Countries worldwide gauge their success in family planning based on contraceptive prevalence: the percentage of women of reproductive age that use contraception. By the early 1980s, numerous developing countries were conducting contraceptive prevalence surveys (CPS) to measure this indicator. In 1982, USAID agreed to fund a CPS for Zaïre, to be conducted by the National Institute of Statistics and led by a local demographer, Mr. Paul Bakutuvwidi Makani. Westinghouse Applied Health Systems provided technical assistance. Given the vast geographical expanse of the country, the weak transport and communication networks, and the relative inexperience of local personnel in survey research, the decision was made to limit the survey to four cities (Kinshasa, Lubumbashi, Kisangani, and Kananga), plus two rural areas (Vanga and Nkara). Vanga was chosen as the rural health zone with the most advanced primary healthcare services including family planning; Nkara – with no FP services – would serve as a comparison zone.

The survey results showed very low levels of modern contraceptive use among married women: ranging from 2–8% in the four urban areas, 11% in Vanga, and 2% in Nkara. Whereas these levels were comparable to other sub-Saharan francophone countries, they were rock bottom by international standards.129

Figure 5.9 Survey research team in Menkao village, 1988. From right to left: Bakutuvwidi Makani, Mme. Nabintu, Luya N'Lendi, Mbadu Muanda, Kashangi Chiruba, and Amundala Twaforla

The study also yielded evidence of the relatively widespread use of traditional methods. In all four urban areas and both rural areas, the percentage of women using a traditional method (rhythm, abstinence, withdrawal, or a folk method) was two to three times higher than those using a modern method.130 These findings suggested a motivation for preventing pregnancy that was yet to be matched by the use of effective contraceptive methods to achieve that end.

The 1982–84 CPS whet the appetite of donors, program managers, and researchers for a nationally representative survey of contraceptive prevalence. Indeed, several USAID projects stated their objectives in terms of specific levels of modern contraceptive prevalence to be attained. Yet it would be 25 years before the DRC Demographic and Health Survey of 2007–08 would provide nationally representative reliable data on contraceptive use.

#### The Population Census (Recensement scientifique de la population) of 1984

Since independence in 1960, the country had not had a population census. UNFPA worked with the government in preparing the census in Zaïre, and on September 5, 1980, a presidential ordonnance called for the Recensement scientifique de la population (scientific census of the population). To this end, the government created a national census commission. Initially planned for 1982, the data collection was delayed until 1984.131 The work was organized under the Department of Plan, with the National Institute of Statistics responsible for data collection. It was funded by the Conseil exécutif du Zaïre (President's Cabinet), UNFPA, and Great Britain.132

In preparation for the event, local census committees were created in the nine regions of the country, 27 sub-regions, as well as 13 urban committees and 143 rural committees. The National Secretariat for the census divided the country into 28,151 enumeration areas, each with its own enumerator, and 2,896 aires de control (supervisory areas, with one supervisor for every ten enumerators).133

Training in multiple waves ("cascade training") involved the training of trainers, regional and subregional supervisors, subregion supervisors in the municipalities, zone supervisors, and enumerators. Then, between July 1–15, 1984, data collection occurred simultaneously in all enumeration areas.134

A post-enumeration survey was conducted to evaluate the coverage and error rates for the census. The census yielded an estimate of 29,671,407 persons on July 1, 1984. The results were published in December 1984.135

The only primary data that survived from the 1984 census were the questionnaires, which quickly deteriorated under poorly archived conditions.136 To preserve these data, the Demographic and Statistical Observatory of the Francophone Area (ODSEF) successfully digitized these questionnaires in 2012–13. The database for the 10% sample disappeared.

What makes this census remarkable is that no census has taken place in the country since 1984. Current estimates of population size by province still must be based on extrapolations from the 1984 census, combined with data from surveys, including the Multiple Indicator Cluster Surveys (1995 and 2001) and the Demographic and Health Surveys (2007 and 2013–14). Vital statistics, used in other countries as complementary data sources for demographic projections and prospects, are not of sufficient quality for this purpose in the DRC.137

One might assume that the government would be eager for a new census to obtain updated estimates of the size and distribution of the population, which has undoubtedly shifted over the decades since the 1980s. Instead, there seems to be a strong aversion to conducting another census, not only because of the financial and logistical challenges but more importantly, the political implications of having exact numbers that could bring into question the allocation of resources. For one, it might change the number of seats allocated to different provinces in the parliament. In a country where population size is equated with strength and power, some within the government prefer to have softer "estimates" that can be manipulated to fit their political purposes.

#### Attitudes toward limitation of births

The mantra for family planning in Zaïre since its inception was Naissances Désirables, with an emphasis on birth spacing. Some Western population experts conjectured that if couples began to space, there might be a gradual transition to birth limitation (smaller families). To this end, a number of Zairian physicians were trained in tubal ligation, abroad or in Zaïre, to ensure that tubal ligation (and in some cases vasectomy) would be available as part of the method mix. Yet few women opted for this practice as an elective means of pregnancy prevention. Rather, the few who had the procedure did so out of medical necessity.

