Global health, gender equity, and rebuilding Rwanda

Dr. Agnes Binagwaho Transcript

Sabrina Merage Naim
From Evoke Media, I'm Sabrina Merage Naim, with me is Kassia Binkowski, and this is Breaking Glass - a series of conversations with women around the world who are shattering glass ceilings and challenging social norms. They are audacious, gutsy, and their stories are echoed across borders and generations in a rallying cry that is changing the narrative for women everywhere. Today, conversation takes us to Rwanda to chat with Dr. Agnes Binagwaho - pediatrician turned Minister of Health and now the senior advisor at the World Health Organization. Dr. Agnes co-founded the University of Global Health Equity, where she's disrupting yet another system and trying to rebuild global health education to achieve gender equity and create more leadership opportunities for women.

Kassia Binkowski
Sabrina, I think what's particularly amazing about this story is that Dr. Agnes left Rwanda with her family when she was just a child, she pursued and completed her medical education and training in Europe, and then she decided to move her young family back to Rwanda, just two years after the mass genocide occurred.

Sabrina Merage Naim
It's true. Her story today takes us right back to that moment, landing in a broken and dangerous country, pushing through her fear and desire to run back to the safety of Europe like any of us would. And since then, Dr. Agnes has rebuilt the country's health sector and become one of the foremost public health leaders and advocates. It's really an incredible story.

Kassia Binkowski
It is. We're talking today about genocide and social justice. We're talking about gender equity, and health leadership. But perhaps most importantly, we're talking about what exactly Dr. Agnes wishes for the next generation of girls growing up in Rwanda. Let's dive in. Dr. Agnes, thank you so, so much for joining us today.

Dr. Agnes Binagwaho
It's my pleasure to be with you Kassia.

Kassia Binkowski
It really is an honor to have you on the show. Your family left Rwanda in the late 1950s. It sounds like your father went to Belgium and he had a medical career of his own and you started your own medical career in Europe. You had two young children. And then in 1996, just two years after the genocide of 1 million Tutsis, you decided to take your young family back to the country where you were born. Can you take us back to that moment and kind of start your story there? Why did you decide to go back to Rwanda,

Dr. Agnes Binagwaho
I decided to go back to Rwanda because the father of my daughters decided to go back anyway. And I thought that we need to give a try. I just just said "Let's go." I didn't believe it would work. But I will say, let's go we need to give a try and at least show that we are from goodwill, that it's important for the family to be together, for young kids at that age, especially around that period when there was too much - even if we were not directly traumatized - it was a very stressful time for all of us, and especially the kids who cannot understand that. Because so many cousins were killed so many, and they know they were killed. If their father would have gone alone they would absolutely be too distressed. So we better go together. That I felt that it will be better for the family. And that's how I went.

Sabrina Merage Naim
So that must have been extremely challenging for you, given you left Rwanda when you were a child. You had medical degree, you started your medical career, your children were all born in Europe, you had a life there. And what was happening in Rwanda was a very extreme situation, that for all intents and purposes, you had already shielded your family from the danger of it. And then you decided to kind of go dive right back in. Leave your career, start fresh. Take your children there. What was it like when you first went back? What was the environment like for you and for your family?

Dr. Agnes Binagwaho
It was hell. What is the there was nothing we were used to. We had the comfortable life. Even what we were eating was not the same. My children had to leave their friends, we were starting in an environment where the equipment, the knowledge, the staffing was at that time substandard. And also a country where we didn't have real connection at that, at that time because we will be broke. No, I grew up knowing I would never go back there. And my children also. And so it was not easy. The only thing that was sure is that if we were keeping some rules of security, we were safe. That there were no direct threats physically of security. There was a curfew at a time, at six o'clock, you had to be done, you cannot be in between the town. You just have to respect that. And so that's what we found.

Sabrina Merage Naim
So you you arrived in what you call was hell, it was a really bad situation, there was still a lot of trauma, a lot of heartbreak.

Dr. Agnes Binagwaho
People were coming the entire time, they were coming from Congo, coming to inside, Rwanda to kill people.

Sabrina Merage Naim
So it was still extremely dangerous.

Dr. Agnes Binagwaho
If you respected the security, not being in the town on time, and etc, you were safe. So we were managing to do that. But it was an environment that we were not used to. Yes.

Sabrina Merage Naim
So when you got there, you kind of looked around at the broken medical system, and you thought I might be able to do something about this. But it was an extremely challenging situation. And at some point you wanted to run away. Is that right?

Dr. Agnes Binagwaho
Yeah. I think my first reaction was to run away.

