Bacher’s Blog

View from Butaro Hospital, Burera District, Rwanda

Two types of medicine are being practiced at the Butaro hospital in northern Rwanda; one treats diseases of infection, the other treats the disease of poverty. Using local building techniques, materials, and labor, construction of a new hospital building is now underway in northern Rwanda’s Burera district, near the border with Uganda. Lush terraced hillsides, subsistence farming, and Lake Burera dominate the one hour drive from the nearest paved road - less than 15 kilometers as the crow flies.

Lake Burera, Rwanda

In a joint venture with the William J. Clinton Foundation, and Rwanda’s Ministry of Health, the Boston based Partners In Health (PIH) is overseeing the building of an innovative hospital designed to control infectious diseases like tuberculosis, as well as nosocomial (hospital-induced) infections common to hospitals in sub-Saharan Africa.”

Workers digging foundation, Butaro Hospital, Rwanda

With a local contractor, and a construction crew hired from the local population, PIH is implementing their proven model of community-based care to serve a population of over 500,000, in a region reaching from northern Rwanda to southern Uganda. PIH fundamentally believes health care is a right not a privilege. Community-based care is based on five fundamental principles[i]: 1. Access to primary health care, 2. Free health care and education for the poor, 3. Community partnerships, 4. Addressing basic social and economic needs, and 5. Serving the poor through the public sector.

Ambulance at Butaro Hospital, Rwanda

An existing facility, in the process of being updated, treats the three most common ailments - upper respiratory infections, malaria, and gastro-intestinal problems. It also includes maternity, pediatric, HIV/Aids, and other treatment wards. Equipped for x-rays, minor surgeries, C-sections, and physical therapy, the present hospital can handle most medical issues. Conditions requiring major surgery are transferred to larger facilities.

Butaro Hospital ward, Rwanda

Butaro’s new hospital building was conceived by a team of architects from Harvard’s Graduate School of Design, working in conjunction with PIH. Lead architect, Michael Murphy, began preparations after being contacted in 2007 by Paul Farmer, the founder of PIH. Farmer challenged Murphy to generate an architectural solution to the medical problem of infection transmission in sub-Saharan Africa. Of particular concern, halting the spread of recalcitrant airborne infectious diseases, such as tuberculosis, where a patient can come into the hospital for an easily treatable condition like a broken bone or the stomach flu, and leave with TB.

Michael Murphy - Architect, Butaro Hospital

“The problem of airborne disease in developing countries is so huge and complex that a multidisciplinary approach is the only way to address these issues,” states Murphy. “We believe that architecture can save lives through effective healthcare design.”[ii] The Butaro project inspired Murphy, along with ten other students, to form the non-profit MASS (Model of Architecture Serving Society), in January 2008.

Transfering supplies between buildings, Butaro Hospital, Rwanda

Rather than depending on high cost and high energy intake methods like the negative pressure air evacuation systems more common in wealthier countries, the new Butaro hospital relies on simple design features to reduce the spread of airborne pathogens. Open wards with natural ventilation allow air exchange rates on par with western hospitals. A hill top cite provides the advantage of increased wind and air flow, and high permanently open windows amplify ventilation. Interior hallways, where close patient to patient contact is frequent, are eliminated. Exterior walkways and courtyards with wards built around the perimeter also reduce the risk of disease transmission.

Foundation construction, Butaro Hospital, Rwanda

Eloquent solutions, appropriate technology, and determination are all in play, but the design and it’s structural endpoint are only the beginning. Construction techniques and applications are the unexpected story. In a country where 60% of the population earns less than one U.S. dollar per day (88% earns less than two dollars per day),[iii] the Butaro hospital project directly treats the disease of poverty. All labor comes from the local population where subsistence is a way of life, and a full stomach is never guaranteed. Typical of Rwanda, people living in this area have no electricity and no running water.

Woman hauling dirt from construction site, Butaro Hospital, Rwanda

The construction crew works in one week shifts, then a new group comes on. Work groups cycle once every six weeks, spreading employment to six times as many people than if only one crew were hired. Local building techniques are the rule; earth moving machinery is all but absent. Foundations are dug with pick and shovel. Dirt is removed on foot, in large bowls atop a woman’s head.

