Dr. Agnes Binagwaho Is Credited With Turning Rwanda's Health Care Around : Goats and Soda When she was a "little mouse," the Rwandan pediatrician tried to make as much noise as a lion. Now as a global health activist, she's learning to make change "without screaming too much."
NPR logo Agnes Binagwaho Is A Doctor With 'Sassitude'

Agnes Binagwaho Is A Doctor With 'Sassitude'

Dr. Agnes Binagwaho: "When I was a little mouse, I tried to make as much noise as a lion. When I became stronger, I made less noise because the objective was to change. And sometimes to change, you better study and try to do it without screaming too much." Carolyn Rogers/NPR hide caption

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Carolyn Rogers/NPR

Dr. Agnes Binagwaho: "When I was a little mouse, I tried to make as much noise as a lion. When I became stronger, I made less noise because the objective was to change. And sometimes to change, you better study and try to do it without screaming too much."

Carolyn Rogers/NPR

Years before she became the health minister of Rwanda, Agnès Binagwaho tried to lock a fellow pediatrician in a hospital room. She saw a doctor in an examining room with a mother who held her sick daughter in her arms. And he was asleep.

Binagwaho was appalled. She examined the girl herself in a separate room and then asked a nurse to shut the door on the doctor, who wouldn't be able to get out without the nurse's key.

The medical staff wasn't too pleased. "They found me more guilty for trying to close him in that room for the night than him for mistreating the kid who could have died," she says.

Throughout her life, Binagwaho — affectionately called "Dr. Agnès" by colleagues — has been unafraid to defy authority by speaking her mind. In the process, she has helped to transform Rwanda's health system.

In 2015, she was given the $100,000 Roux Prize from the Institute for Health Metrics and Evaluation at the University of Washington, cited for using data to improve the country's health care. When she found that a significant number of Rwandans were dying soon after birth, Binagwaho and her staff invested in equipment and training to bring down the number of neonatal deaths, a campaign that has seen success.

She has used "data to effectively and efficiently overcome Rwanda's health challenges," says Tom Achoki, IHME director of African initiatives.

YouTube

And now she's a movie star as well. Binagwaho appears in the new documentary Bending the Arc, about the groundbreaking methods Partners In Health uses to deliver health care. In the film, she definitely speaks her mind. At a meeting where questions are raised about allocating funds for health care in a poor community, she says bluntly, "People are dying, brother."

"She is both doing the work and holding this utopian goal in mind," says Dr. Paul Farmer, co-founder and chief strategist of Partners In Health, which delivers health services to poor countries, including some of Rwanda's most destitute villages. Farmer met Binagwaho at a U.N. General Assembly meeting on AIDS in 2001 and was immediately impressed by "all her sassitude."

When a man made a sexist remark about Binagwaho during a delegation trip, she wryly informed the laughing crowd that she would prescribe him Viagra.

She also fought to provide Rwandan girls with HPV vaccinations to lower their chances of getting cervical cancer by partnering with American pharmaceutical company Merck. About 93 percent of eligible girls were vaccinated; people in developing countries often wait years for vaccinations available in high-income countries.

"When I was a little mouse, I tried to make as much noise as a lion," she says. "When I became stronger, I made less noise because the objective was to change. And sometimes to change, you better study and try to do it without screaming too much."

Binagwaho was born in Rwanda but her father moved the family to Belgium in 1958, when she was three years old, so that he could attend medical school. A year after they left, Rwanda's "Wind of Destruction" began — clashes between two ethnic groups that resulted in the deaths of thousands of Tutsis.

She says her parents didn't teach her much about Rwandan culture, thinking she would never return. But it didn't matter. "I always believed I was a Rwandan," she says. "I had a sense of belonging but to what, I was searching." She read books written by Rwandans and went to events with fellow Rwandans.

In 1994 while in France, she watched news reports about 800,000 Rwandans who were murdered in 100 days. Two years after the genocide, she returned to the country. Her husband had lost half of his family and wanted to go back. She went — not knowing the national language of Kinyarwanda — and saw people so depressed that they stopped caring about life.

"Everything was destroyed. Even the morale of the people was destroyed. That means there was also no accountability — health professionals were careless and created a lot of damage. But even with the little we had, we could have done better."

Binagwaho's work helped turn the war-torn country around, says Farmer. She insisted that health — physical, mental and social — was a human right for all. That meant reaching people everywhere, regardless of their ethnic group, location or income.