Sabrina Merage Naim
And why didn't you?

Dr. Agnes Binagwaho
The reality is that I did say "Oh, my goodness, there is nothing. No equipment. No lab capacity that I'm used to." I spend my day saving a baby and I come to learn after had died because he was badly managed for something, etc, etc. So I say if I stay in this situation, I will lose my my mind. And why I stayed is because I realized that it was a very selfish reaction. I'm going to lose my mind because I cannot support difficult situation that I I am not even suffering directly. Because what about the mothers who are losing their kids, the parents and the kids themselves who lose their life. So I just realized that that was the wrong reaction. You don't make your life to be comfortable. It's time to do to make your life to be of service.

Kassia Binkowski
Paint a picture for us, if you will, of Rwanda at that time. Specifically, what were the greatest barriers that women were facing to quality health care? What did that look like? What did the system look like that you came back to?

Dr. Agnes Binagwaho
So we need to say that it was not only children and mothers. I was a pediatrician. So I was directly concerned by children, but it was everybody you know. To give you an example, the simple equipment to measure the level of electrolytes - that means really sodium and potassium in the blood - that means the basic were not there after the war. Or maybe it was there and was destroyed, I don't know. But it came after the genocide. So, the situation was risky health services for everybody. Everything was to be repaired. There was very few doctors you know. We were five pediatricians at that time, for millions of people. But it was the same in surgery, and gynecology. And so you have to understand what I discovered is that the neglect of education was an agenda. The less the population is educated, the more you can plan something like the genocide, so high education was not promoted. And I saw that because for doing all that the salary, for example, the salary was peanuts. But somebody who was sweeping all day and the salary for me, as a pediatrician - we were almost getting the same salary. And I'm not for difference in salary, no. I just want to tell you that even a general practitioner was earning more to work less during a Sunday, from seven to five. I was there from seven to seven. And the general practitioner was earning more, just because they were caring about adults. And I was just caring about children. So it was that pyramid of knowledge upside down.

Sabrina Merage Naim
You landed in the country right after this genocide. There were still killings, it was still dangerous. The health care system was broken. You're talking about some very serious corruption in the system, a lack of education among the mass public. What, what was your first thought of "Okay, this is what I'm going to do." And how did you even proceed? You say that there were not really enough doctors. My guess is, were there even any female doctors at all? I would love to hear that. And I'm wondering if there were, what was the path like for women in the medical profession? And then what did you do with your knowledge of this mass corruption in the system?

Dr. Agnes Binagwaho
So there were some woman, but there were very few doctors. But anyway, there were some women. And so that's me after 1994, the system had to be revised totally. But that took years for the leadership to do that. Especially because during the first years, the leadership was busy keeping us safe. So those structural and legal changes came slowly by slowly, but they came and they were worked on. And what I decided to do, I just said people are not well trained, it's not their fault. Let's see how we can transfer skills, what teachers and clinicians can transfer skills, and also helping the Ministry of Health to help catch up with the good standards of work, changing etiquette. It was everything that was done, but we were quite a number who wanted to do that.

Kassia Binkowski
What was your position at that time? I mean, was that amount of responsibility kind of part of what you came back to step into? Was that a product of you came back as a pediatrician and you just saw that there was more that needed to be done? What was your role at that time when you first came back?

Dr. Agnes Binagwaho
I was a pediatrician. I was a pediatrician in the biggest hospital, which is still the biggest hospital of the country. And I was working there and teaching, teaching from there. Teaching nurses, other the professionals, and helping structure the wards. So no, I was a pediatrician like I like to be.

Sabrina Merage Naim
And then from there, you worked your way into so many different areas and eventually became the Minister of Health. You tackled resource constraints, infrastructure limitations, corruption, so much more. What were some of the main barriers of resistance that you have been faced with in rebuilding Rwanda's healthcare system?

Dr. Agnes Binagwaho
So the barrier we faced in the beginning was urgency and urgency with people who were not trained enough to understand what we wanted. That's mean it's a cultural shock for both sides. You give care like this, because you always have been giving care like that. And you have someone just come and say, "No way," etc. So this was the first barrier to help them understand what you want to achieve. The second barrier - I was not speaking the national language and even the national behavior. And I was a very impatient lady, now I behave because I'm a grandma, and I'm supposed to behave, and I'm old. But at that time, I was really impatient and made the world know that I wasn't patient. And it was a barrier. People didn't necessarily understand what I wanted. It's like you come into a community, because I was coming from outside and I have the nationality, but I was a total outsider. And the connection, you know, and the impatience I had.