From cement to cinder blocks - mixing, molding, and drying, Butaro Hospital, Rwanda

Cement is mixed by hand, and cinder blocks molded and dried on location. Furniture and other finished wood products are constructed on site. Anything that can be dug, mixed, cut, formed or fashioned into shape is done by the local people with local means.

Woodworking at Butaro Hospital site, Rwanda

Meals are fed to all, clean drinking water is readily available, and health care and education are provided. Construction of the new hospital is as much about development and poverty reduction as it is about improved health care. Work is one of the treatments.

“It’s a clear example of how you could rehabilitate an entire community by investing in one infrastructure.” Michael Murphy.

Worker at Butaro Hospital construction site, Rwanda

All photography copyright Adam Bacher.  Absolutely no usage without prior authorization.

TIG is a Rwandan program allowing people found guilty of participating in the genocide to serve all or part of their sentences doing community service. TIG, “Travail d’Intérêt Général,” is a French acronym that means “works of general service.” The program is normally referred to as community service, but it is not the same kind of community service we see in the United States.

TIG prisoner giving thumbs up.

The program allows eligible prisoners to complete their sentences through participation in activities such as clearing ground, road building, construction of houses for genocide survivors, clay mining, and brick and tile manufacturing. Participants are referred to as tigistes and they engage in hard physical labor: breaking and hauling rocks, digging with picks and shovels, and manually moving earth by hand, sack, or wheel barrel. Many of the workers do not wear shoes.

This new road is being excavated and leveled by TIG members. It leads to an area where other participants are constructing homes for genocide survivors - Rwanda

The Rwandan government hails TIG as the best way to blend justice and reconciliation, helping to ease confessed killers back into Rwandan society. Reintegration, skill training, re-education and sensitization are part of the TIG design.

A million people were killed in the genocide; millions more were implicated, both directly and indirectly, as participants in the killings. Supporters of the program reason that all who participated cannot possibly be imprisoned, and TIG administers appropriate justice while serving to reconcile the Rwandan population. However, the program is not without its controversy. Some victims’ groups believe that consequences for the guilty are too lenient for the crimes they committed.

A day spent touring the TIG work sites was not about testimonials from the prisoners, evaluating philosophical approaches, punitive effectiveness, or rehabilitative results. It was centered around operational functions and the people carrying them out.

Row by row new homes are being built for genocide survivors by TIG prisoners - Rwanda

I toured three primary sites in eight hours, as well as a camp compound where large orange tents provide living quarters for the tigistes. By the end of the day I had seen every aspect of housing construction for genocide survivors. The tigistes mined raw materials – from dirt for bricks, to clay for molding roofing tiles, to earthen materials used to make the hard concrete pads that serve as foundations for the houses, and the smooth adobe that covers and seals the brick walls. Each process began with digging earth.

Homes are built from the ground up, starting with excavation – not of a basement, but a thirty meter rectangular pit – the toilet.

After clearing the land, TIG prisoners in Rwanda dig the toilet. The first step in construction of a new home.

Bricks that make the core walls of houses also begin with excavation. Red dirt, the hallmark of African soil, is dug from a hillside, sifted, sorted and carried off.

Raw materials for brick-making are excavated from hillside soil.

TIG members sifting dirt for making bricks

Sifted dirt is ready for brick-making.

A hundred meters uphill from the quarry are two hydraulic compressors designed for molding bricks. Each machine, the size of a refrigerator, is run by a small kerosene generator. Other than the car we drove in on, they are the only machinery on site

Forty minutes by car, nestled at the head of an open valley with terraced hills rising from three sides, is a tile and brick factory. Clay mined from a river bed is used for construction of rounded roof tiles and other types of brick and building materials.

TIG tile and brick factory

On the right, a large pile of mined clay awaits processing. On the left, a TIG member works the clay with his feet.

Again, the first step begins with excavation. Clay is carried and piled inside open buildings where it’s processed for tile and brick molding. Processing consists of stomping and beating the clay with Neanderthal sized wooden clubs.

TIG workers beat the clay until it reaches the proper consistancy for tile and brick making.

When ready, it’s taken to other areas for tile and brick fashioning.

