable to post. In her place, we have a bonus post from one of her Rwandan neighbors, Dr. Josh Ruxin, from his work on Nick Kristof's NY Times blog.

Let’s say you’re an African country. Here’s your New Year’s choice: Democracy or development? Which is more important? Which should be pursued first? This might seem like a silly question — both are important and should be pursued in tandem, right?

Well, it’s a harder question than it might seem. The experience of developing countries over the past 50 years offers conflicting evidence: countries like Singapore, South Korea, Taiwan and Japan developed quite rapidly in the years after World War II under military or one-party rule, while some multi-party democracies like India and Peru crept forward, posting persistently anemic rates of growth.

On the other hand, military dictatorships in places like Burma and North Korea have produced nothing but economic ruin. Countries that have bounced between multi-party democracy and dictatorship — Argentina, Brazil, Pakistan — exhibited no consistent correlation between governance model and growth. Even looking at Africa, you can argue that the countries that have recently gotten praise for combining democracy with growth — Ghana, Senegal, and Kenya — transitioned in slow stages from strongman or single-party rule to competitive electoral democracy.

The chaos that has erupted in Kenya over the past week provides some strong evidence that democracy and development go hand in hand, and that economic growth does not necessarily reinforce weak political institutions. Kenya didn’t choose development over democracy. It chose to be a democracy, hoping that economic growth would follow. Indeed, the past 5 years have seen impressive and sustained economic growth. Yet, when the Kenyans who were left out of the country’s expansion attempted to use their franchise to vote out the incumbents and vote in their champions, Kenya’s ruling elite appears to have responded by stealing the election.

Kenya was widely hailed for the smooth transfer of power in 2002 from Moi to Kibaki — something extremely rare on the African continent. Last Saturday, however, the inauguration of the president marked something quite different. Despite the fact that the exit polls showed a strong lead for Raila Odinga, and that the voters of Kenya threw most of Kibaki’s cabinet out of office and decimated the ranks of his parliamentary party, the Electoral Commission of Kenya declared Kibaki to be the winner by a thin margin.

International observers reported that voting had gone smoothly, but that the counting was a suspicious mess. Different final vote totals were reported to the central government than were initially reported locally. There was a suspicious delay in the reporting of votes from Kibaki strongholds, suggesting that local officials were waiting to see how many votes had to be fabricated to ensure a Kibaki victory. It does not seem to be a stretch to conclude that there was wholesale election rigging.

The weakness of Kenya’s political institutions means that those from whom the election was stolen have zero confidence in the willingness of the courts to intervene to protect a democratic process in the face of self-interested tampering by those in power. Accordingly, the result has been predictable but misdirected violence, literally shutting down the country and leading to tribal massacres eerily reminiscent of Rwanda’s genocide in 1994. Luos and Kalenjins have attacked Kikuyus, sometimes demanding identification documents at roadblocks to establish ethnicity. The ramifications of this disastrous turn of events demonstrate that where neither democracy nor economic development are adequately advanced, nations and regions can fall into devastating conflict in a matter of hours.

Zimbabwe’s strongman, Robert Mugabe, threw his nation into a tailspin after confiscating white-owned farms. Today the country may have inflation as high as 100,000 percent, cannot deliver AIDS health care services and floods South Africa with economic immigrants. Similarly, Kenya’s recent choices will have many downstream effects. Here are some of the repercussions, both immediate and far-reaching, of Kenya’s debacle:

1) Fuel. Shortages are spreading across Kenya and will spread to neighboring countries that rely on its ports. Rwanda, Burundi and Uganda are particularly susceptible. And don’t forget, that fuel provides much of the region’s electricity as well.

2) Tourism. The world’s largest industry is Kenya’s cash cow, but for the time being and for years to come, it will be seriously impacted. Since many package tours to Kenya include visits to neighboring countries, regional tourism will be hit hard as well.

3) International organizations. Nairobi is home to offices of the United Nations and to virtually every international organization to be found in East Africa. Increased insecurity over the last several years has imposed an enormous tax on doing business there. Now these organizations may look abroad for more secure surroundings.

4) International investment. Investors have flocked to Kenya because of its vibrant-in-spite-of-corruption private sector. The prospect of seeing investments demolished by violence and instability will deter future investment. Furthermore, it will force investors to think again before considering capital investments in nations where democracy and development are not flourishing.

Kenya has long been regarded as stable and safe (though deeply corrupt). It’s been a tourist destination for decades, giving millions every year a gorgeous glimpse of African wildlife. The country has been open to investment for decades, and many Kenyan businesses are flourishing. Because of that veneer of stability, foreign news correspondents seem unable to analyze the deteriorating situation in context. Some are seeing, with alarm, a replay of the Rwandan genocide. Even the opposition candidate Odinga, exhibiting a keen instinct for calming the situation, declared that the violence amounts to “genocide on a grand scale.”