In 1987, the Operations Research Unit at the PSND conducted a study to better understand community norms around permanent methods of contraception. Since vasectomy was virtually unknown (except in one or two church hospitals) and presumed unthinkable in this society, the study focused instead on tubal ligation for women. Focus groups among men and women (separately) were carried out in the local language in five different Zairian regions, in addition to a survey among women who had undergone the operation. The following excerpts from this research reflect the deep-seated aversion to birth limitation.138

The ability to have a child was so closely linked to manhood and womanhood that most considered it out of the question to voluntarily do away with that potential. Even if one thought they had all the children they wanted, one never knew what the future would bring and if one day they would want or need to have another child. As one male participant explained, "Both families aspire to numerous progeniture. If we decided on tubal ligation, my wife's family could interpret that I didn't love my wife and was looking for a way to have children outside of marriage… My own family would be tempted to believe that I am contaminated by my wife and that she is the one who commands in the household."

Economic hardship was not reason enough to limit the number of children one would have. Couples should be willing to make economic sacrifices for the sake of expanding their clan. It would be selfish to hold back on having children for monetary reasons. As one man explained, "The high cost of living can in no way cause a couple to limit their births. Whoever would yield to the program of tubal ligation is incapable of taking responsibility, because our parents who had fewer resources than we do managed to raise us relatively well."

Even the women who underwent sterilization and were satisfied with their operation felt it should be done for medical reasons only. As one woman said, "If I knew of someone who was sick all during her pregnancies or had a problem delivering, I would recommend that she have the operation since she risks dying and leaving her children behind… But if she tells me that her husband is unemployed, that they don't have a house, that they are incapable of taking care of their children, then I could not recommend it."

Having a tubal ligation would result in marital conflict. "The woman's role within the marriage is to produce children, and a deliberate cessation of this could result in loss of the husband's affection or dissolution of the marriage." One man explained, "It is very difficult for a sterilized woman to be a respected wife since she can't have children anymore."

One woman who had undergone tubal ligation recounted the consequences. "In my case, all our neighborhood made fun of me when they learned I'd had a tubal ligation, more so because my husband took another woman to give him children, even though he'd agreed to my operation because of the difficulties I had in giving birth. Sometime after the operation he took another woman without warning me or even telling me. I have even heard my friends say that it's good, that I was too proud. Now my co-wife has become their friend. But I say let them mock me. My five children are enough for me."

These stories speak volumes about the norms and beliefs that prevailed across the country in the 1980s, as family planning programming was beginning to expand in both urban and rural areas. Rare was the woman or her husband who wanted to definitively cease childbearing. Societal approval for spacing remained widespread, but few were ready yet to voluntarily put an end to their ability to produce a child.

#### Reflections on the 1980s

At a time when USAID/Washington wished to shift population funding toward Africa, Zaïre offered an interesting opportunity. Despite Mobutu's despotic rule of the country, Zaïre was an ally of the United States, thanks to the Cold War.

Given the size of the country and its high levels of maternal and infant mortality, family planning could make a sizable contribution to the development of the country and to improving the lives of women and families. Despite the strong pronatalist societal norms, by the late 1970s, AZBEF and the ECZ had demonstrated an opening to family planning programming.

Through the 1980s, USAID/Zaïre stepped up to address this challenge with funding to three major initiatives that would increase access to contraception: PSND, SANRU, and the Zaïre Social Marketing Project. To this end, it channeled funding through three different mechanisms: the Ministry of Health, a faith-based organization (ECZ/SANRU), and the private sector (the Social Marketing Project), respectively.

Centrally funded projects brought additional technical assistance and resources that advanced family planning programming across a wide range of specialized areas: training in service delivery including permanent methods, program management, population policy, private sector initiatives, behavior change communication, and operations research, among others.

The obstacles were colossal. Politically, birth spacing was not a priority in a country overridden by high levels of malnutrition and every infectious disease imaginable. Logistically, the country struggled with the absence of passable roads, a reliable national airline, a postal system, and telecommunications. Managerially, public sector health programs lacked trained staff, functioning systems, and a culture of accountability. Culturally, large families were the societal norm and children were widely considered a source of wealth.

Against this backdrop, numerous Congolese and their American counterparts worked to develop a system of family planning service provision for both urban and rural areas. USAID provided ample financial resources to drive these three initiatives to expand and flourish. Of the three main projects – PSND, SANRU, and the Zaïre Social Marketing Project – PSND was the flagship for family planning, intended to improve the acceptance of birth spacing and increase contraceptive prevalence in urban areas across the country. Its greatest achievement was to establish a network of some 140 family planning units in 14 cities across the country, thus increasing the availability of services in these locations. Yet, for multiple reasons – managerial shortcomings, logistical hurdles, and societal norms – the work of the PSND did not result in an appreciable increase in contraceptive use. By contrast, both SANRU and the Zaïre Social Marketing Project were judged to be model projects that achieved their respective objectives, despite the challenging environment of the DRC. SANRU developed an extremely effective mechanism for supporting rural health zones across the country in delivering primary healthcare, but family planning – while part of the package – was not a priority. The Zaïre Social Marketing Project excelled in creating demand and selling large quantities of condoms and one spermicide in urban and peri-urban areas, but its main focus was HIV/AIDS prevention, not family planning. In short, both contributed to family planning but less directly than was expected of the PSND.