Roofing tiles are shaped around a wooden form, then left for drying. Later they will be baked in an oven for hardening.

Later that afternoon we ate lunch with administrators at a camp where large orange tents had been erected for shelter and sleeping quarters while these tigistes finish their time in the program.

In the TIG program, members work 3 days on then 3 days off. A few are allowed to commute from their homes. Most live in the field where projects are under way. Each tent holds between fifty and eighty people.

Lunch is eaten outside and inside the tents.

All photography copyright Adam Bacher. Absolutely no use without prior authorization.

Hi All!  The internet has been uncooperative.  Uploading of photos is next to impossible.  Today I snuck a couple in.  New stories and photos will begin appearing later next week when I return to the states.

Today I spent seven hours in an abandoned brick house with three orphaned children who have occupied it for the last two years;  John Pierre is 9, Deborah is 12, and Cintia is 14.  They live and care for themselves but for an aunt who appears every few days and gives little to no support.  The children are sustained by sponsors from the Itafari Foundation, based in Oregon, and Christ Gospal Church based nearby in Kigali, Rwanda.

John Pierre was still in bed when I arrived.

Inside the house where children live.

The full story will be posted soon.  Thanks for your patience.

All photography copyright Adam Bacher.  Absolutely no usage without prior permission.

A baby billy goat.

All photographs copyright Adam Bacher.  Absolutely no usage without prior authorization.

Rwanda is a country of great natural resources; not mineral deposits, not oil, not coal, not gem stones hidden in the earth. Rwanda’s natural resources are home grown – its people.

Fifteen years ago the country was the scene of one of the humaniy’s worst genocides . One million people were killed in the course of one-hundred days.

Today Rwanda is an example of peace. The people have chosen not to allow themselves to become captive to decades of retributional killings. Distinctions between ethnic groups, political extremism, wide spread corruption, media manipulation, and other factors that led to the genocide have all but disappeared. Rwandan’s are working hard to reconcile their differences, and grow themselves out of poverty - toward peace and prosperity. They are an example to the world of what is possible.

Innovative means are empowering the people to empower themselves. During the month of January I’ll be in Rwanda reporting about and photographing the people and programs of the country.

ASSIST-Rwanda is a locally based non-profit, youth advocacy, organization. They work with orphans and at risk youth on education, skill development, micro-business projects, employment, and HIV/Aids prevention. One of their programs is setting up business cooperatives with orphans and child headed households across the country. I visited some of these cooperatives in the northern area of the country, out of the city of Ruhenguri.

Youth cooperative meeting in Ruhengeri, Rwanda

The day I arrived, members of six cooperatives were meeting to finalize charters, elect officers and formalize their businesses. A year ago these teenagers lived in abject poverty; clothes worn and tattered, not  attending school,  unemployed, hopeless. When asked whether one year ago they could have imagined where they would be today, the answer was a resounding “no.” Now they are business owners. They’ve been trained in sewing, carpentry, and welding.

Youth sewing cooperative

The cooperatives ASSIST-Rwanda has helped form are lifting them out of poverty. Today they have vocational skills and employment. Many of them are going to school. All of them have hope for the future.

Member of youth carpentry coperative

Member of youth welding cooperative

All photography copyright Adam Bacher. Absolutely no usage without prior authorization.

In September 2000, the largest gathering of world leaders in history adopted the UN Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty. They set out a time-bound series of targets known as the Millennium Development Goals (MDG), with a deadline of 2015 for meeting them.

These goals are quantified targets for addressing extreme poverty, hunger, disease, inadequate shelter, while promoting gender equality, education, and environmental sustainability. They are basic human rights of all people on our planet to adequate health, education, shelter, and security.

In 2002, the United Nations Secretary –General, commissioned the Millennium Project, and its 8 basic goals:

1. Eradicate extreme hunger and poverty

2. Achieve universal primary education

3. Promote gender equality and empower women

4. Reduce child mortality

5. Improve maternal health

6. Combat HIV/AIDS, malaria and other disease

7. Ensure environmental sustainability

8. Develop a global partnership for development

There are twelve Millennium Villages in sub-Saharan Africa. In Rwanda, a Millennium Village cluster is located in Mayange, less than an hour’s drive from the capital of Kigali. Shortly before returning home, I spent a day touring a portion of this village. Located in Rwanda’s Bugesera District, the area is one of the most underdeveloped and arid parts of the country. With limited water access, one solution was to build cisterns between houses to catch water run off. The girl seen below is leaning against one of them. Gutters from homes on either side divert rain water into the cistern. At the bottom is a spigot for filling water cans.

