In Congo, a Peace (of sorts) has Finally Settled in Nervously But a Raging HIV Epidemic Continues Unabated

The problem with border crossings is that you don’t know what is happening on the other side. I was nervous, fiddling with the busted zipper on my duffel bag, as I waited for the Rwandan official to clear me onto the bridge over the Ruzizi River. At the other end of the bridge was the Congolese town of Bukavu.

My driver, Evariste, was hanging around till I got through the formalities, protecting me from a bustling crowd of Rwandan gawkers, smart-mouthed Congolese market women with baskets on their heads and polio victims in wheelchairs. Rwanda, 10 years after the three-month-long genocide of 800,000 Tutsis and moderate Hutus, was still in a state of depression and fear. Now I was about to cross into Congo, the country that used to be called Zaire, which collapsed into war in the aftermath of the genocide. Peace had finally broken out in Congo in May 2003.

In Bukavu the Dutch branch of Médicins Sans Frontières — Doctors Without Borders — began providing HIV treatment immediately after the peace treaty was signed; it was the first non-governmental organization in the enormous country to treat people with free anti-retroviral drugs. The omnipresent NGOs provide most of the humanitarian services in places like eastern Congo. I was amazed that anybody there was doing anti-retroviral treatment.

South Kivu, the province over the river, had been at war since 1996, when the army of Paul Kagame, the Rwandan strongman, attacked the camps of the Hutu “genocidaires” who fled Rwanda after the genocide. The genocidaires took over the refugee camps along Lake Kivu, proclaiming the formation of a new army to “finish the job.” Kagame’s army dispersed the camps and drove hundreds of thousands of Hutus west into the jungle. Perhaps 200,000 disappeared, swallowed up by disease and starvation. The Rwandans kept going, overturned the corrupt (and U.S.-backed) Mobutu government, which supported the genocidaires, and threw Congo into a long war. Six of Congo’s neighbors invaded, looting diamonds, gold, timber and whatever else was salable. Three million people are believed to have died in a war which, though hardly noticed in the United States, was the worst since World War II.

But in May the last of the invading armies (the Ugandans) had been negotiated out, and U.N.forces had taken over peacekeeping in eastern Congo. Bukavu was relatively peaceful, said an NGO worker I met in Rwanda. Oh, there had been a couple of nights of automatic-weapons fire two weeks ago, and there were several thousand Hutu militia still roaming around, not to speak of the Mayi Mayi … but relatively peaceful.

Trying to look casual, I picked up my duffel bag and walked nervously out onto the bridge. “Don’t let them keep your passport,” Corry Kik, the MSF director said, meaning I might need it in a hurry if things blew up. But the Congolese border official stuck it in a deep drawer of his desk. I watched it disappear with a sinking feeling.

Corry picked me up in a standard-issue white Toyota Land Cruiser with a 10-foot whip aerial on the front. We rode into town 2 feet above the populace, looking down on the busy street. It was full of animated, cheerful, chatty-looking Congolese, different from the taciturn and suspicious Rwandans, who gave you hard-eyed stares as if to penetrate your secret motives.

A spectacular view of the town and Lake Kivu opened up — red roofs on waves of green hills rising up from the lakeshore. Closer up, there were huge potholes in the main road that wound round the lake, no building that looked less than 30 years old, and troops in camouflage fatigues camped at major road intersections. Whose troops were they, I asked Corry.”Whoever’s in charge.”

The shooting two weeks ago had been a confrontation between the provincial governor, caught stockpiling weapons from Rwanda, and the national government in Kinshasa, she said. After two days, MONUC, the U.N. mission in Congo, had managed to negotiate a cease-fire — for the moment. Bukavu was 1,000 miles of roadless jungle from the capital, and the Rwandans were unlikely to relax their hold on the eastern provinces completely.

Corry dropped me at the Hotel des Orchides on the lake. Hardwood jungle sprinkled with flowering vines ran down to the lakeshore. Everybody was speaking French. The manager was a Belgian left over from the colonial era. “He has trouble with army officers coming in and drinking up his stock,” Corry said.

