What lessons can foreign aid take from post-genocide Burundi? This is not the question that Tracy Kidder’s Pulitzer Prize-winning book asks, but within the narrative of “Strength in What Remains” there are important lessons in development effectiveness. The hero, Tutsi medical student Deogratias (Deo), survives the genocides of 1993, and then homelessness and isolation in New York City. For Deo, a recovery from the trauma of his past has meant the unrelenting pursuit of his childhood mission to build a village medical clinic in regional Burundi. His story is riveting and profoundly moving – and the success of the clinic (Village Health Works) and is among its most rewarding aspects.
Though haunted by nightmares and sleeping rough in New York City, Deo meets a number of kind strangers who give him shelter, encouragement, and access to what he says will heal him most – books. Eventually he gains entry to pre-medical studies at Columbia University, no less, and later enrolls at the Harvard School of Public Heath. His recovery is a long and wrenching process.
Kidder’s attempts to render Deo’s journey accessible to the reader make for difficult though compelling reading. He is a witness, and his own voice in the narrative helps the reader not to turn away. Kidder admits that he cannot follow Deo emotionally into the “place beyond horror” that Deo must return to as he confronts his past, and in this sense we are at least partly relieved of that journey.
Perhaps the most harrowing scenes in the book describe the memories Deo carries of what he saw and heard as he escaped machete-wielding mobs possessed by an evil of apocalyptic proportions. The description of Deo and Kidder’s visits to numerous massacre memorial sites in Burundi and Rwanda more than a decade after the genocides is also deeply unnerving. Deo is by turns enraged, haunted, and in tears, and tells macabre jokes that Kidder struggles to appreciate. Afraid and full of sorrow, Kidder begins to wonder if there is such a thing as too much remembering.
But Deo has harboured a longstanding childhood ambition, and this will save him. As a boy, Deo watched his best friend Clovis die suddenly of malaria and had prayed for magic to “get his friend back to life”. This prayer stayed with him, and during the successive summers of his high school years, Deo convinced friends to help him make mud bricks for a medical clinic he was determined to build. It would be sixteen years before he succeeded, during which he would survive a massacre within the very teaching hospital he attended as a medical student.
How did Deo succeed where many others have failed, including a European Church-funded clinic nearby? Deo doesn’t need lessons from the OECD’s Development Assistance Committee about sustainability, local ownership, gender and capacity building. He had gained the support of the village early on, through means including continuing efforts to make the bricks for the clinic’s buildings. As his plans gain momentum, Deo creates a separate committee for women when he sees their skill in determining village health and, consequently, clinic priorities (there is no mention of donor sectoral requirements or funding exigencies).
An international infrastructure company tells him it will cost USD50,000 to develop a road critical to accessing the clinic. In response, 166 impoverished Hutu locals donate their labour and tools – mostly shovels, pickaxes and machetes – for the six weeks it takes to widen the road. One works while carrying a feverish baby, who will die because there is no medical care in the village, in the hope that the road will save her next one.
This is not just a village effort. There is significant international expertise involved, but it is of note that the foreign aid links into this village health project are mostly created by Deo himself, with the continuing mentorship of his US mentor Paul Farmer (physician and anthropologist). Deo had tracked Farmer down after reading one of his textbooks on poverty and medicine, and had interned in Rwanda with his NGO Partners in Health. Now Deo’s mentor, Farmer mobilized several NGOs to work together to provide solar-powered electricity, a generator and fuel for the clinic, and to provide computers and a satellite system so the clinic can maintain records. Farmer also negotiated access to inexpensive supplies and medicines, including free HIV and TB drugs, from national and international health authorities. Upon his return to the clinic, Deo brought with him friends from medical school, one of whom would later return to run the clinic on a volunteer basis.
Village Health Works’ success is driven by its core belief in grassroots (that is, led and driven by the community), holistic, results-driven, collaborative, and scalable development. At a time when donor are increasing their focus on development as a tool for promoting national economic and trade interests, Deo’s focus on village-led poverty alleviation, and his successes, make for deeply nourishing reading. Village Health Works has drawn in the best that the international aid community can offer in terms of technical expertise, funding and responsiveness, alongside the commitment, courage and initiative of the villagers themselves. Perhaps the most valuable lesson from Deo’s story for aid practitioners is the power of international aid when it is truly village, rather than donor, led.