Fertilizers, drought resistant crops, and grafting techniques are utilized to help improve farm yields. The farmer below took us to his fields to show what crops he’s growing.

Cassava, grown for its starch filled roots, is highly adaptable to these soils.

Grafting fruit-bearing trees to native root stocks is also successful in this area. Avocado, mango, pomegranate, and orange grafts will become productive in as little as two years. Shown below is a newly grafted plant. The graft is the cut line on the midpoint of the stem, enlarged in the box on the lower right.

The school that serves this area has 700 students and 9 teachers.

Unique among the millennium villages, one of Mayange’s goals is to help heal the wounds of genocide. In one area we visited, homes were built by survivors and perpetrators working together. Today they live side by side in peace. The woman below lost her entire family.

This man participated in the killing of seven people in the area. After serving ten years in jail, he is now welcomed in the community.

The newly built health clinic and maternity ward serves the needs of the community.

Other members of the village…

Copyright Adam Bacher. Absolutely no use without prior authorization. All rights reserved.

When the genocide began on April 7th, 1994, many ethnic Tutsis and moderate Hutus took refuge in churches, believing militias would not enter these areas which were perceived as sanctuaries. At the Nymata Catholic Church, located in the Bugesera district, 35 km south of the capital of Kigali, 10,000 people were killed in and around the grounds between April 14 - 19. Other large scale massacres occurred in Catholic Churches throughout the country as priests, nuns, and church officials systematically fled Rwanda after the genocide began. In some cases, priests and other officials were complicit in the killings.

The Bugesera district was one of the areas most devastated by the genocide. From a population of 62,000, only 2,000 survived. The photo below shows the front of the Nyamata church. People congregated there from all around. To protect themselves they padlocked the iron gate, hoping to keep the Hutu militias and their Interahamwe leaders at bay. Thwarted on the first attempt to take the church, the militias came back with grenades. The hole in the gate shows where one grenade was used to gain entry. The banner over the door reads:

If you knew me, and you really knew yourself, you would not have killed me.

Inside, militias found thousands. The sanctuary below would have been overflowing beyond maximum capacity. Every space, concealed or open, was filled with frightened people hoping to escape death. People were inside closets and cupboards, under the alter and under the floor boards, any place large enough to fit. The militias came in shooting. Daylight can be seen through the bullet holes in the ceiling.

Most would have preferred bullets to machetes. Nearly all were killed by machetes.

The blood stains on the walls – shoulder height throughout the building – are mostly faded. The fabric covering the alter still bares the staines.

Everyone in Rwanda had to carry an ID card like this one. Your photo goes on the left side, at the top center. Just below, in bold, is a spot to check your ethnicity. The edges are darkened with blood, and the hole is from a bullet.

The basement of the church now holds one of many mass graves. Eight others are accessible behind the church. This grave is typical. The entrance begins with twelve steep steps down.

Short narrow hallways go off to the left and right, a shoulder and a half wide. On each side, racks of skulls and bones cover floor to ceiling. Some of the graves have coffins, each filled with many sets of bones.

After release from prison, one of the genocide perpetrators revealed he had participated in a larger number of killings. The names of all his victims are listed on this plaque.
Copyright Adam Bacher. All rights reserved. Absolutely no use without prior authorization.

Copyright Adam Bacher. All rights reserved. Absolutely no use without prior authorization.

In times of armed conflict, children are among the most vulnerable - as victims, hostages and worse. During the genocide in Rwanda, one million people were killed in the span of one-hundred days. The killers did not discriminate; men, women, or children, any who were identified as from the “wrong” ethnicity were killed.

With the fall of the genocidal regime, perpetrators (genocidairs) and organizers of the atrocities (Interhamwe) fled Rwanda to avoid prosecution, along with large numbers of the population who feared retribution.