At dinner at Mama Kinja’s restaurant, the MSF doctors and nurses, Dutch and Canadian women and one saturnine male lab tech from San Francisco ran around giddily, exchanging excited gossip with other NGO staffers. NGOs are run by cautious older professionals like Corry, who watch the security situation. She was the one who would have to pull the MSF team out if things blew up. But the staff is composed of young people on short-term contracts. Back in Rwanda, the young staffers had been subdued by the 10th anniversary of the genocide. Mama Kinja’s was bubbling like New York on a Saturday night.

Corry had been in Congo a long time and had been working to set up the HIV treatment projectfor four years. She had been at the notorious camps in Goma at the north end of Lake Kivu when the Hutu militias took over and the NGOs found themselves feeding and treating a genocidal army.The eastern Congo was complex. It wasn’t so much that you didn’t know who the good guys were, I thought. It was more that there weren’t any good guys left. I asked Corry if she thought MSF had been right to pull out of Goma.

“Look, 90 percent of the people in the camps were just people. So 90 percent of what we did was good.”

Next morning we set off for the MSF clinic, through a roadblock on the edge of town where soldiers were checking for weapons. They casually waved us through as if the white Land Cruiser were moving in a parallel universe. Congolese women, all of whom seemed to be wearing wigs, stared at us curiously, and school children waved delightedly. I thought things looked pretty cheerful out there in Bukavu. No children had waved in Rwanda.

In the news of the day, the U.N. was investigating a cannibalism incident in the hills to the west, attributed to Hutu militia who had already eaten up the local cattle. Three heads had been found in a tree with the message “the man who has a rifle need never be hungry.” The MSF clinic was high on a hill with a spectacular view over the lake and town. The clinic was behind a gate in a high fence and almost invisible under flowering bushes and trees. Inside, patients, mostly women with small children, were sitting nervously on benches waiting for a staff of local doctors and nurses to check them in. Out back, other women were laughing and shouting, waiting for their turn at the food distribution center. Like many front-line treatment programs, MSF was feeding its HIV patients because there was no point in treating them if they were going to die of malnutrition. The U. N. World Food Program was providing the food.

“You’ll want to talk shop,” Corry said, dropping me off with Heather Culbert, a young Canadian doctor who was treating the HIV patients. Heather was nervous because she had only been working a few weeks and she wasn’t familiar with African AIDS. I told her I liked to watch doctors work with AIDS patients because it made everything real. I thought there was an obligation to look and listen even if what you saw in patients who didn’t have access to anti-retroviralswas terminal disease and fear.

She was dealing with a woman with a cough, not on anti-retrovirals but on monthly prophylaxis with cotrimoxazole. She decided the cough wasn’t serious and sent the woman away, earning a black look. Patients liked to be given something, she said. The next patient needed a diagnostic test for a non-HIV-related condition. “On ne peut pas payer pour ses soins,” she said. We can’t afford to pay for that care.

No. 3 had hugely swollen lymph nodes behind her ear with large weeping abscesses — usually a result of tuberculosis. Heather wasn’t sure. She wanted to swab the abscesses and send the results to a lab for culturing to see if it was TB, but there probably wasn’t anybody in all of eastern Congo who was doing TB cultures. She would treat “presumptively,” as doctors put it, and see if the patient got better. That was what AIDS medicine was in places like Bukavu. The patient stared at us with big alarmed eyes.

Awoman in a Bambi T-shirt came in with her baby. Most of the women here were wearing American surplus T-shirts from the market along with brightly colored pagnes, wraparoundskirts, often with political slogans on them. The baby boy had a sore on his penis and couldn’t urinate. Heather diagnosed it as a yeast infection — “it’s really messy down there; we’ll give him some treatment for that.” It was a bad sign because it might mean he was HIV positive, but he wouldn’t get tested until he was 18 months old. There was an older brother, the woman said, but “déjà il est mort d’HIV” — he had already died.