Sabrina Merage Naim
What was the challenge in educating your patients or the parents have your patients, when you say that some days, you would spend all day saving a baby's life, and then the next day, the baby would die, because they just did not have the knowledge or understanding of care? How would you tackle that?

Dr. Agnes Binagwaho
Badly. Very badly, but I had also to understand that when you are not taught you don't know. And the only way to change that is education. Because people were not bad, they were just not knowledgeable. People had better equipment and drugs coming, but they were not taught how to use it. And that's also something we link to the history of the health sector in Rwanda, they were as much a victim of bad education.

Kassia Binkowski
As a woman, and as an outsider, were you taken seriously right away? Was there some credibility that you had to build up? Or what pushback and treatment did you receive stepping into that role?

Dr. Agnes Binagwaho
I got credibility quickly because of results. People were dying less when they came to me. Okay, so this is also something I learned - a woman has to do more effort than men to be credible. Women have to have more success than men to be considered. So you need to be excellent in what you do, if you want to have a place at the table to talk. And that's what I had the chance to do. And the chance I had was the education I had and the willingness to share it. So that was not an issue. Now socially, of course, my attitude was non-culturally adopted attitude. And I decided that I didn't care because I wanted to be myself. And if I try to behave if I wil at a certain point forget. And so why do that? As much as I'm sincere, and honest, it was some times seen like absolutely a very strange attitude.

Sabrina Merage Naim
I just want to acknowledge how unusual and important this is because women around the world are told to fit into a mold, are told to behave a certain way, are told to come to the table, you know, as good little girls. And for you it was literally a life and death behavior for your patients. If you did not come with this "I don't care about your ____" attitude. I don't care about your corruption. I don't care about making enemies. I don't care about any of that. I care about building a system for the safety and welfare of the people of this country. If you did not push through, then many, many more people would be dead because of it. And you came to the table with a certain amount of force that maybe people were not accustomed to, but it saved lives.

Dr. Agnes Binagwaho
Yeah. And that was my objective. Also, it was against my values to just give up, because there is a life there. You can't. No, you can't. So yeah, I decided to be who I am. In any case, life would be so sad when you are not who you are. A good person - that's the only thing you have to do, to fit in. But for the rest, just be yourself.

Kassia Binkowski
Where did that personality trait come from? I mean, were there role models that you looked up to? Was it something that your parents instilled in you? Where did that come from?

Dr. Agnes Binagwaho
My oldest memory is my first week at class in Belgium. And I tell the story so often that I believe, you know? I was so proud because I loved school, I was so proud to explore that I received the books to learn to read. And we received an origin book with a lot of pictures. And in that picture all the angels were white. And there is only one black person, which was an ugly devil. So I didn't understand. And I raised my hand and I asked, "Tell me why there is no black people in paradise?" Because you know, there were pictures of paradise with God, white God, white angel, white people. And I say, "Oh!" and you know, what was the answer? I was punished for being impolite. I was sent to the corner in front of all the class. And I didn't understand why. Because I didn't know even if there were not many black people in Belgium. So I didn't understand it was an origin school with nuns. The person who did that was a nun. So I just went to the corner. And I just say, I did nothing wrong, this person is wrong. I can sit and do nothing, but I swear something - I will always try to find a truth. If I have to go to the corner 10 times, I would go to the corner 10 times. So after that, I learn where it came from. And I learned also that they that even if she used her power to put me in the corner, she was afraid about something I didn't get. And for me that I did, you know, they were the old powerful people who just know everything about the world. I was seven and totally naive. So that, I guess, was the best thing that happened to me.

Sabrina Merage Naim
You know, you're talking about something that happened to you, when you were so young that even then you knew that you were right. You're talking about representation, that representation matters, it matters to you to see yourself reflected back from photos, TV movies, to know that you are not alone in the world. And we've been talking to a lot of women who have been through similar situations where they don't feel like they're being properly represented or that their values are being heard. And they were seen as renegades, or you are seen as being insolent as a little girl. And then eventually community and the culture catches up, you know, and recognizes that no, you were right. Even back then you were right. And you had to just be quiet about it. But you made yourself a promise that probably changed your entire life trajectory and has changed others. So I'm curious as to how you now have communicated that to your kids to ensure that the next generation stands up in the same way that you did as a child. And carries those values forward.