The Interhamwe quickly began to recruit militias; they reorganized as rebel forces operating over the northwestern border of Rwanda in the Democratic Republic of Congo, formerly Zaire. Large numbers refugee Rwandan children were recruited and forced to take part in new attacks and atrocities, carry loads of ammunitions, work as messengers, and cook and assist in other tasks.

For rebel groups, child recruits are seen as the most expendable. Easily manipulated, children were forced to commit some of the most brutal atrocities including the rape, maiming and slaughter of victims. If they refused to take part they were killed. Over time, many child soldiers have escaped and returned to Rwanda. In other cases, Rwandan army units liberated them. To date, child ex-child combatants that have returned to Rwanda number in the hundreds, with an estimated 2,000 remaining in the DRC soldiering for Interhamwe groups against their will.

In February, 2004, the Rwandan Demobilization and Reintegration Commission, opened a Child Ex-Combatants Rehabilitation Center, an hour’s drive east of Kigali. This week we were invited to tour the facility. Situated in a wooded setting near the shore of lake Muhazi, the center in on the grounds of a former military training camp. It had a feeling similar to that of many summer youth camps I’ve seen in the United States.

Take away the mosquito netting, and the bunk house bore resemblance to a rustic youth camp; beds made and lined down the wall, clothes hanging from the headboards, tennis shoes and sandals on the floor, drawings tacked to the walls, boxes with personal goods next to or underneath the beds.

The goal of the facility, according to a paper we were given entitled “Confronting the Challenges,” is to “diligently respond to the need for these children to be repatriated, rehabilitated, reunited with their families, and reintegrated into main stream society, thus restoring their right to enjoy their childhood and grow up into responsible citizens.” When I asked about the current group, I was told they had a population of 36 kids, two of which were under 10 years old, the bulk between 12 and 17. I’m usually good at staying dispassionate on photo shoots, however it was hard for me at this location. I had trouble getting the thought out of my mind that some of these kids were the same age to my two daughters, 11 and 13. A problem compounded when I started hearing the list of atrocities many of them had been forced or seduced into committing.

One of the conditions of our tour was that I would not publish any photos of the children’s faces. Most looked very hardened, a few soft and innocent. They wore the same khaki color uniforms of public school children. I had hoped to see and photograph them during their daily classes and activities, however, we met only at the end of our tour. The kids were grouped together in a covered area seated in rows on benches. Six of the older children greeted us with a traditional Rwandan dance.

The facilities’ social psychologist gave us with a brief overview of the of center and it’s philosophical approach. Rehabilitation includes, among others: psycho-social support, art therapy, civic education, literacy and numeric teaching, socializing and life skills activities, and community sensitization and advocacy done in the communities where the children will be reintegrated. On the walls around him were examples of the typical progression of art from when the children arrive to when they leave. The pictures in the photo behind him were common to new arrivals, depicting scenes of guns and battle.

As time progresses the art shows more customary scenes.

When Victoria Trabosh, President of the Itafari Foundation, addressed the group she used phonic flash cards to teach some english words. With her sense of humor and masterful interpersonal skills, I watched the tough and closed looking group briefly show their child side with laughter and boyish smiles.

All images copyright Adam Bacher. All rights reserved. Absolutely no use without prior authorization.

At 5:30 in the morning, myself and Chysologue (my interpreter) were dropped off by motorcycle taxi to a family’s house, in a village where the few that have transportation may have an old gearless bike.  I spent my time there following and photographing, “the day in the life” of two children, brother and sister.

Sunrise - an hour after I arrived to Claudette’s house.

It was before dawn when we arrived at Claudette’s house. Her 16 year old brother, Justin, and two children, John Claude (8), and Naomie (10), were already awake. The young ones were completing the first of the morning routines, taking the chickens out of the house and putting the larger ones in the mud walled pen outside.

This chicken wanted to come back in.

The family I was with count themselves among the most impoverished in Rwanda. Where they live has no running water, and no electricity. Their house was made of mud, bricks and a fabricated sheet metal roof. The floors were the hard red dirt common to this part of Africa. Yet their spirits were of the richest the world has to offer.

John Claude boils water to use for breakfast, in the cooking area on the side of the house.

Justin bathes while the children continue with their morning chores.