Heather started recruiting the mother to go on anti-retrovirals. MSF had about 40 people on the drugs, she said. They had started off too conservatively, trying to recruit only people who were at a late stage of disease. Now they were trying to recruit 10 a month, but it was difficult getting people to come to the clinic — probably they were afraid — and only four of this week’s eight eligibles had showed.

Corry came back and dragged me outside to show off the food distribution center. Now there was a full-fledged market out there, with women sitting and gossiping on the ground while two cheerful matrons — patients on anti-retrovirals themselves — lifted sacks of flour and beans and measured out oil. Chi Chi, the director, was an enormous muscular Congolese clearly having a great time surrounded by all these women. “Mama Agathe,” Corry said, pointing to one of the matrons. “Femme forte!”

Mama Agathe, the strong woman, flexed her muscles grinning, and pointed back at Corry:”Mama Corry!” Mama Corry, you’re the boss, she meant. You did it. That evening the lights went out in Bukavu. Maybe all the electricity was going to the huge Primus brewery down by the lake, the staffers said. It happened sometimes.

We had finished our tour of clinics and hospitals. There was nothing available in the hospitals for patients who couldn’t pay — no beds, no medicine, no food. MSF was renting rooms and hiring nurses for its HIV patients. This produced the uncomfortable two-class system that is one of the big problems of HIV treatment in Africa: Why should the HIV patients get all this attentionand everyone else be left to die? I put this question aside and went off with the staffers to the Welfare Restaurant, set up inside the U.N. compound. It was the only other place to eat besides Mama Kinja’s, and sold the only cheeseburger in Bukavu.

Inside, two terminally bored officers from the U.N. command, one Senegalese, one Uruguayan, sat numbly at separate tables, their legs splayed out in front of them, staring separately into space. Could it be that boring in Bukavu? They gave the young female doctors and nurses longing looks as we sat down. Corry had stayed home again; she was cranky and withdrawn. Perhaps she was worrying about the security situation or perhaps it was simply that she had seen too much of life in eastern Congo.

“I’ve done everything,” she said “emergencies, evacuations, feeding centers, vaccinations, outbreaks.” Now she was pitting some young doctors and nurses and Mama Agathe against an HIV epidemic that could easily be infecting 10 percent of the population in South Kivu. And nobody quite knew who was in control of the province. We climbed into the white Land Cruiser to go home, and the driver called in to the communications center at the MSF house on the lake. MSF employees moved only in the vehicles and called in their position every time they moved.

The staffers lived in a house out in the suburbs, and I caught an undercurrent of nervousness as we headed out into the darkness. But the armored personnel carriers had left the compound, so hopefully MONUC was patrolling the city. I admired what MSF was doing here, I thought, as we drove through the dark and silent outskirts of Bukavu, and what it was doing in the other HIV treatment programs it had set up across the continent. But even more I admired the cheerfulness of the Congolese, in the street and in the restaurants and at the HIV clinic on the hill. In halting French, I asked the driver how it came about that the Congolese were so cheerful, in spite of so many wars and so much poverty and disease? “Nous sommeshabitués,” he said philosophically. We’re used to it.

Three days after I left Bukavu, the Rwandans closed the border. Tension between insurgents thought to be backed by Rwanda and troops loyal to the Congolese government continued until, on June 2, troops from the main Rwanda-backed faction seized the town. The insurgents claimed that genocide was being planned against Congolese of Tutsi origin.

Riots protesting MONUC’s inability to prevent the seizure of Bukavu broke out in Kinshasa and other Congolese cities. MSF staff took refuge in the MONUC compound. Later, the group was withdrawn to Kigali, the Rwandan capital. Heather Culbert fled in jogging clothes and had to cross the border without a passport. Government forces retook Bukavu on June 9. At least 100 people were killed in the fighting. International observers since June 9 report no evidence of genocide. Corry Kik and her team remain in Kigali.

Andrew Moss is professor emeritus of epidemiology and biostatistics at the University of California at San Francisco. He is following the progress of AIDS treatment in the developing world.