As a pediatrician, she saw children who were orphaned when their parents died of HIV. At the same time, some of her young patients were HIV positive. Rape was widespread during the war, and witnesses later reported that assailants announced their intention to infect women and girls with the virus. She believed in the importance of HIV treatment and prevention.

Binagwaho went on to lead Rwanda's National AIDS Control Commission from 2002 to 2008. During her tenure, she and her team aimed to connect public, private and community sectors to provide better HIV care.

During those years, HIV care improved. According to the U.N., the number of people dying from HIV each year fell from 15,000 to 7,700 — 44 percent in six years. New infections were cut in half.

In 2008, Binagwaho began serving as permanent secretary in the Ministry of Health and was appointed its minister in 2011. To reach the country's poorest, the ministry trained 45,000 people as community health workers, sending them into the homes of people who often don't receive care. It also gave community workers cell phones that allowed patients to contact doctors through Twitter.

By 2010, maternal mortality dropped more than 60 percent from the 1990 figure. Life expectancy rose from 28 years in 1994 to 56 years in 2012. Health insurance coverage is practically universal at more than 90 percent, and the poorest receive free care. Despite being one of the poorest countries in the world, Rwanda has one of the fastest growing economies in Central Africa.

Binagwaho utters a line that feels worn down with use, directed at skeptics who question the validity of spending money on health care in developing countries: "Health is key in development. It increases the GDP of the country. We seem just to spend money, but it's not true. Health equity is a business plan."

Despite her track record, she has faced controversy. In 2016, President Paul Kagame — who is both admired and accused of running a government that silences opposition — relieved her of her duties amid allegations of mismanagement of health resources. She defends her tenure by saying, "I served from 2011 to 2016, longer than any other minister of health in Rwanda and the President decided it was time for a change. I'm proud of what the team I was leading has accomplished."

Binagwaho still lives in Kigali, Rwanda's capital. She's had more than 100 peer-reviewed articles published, including one in BMC Pediatrics on how Rwandan children with HIV often have depression and require better mental health care. She is a senior lecturer at Harvard and an adjunct professor at Dartmouth. And she's counting down the days until she moves north to rural Butaro, where she is buying a plot of land to live near her latest project.

The University of Global Health Equity was dreamed up by Binagwaho, who serves as the university's vice chancellor, and two other humanitarian-physicians, including Paul Farmer and Dr. Peter Drobac. They want to train new generations of health-care workers to provide services in the poorest of communities.

The initial $30 million funding came from the Cummings Foundation and the Bill & Melinda Gates Foundation (which is a funder of NPR). Though the construction of the campus is not yet complete, the university has 46 students. The first 17 graduated with a Master of Science in global health delivery. Each two-year student receives partial financial aid for the $8,250 annual tuition.

The latest batch of applicants come from 29 countries on four continents, according to John Urschel, director of the University's partnership development. Urschel describes them as people "who are desperately looking for an alternative to the traditional idea of global health. These are activists who want to learn how to improve their communities, they want to learn how to marshal political will. They're in the field and they're frustrated with what they see."

Nothing makes Binagwaho angrier than "unnecessary death." She says she has watched too many people in the developing world die of treatable conditions just because they lack access to good health care. "Equity is in the heart," she says. "Meaning you always make sure to include everybody, leave nobody out."

The United States, says Binagwaho, has yet to learn that lesson.

Her fervent desire to help everyone and to prioritize the most vulnerable echoes back to her earlier days as a pediatrician in neonatal care.

"All life is very precious, but the beginning is magic," says the mother of two daughters. "You are a human being and you just come out of water, discover the world and you scream. For the majority of births on Earth, I think, it's a joy, this new life. It's a mission that each human has — protecting life, giving life, continuing life."

Sasha Ingber is a multimedia journalist who has covered science, culture and foreign affairs for such publications as National Geographic, The Washington Post Magazine and Smithsonian. You can contact her @SashaIngber.

Correction Oct. 29, 2017

A previous version of this story incorrectly stated that Agnès Binagwaho was relieved of her duties by President Paul Kagame in 2015. The year was 2016.

The university where Binagwaho serves as vice chancellor was also incorrectly cited as the University of Global Equity. The correct name is the University of Global Health Equity.

In telling the story of locking a doctor in a room, Binagwaho misspoke. It was a nurse who closed the door, not the child who was a patient.