Dr. Agnes Binagwaho
I think you educate as much by what you do, as what you say. And I hope I have transmitted that to my two girls. But moreover, to the students we have at the university, and to the people we interact on day to day basis. Because every interaction is a teaching receiving action. So when you talk about representation, and when I was seven it's just that I didn't understand why they were not people like my mom and my dad in the paradise. You know, we're good people. So I didn't phrase it in my head, as I need to be represented. I just said there's something wrong there. They forgot a big bunch of the world that was my world. But afterwards, even now, the big movement out there, it's about that. Black lives matter - it's about having the same rights, having the same right to live, to life, to be represented, and not to be killed, just because you're black and you pass by. So yeah, this passed through color, but it passed through anything. And I think it's a classical question all along the life of anytime homosapiens exist. And it's called equity.

Kassia Binkowski
So let's talk about equity for a second because you have worked alongside Paul Farmer, Partners in Health, you're co-founder of the University of Global Health Equity in Rwanda, which is doing incredible things for health education. What is the role of gender equity, specifically in healthcare delivery?

Dr. Agnes Binagwaho
So it's everywhere. It's among patients, because I want to tell you, that women don't hav the same attention than men have. In everything, even in research. Do you know that the medicine - except hormone and contraceptives - but the medicine you take for your heart are tested on average, on white young men, because they don't have menstruation. They're not going to feel pregnant, blah, blah, blah. So we swallow drugs that are made up for men. So even in research, in ordinary health, we don't have an equity approach. Now, if you look, access to education, in a big portion of the world, access to scientific education is not the same. Not that parents say don't go there, but they just say "Hmmm, at which age will be will you be married? You know, it's not good to have children too late. Oh, at that age, no man will want you." Blah, blah, blah. So by cultural pressure and, and community pressure, women don't go into long studies like medical education. And after that, doctors have night duty. To go out etc at night, your family needs you. So so there is a lot of barriers in health, starting with education, continuing with service delivery, continuing with the profile of the workers. But just to tell you that even there, there is no equity. The majority of the people who are studying global health are women. How do they make only 25% of leadership position? And it's not because they are not brighter. It's just because they are women.

Kassia Binkowski
What are you trying to do? What is the university doing? What that next push look like in your career? I mean, you've already transformed the Rwandan health system. You know, you've achieved some of the highest rates of pediatric vaccination anywhere in the world. So your work on the system's level has clearly had a tremendous impact. So now looking at at gender equity and leadership roles now looking at education, what are your goals going forward?

Dr. Agnes Binagwaho
Educate more women. To have social justice, you need to be inequitable. To fill the gap for the medical education, we take seven girls for three boys. So we take all the best that are there up to the time we have our class filled. So that's mean, purposely recruiting students to have 70% of the brightest girls and 30% of the brightest boys.

Sabrina Merage Naim
But you're saying that even though women make up the majority now of that system in education -

Dr. Agnes Binagwaho
In our university.

Sabrina Merage Naim
Yes, in your university, the majority is women, but they are still not getting the jobs. So how are you educating the men?

Dr. Agnes Binagwaho
Our medical education is new, we are recruiting the second cohort 70% of girls again. So they will find jobs, because we will give them the advocacy tool to not remain quiet, and to be self confident. There is also a cultural bias that women are not born with, but that growing with given by education, who put us behind the scene. And we are educating our students to refuse that track. Decently, don't do a revolution. Don't put things upside down, but don't let it go.

Sabrina Merage Naim
How do you stay optimistic when the stakes are so high and when the barriers are so great?

Dr. Agnes Binagwaho
You know, if you look at the story of Rwanda - 1995 or 1996 - you talk about Rwanda to somebody and they say "Oh that country's future is so bad. Oh, that country don't even invest a minute in it." Look where we are now. Bright, shining country.

Kassia Binkowski
What is your wish for your daughters? What is your wish for the next generation of girls growing up in Rwanda?

Dr. Agnes Binagwaho
I wish that the spirit of service remains. Because this beautiful country has been built on the back of the spirit of service. The first people who came back and worked here were paid with beans, rice and no money. And I think I came back here my salary was $75a month, coming from France where I had a full salary well paid. And trust the future. All this would not have been possible if you didn't say "Ok, let's let's give a try," like I did. I came in said I was sure I was a good fail, because nothing was working. I was putting the salary, the cost of the house, the cost of education for the children and there was such a big gap and we decided what to do. "Okay, let's do private practice after work." So there is all ways something you can do. Trust the future. Because if you are at service and you do something good it's not dramatic to fail. But it's dramatic not to try.

Sabrina Merage Naim
Breaking Glass is of production of Evoke Media. Evoke is a nonprofit organization that exists in order to elevate the people and stories that are working to make the world a more unified and equitable place. Learn more at weareevokemedia.com