On this day I witnessed something incredible. It didn’t come in a box, it wasn’t in a museum, it was no great feat of science, engineering, or technology. In the course of an average day I witnessed an astonishing abundance of laughter, joy, community, neighbors and strangers coming together.

John Claude and Naomie have breakfast.

Claudette waits in front of the house to see the children off to school. The house is divided into two apartments, and the four of them live in the right half to this structure. The chicken pen is in the lower right.

Leaving the house for school.

On the way to school with some friends.

After breakfast and chores we walked to school. The kids are fortunate, the school is under a mile from their house. Today their mother will walk with us to introduce me to the principal and ask permission  to photograph at the school.

In much of Rwanda, no one has ever seen a fair skinned person before.  When we arrived at the school many children crowded around me, and continued to throughout the day.

Their shoes, imported from China, are foam rubber and the least expensive available. I couldn’t get over how much they resemble the latest fad for school children in the United States. With a few minor modifications, they’re no different from the crocs shoes that sell for thirty dollars and up in the U.S.

This was a common view for me before school started and during recess.

The schol day began with the students lining up outside by the flag to sing the national antheum and recite a short prayer. Then, class by class they filed off to their rooms to begin their studies.

The start of school began with cleaning; the chalk boards, the classrooms, the walkways outside.

John Claude struggles to work a math problem and his teacher helps him out.

At 9:30 a.m. it’s already feeling like a long day.

Next I went on to Naomie’s class.

Naomie stands to answer a question after being called on.

Some other students in the class room.

At 12:15 school let out for an hour and a half to give the kids time to go home for lunch. In some schools, where resources are more plentiful, the children will stay in school for lunch. One of the endearing qualities about Rwandan culture is the closeness and affection shared among friends, young and old. This next photograph is a scene I’ve observed many times since coming here, in the city and the country side. You would only see this between friends. Couples do not show their affections in public at all.

After school the kids had two things to they needed to accomplish: get water and collect fire wood. In many areas of Rwanda, running water is not available. Some people spend as much as three hours a day walking to get water. Water is survival, and in Rwanda it’s carried mostly in 20 liter yellow jerry cans.

Not an uncommon sight, this man has just finished filling 5 water cans and is on his way home. 20 liters of water weighs 44 pounds (Add the container and it’s 50 pounds a can).

The next time you think you have it bad, imagine caring 50 pounds of water on your head, or carrying 100 pounds (50 on each arm)? Now imagine doing that with a malnourished body on an empty stomach.

John Claude and Naomie are fortunate, their water source is less than a half mile walk from home. Going with empty cans isn’t bad. For kids there are 5 liter containers.

The government has piped water into many areas. Their immediate goal is to have water access within a 2 kilometer walk for everyone.

For a child, 20 pounds of water makes the walk home a much bigger choir. As soon a I took this photo, I also took a can from each of them.

After returning home to drop off the water, we headed out to collect fire wood. The walk was much further this time, almost an hour, to a spot where Claudette is renting a small plot of land to cultivate food. Here the children collected fallen wood from the side of the road. I began to help, but the wood they were gathering had small barbs on the branches and was piercing my skin. Due to deforestation, cutting down trees is strictly regulated in Rwanda.

Naomie gathering wood.

Walking back Naomie was able to easily balance her load. John Claude had to hang on.

The last thing the family did before I left was feed the chickens. Each bird was taken from the pen, and one by one Claudette tied a crudely fashioned rope to their legs.

John Claude holding two chickens awaiting to be tethered.

Then the chickens were placed on the ground and given corn.

Naomie holding a rooster to be put back in the pen after feeding.

The last photos I took before leaving for the day were of two of Claudette’s friends. This woman lives with her family in the other half of the house.

This woman looked wiser than most people I know.

And she had a great smile.

If you’re interested in sponsoring a child in Rwanda, or want to help in another way, I encourage you to contact the Itafari Foundation, a 501(c)(3) organization ( http://itafari.org ), and help support their extraordinary work. You can give directly through their secure website, or send a check to Itafari Foundation, 27 El Greco, Lake Oswego, OR 97035. USA

Murakoze Cyane (thank you very much!)

Copyright Adam Bacher. All rights reserved. Absolutely no use without prior authorization.