What a shocking difference a few feet makes. On the Rwandan side of the crossing, the roads are tidy, neat, maintained. The earth is red and the wind blowing through the trees, the lapping of the shores of Lake Kivu, is serene. There is a sense of order even within the clear poverty; I feel the purposeful attempt at self-improvement, through agriculture and the tiny, colorful flower gardens.

After passing a few ramshackle villas at the border, Goma opens up as a relentless, vast dusty slum. There is rubble, garbage, filth, people covered in muck and grime, buildings that are nothing more than lean-to shanties. The earth is gray, drab, choking with dust, visibility limited by dust – the result of lava flow from a nearby volcano. In our clinic, the back wall is thin – made of mismatched boards roughly nailed together. The padlock surely indicates someone’s sense of humor. The director of the clinic does a good job of keeping the space tidy, but it’s hard. Even here where women gather for family planning and maternal/child health information, to give birth and for gynecological care, there are patches of rubbish.

I sat with the director and we talked shop. He has a routine of in-home visits to generate interest in family planning (birth control, birth spacing, pre- and post-natal care). He has office hours around these topics Monday through Saturday, and the hours are painted on a rough white stucco wall in a sweet shade of blue paint. He reports that 20 to 25 new women present each month to access services. Though this number sounds small, he says it represents significant cultural change; men want their women to produce as many babies as possible. Women are for breeding. For them to begin seeking fertility regulation is big news. In terms of options, injectable birth control is most in demand. There is a misconception that IUDs make one sick, so he is dealing with that one woman at a time. The Pill, he said, is terrible, as compliance is very erratic and the water with which they take it is infested with parasites, fecal matter, et cetera. The babies he delivers are often premature and the infant mortality is of the highest in the world. He treats women who are victims of sexual violence daily. Children are common, little girls four, six years old – normal, every-day occurrences, including gang rape. They suffer traumatic fistula rupture and more. They become HIV-positive. They become outcasts.

When I asked about where this pervasive practice of rape comes from, and if it was cultural, he said it was not cultural to begin with. He repeatedly said it is a weapon of war, and that there has been armed conflict for so long, it has become the cultural norm the way political instability is their norm. Now, it is all that generations know.

I asked him whether he believes the Congo is fit to receive international aid; can donors trust the money gets to his clinic and others, will the products and services reach the people? He said if money can come to la base, (the base), then it will benefit the base. We discussed at length accountability and transparency, and some good movement on the government’s part in creating a parliament and other bodies that will get the money to the neediest quickest. They need the money as sorely as anywhere I ever visited. I am straining to convey the urgency of the need here.

The stench of Goma is putrid. There is no sanitation. The water is unsafe. The rooms of the next two clinics I visited were stuffed with people who were malarial. Although children under five (undeveloped immune systems) and pregnant women (taxed immunity) are most at risk, here in Goma there were patients of all ages. They looked miserable, their bodies sagging, eyelids heavy, hopeless.