That kind of blithe comparison obscures more than it clarifies. If you rely on the foreign press, the parallels with Rwanda may appear striking: violence committed by one tribe against another (in this case, multiple groups against one); rioting characterized by intense brutality and seemingly indiscriminate murder; most horrifically, hundreds of sanctuary seekers burned to death in a locked church. But there, the similarities abruptly end. What is happening now is terrible and horrifying, but it is not the 1994 Rwandan genocide; something else is occurring, a failure to accompany economic development with a concomitant strengthening of the institutions of political democracy.

It may seem like I’m splitting hairs, but it is vitally important that we understand the distinctions. In recognizing the differences between Kenya today and Rwanda in 1994, we can understand why this is happening and can begin to fight this particular kind of madness.

And we need to fight it. Rwanda’s genocide was fostered over decades, beginning with the identity cards that Belgian authorities forced the public to carry - cards that identified each citizen as Hutu or Tutsi. The hatred that recognition brought about was only one manifestation of a state-sponsored attempt to wipe out an entire ethnic group. This was genocide by government policy, and the directive was carried out with zeal.

However, Kenya’s disaster seems to have hit like a tornado out of thin air. Although it too has roots in the past (including British colonial oppression of the Kikuyu), it is not controlled or sponsored by the government, which is trying to stop the killing, not promote it. We’re seeing the images of Kenyan police in riot gear, lining Nairobi’s streets and patrolling rural townships to suppress rioters. The government doesn’t benefit at all from rioting largely aimed at it and its allies. Therein lies the reason for the fighting. Even though CNN and other networks called the violence “ethnic cleansing” this morning, what we’re seeing here is not genocide, it is the disenfranchised acting out in the only way they can now that democratic elections have been stolen from them.

Although Kibaki’s entourage may be correct in saying that they can quell the “hooligans” who have taken over the country, it’s clear that international opinion for years to come has already been shaped. Just as the genocide in Rwanda came to define its place in the media right to the present, Kenya’s malfeasance will do much the same. While the two catastrophes are of course utterly different, the dimensions of the Kenyan situation will have regional and long-lasting consequences. Cancel that safari trip. Move out of emerging African market funds. You can hear the sound of progress being sucked down the drain.

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Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda, where he administers the Millennium Villages Project in Mayange. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times, and he has given his permission to be cross-posted here. Josh and EGR executive director Mike Kinman team-teach a global poverty module for Trinity, Wall Street's Clergy Leadership Project.

The Word is Getting Out

Josh Ruxin is a Columbia University expert on public health who has spent the last couple of years living in Rwanda. He’s an unusual mix of academic expert and mud-between-the-toes aid worker. His regular posts can be found on the blogroll of Nick Kristof of the New York Times. This is his post from Sept. 28.

It was much to the dismay of family and friends that my wife and I moved to Rwanda. Having seen little more than “Hotel Rwanda” to educate them about the country, they believed it to be a hostile and unstable place. We had a different take: it’s safe, clean, friendly and relatively uncorrupted. Our perception is clearly shared by others and, now, the country’s resurgence is being recognized.

Tuesday, the Mo Ibrahim Foundation released the results of its “Ibrahim Index” — a holistic ranking of how African countries are doing across the dimension of governance. Ibrahim, one of Africa’s most successful and philanthropic entrepreneurs, set up the index to inform the Mo Ibrahim Prize — an annual award of $5 million for a former head of state who has demonstrated excellence in leadership. The surprise to all but Rwandan insiders was that Rwanda made the greatest progress of any country during the course of the last five years.

As the always insightful Steve Radelet pointed out in an earlier post, governance and democracy in Africa mean everything. Having worked in nearly a dozen countries in Africa, I decided to place my bets on Rwanda because it was the first place I’d never been asked to pay a bribe. I’m not alone: donors are lining up to invest in Rwanda, reassured that the money will reach the people who need it most.

None of this is to say that Rwanda is utopia: major challenges remain for improvements in the press and in democracy. Nevertheless, at a time when many nations are spiraling downward, it’s heartening to see little Rwanda making progress against all odds.

Click here to download "The Rwanda Cure" from last month's Forbes magazine, that tells more of Josh's work (with great pictures!)

Also, click here to download "Seeds of Change" from September's Time Magazine, which talks about progress in Rwanda and highlights how coffee is actually making this country richer rather than poorer.