Despite the extensive family planning initiatives in the 1980s, contraceptive prevalence had yet to increase. By the end of the decade, MCPR was still estimated at 2%.139

Unquestionably, these three major projects, supplemented by the operations research under PRODEF and the Kananga Project, created an awareness of birth spacing and contraceptive technology that far exceeded what had existed even ten years earlier. In the span of a decade, this portfolio of projects produced a very solid foundation for the future development of family planning demand creation and service delivery. Had the country evolved to become more politically viable and economically stable, the foundation established in the 1980s could have been the springboard for an impressive national program in the 1990s. But it was not to be.

#### Notes

### 6 The 1990s

### Development Work Paralyzed by Pillages and War

#### Family planning is well-positioned to build on the progress of the 1980s

The 1990s started with considerable promise for family planning. USAID funded PSND (Desirable Births Services Project), the largest project of its kind in francophone sub-Saharan Africa, was hitting its stride. Over 100 Unités de planification familiale were operating in 14 cities around the country. SANRU (Basic Rural Health Project), heralded as an effective model for delivering primary healthcare services, including family planning, to rural health zones, now operated in 100 of the 306 health zones in the country. AZBEF (The Zaïre Association for Family Welfare) had coordination offices in four provinces. The USAID-funded operations research project in Kananga showed a measurable increase in modern contraceptive use in response to targeted interventions. Many large private companies (such as the mining giant Gécamines) had incorporated family planning into their employee health services. USAID remained by far the largest donor for family planning, though UNFPA (United Nations Population Fund) and IPPF (International Planned Parenthood Foundation) contributed additional funding.

The Zaïre Contraceptive Social Marketing Project was delivering impressive results in selling condoms and spermicides.1 The project had expanded to 44 cities and nearly 1,500 outlets. The urgency of the AIDS epidemic reduced barriers to explicitly promoting condoms through the media.2 Whereas government officials and religious leaders had been moralistically opposed to exposing young people to contraception, in the face of the AIDS epidemic they were now desperate to keep their young people alive through condom use.

Because of the success of the Social Marketing Project, PSI's (Population Services International) visibility had skyrocketed.3 Dr. Michael Mersen, then Director of the WHO's (World Health Organization) Global Program on AIDS, stayed over an extra day in Kinshasa after the 1990 International Conference on AIDS and Sexually Transmitted Diseases in Africa, to visit the PSI Social Marketing Project. This visit reportedly played a role in convincing WHO, which traditionally favored aid to governments, of the potential of channeling support through the private sector.

DOI: 10.4324/9781032718897-8

#### 146 The Fifty Years of Family Planning

By the early 1990s, the ministry of health (MOH) was pressuring PSI to spin off a local social marketing entity, ostensibly to ensure the sustainability of this initiative in future years.4 One project insider explained it otherwise. The non-profit sale of condoms was mind-boggling to MOH counterparts. Clearly, someone was making a lot of money, judging from the affluent lifestyles of the expat staff on the project. The MOH had authorized PSI's work in the country but felt they were due their cut. One day, the MOH sent a car to pick up a PSI staff member for a meeting at the MOH; only half-jokingly, he added, "Bring the PSI checkbook." Because a formal agreement protected PSI's work, the project staff continued to operate – deflecting these requests for a cut in the proceeds.

To further bolster the work of the PSND, USAID/Zaïre brought in the Population Council to work with Mme. Chirwisa and other PSND staff in two areas: management systems and operations research. This contract was part of a larger centrally funded regional project known as Operations Research and Technical Assistance (OR/TA) for family planning. In 1990, the Population Council established its presence at PSND by setting up a management support unit, run by Mr. Hervé Ludovic de Lys and assisted by Dr. Mamadou Diallo. It also provided technical and financial support to the operations research division5 (upgraded from a "unit"), directed by Mr. Mbadu Muanda, who had worked with Jane Bertrand as a supervisor on several Tulane studies. Hervé's vision was to conduct operations research from a management perspective – to show what worked and what did not, for the purpose of scaling up effective approaches.

#### Box 6.1 Having friends in high places

One strong advocate for family planning was Mr. Charles Johnson, the USAID/Zaïre director. Mr. Bitshi Mukengeshayi, then Chef de supervision at PSND, tells the story of Johnson's visit in 1990. "How many family planning outlets does PSND currently have in Kinshasa?" Johnson asked.

Mr. Bitshi answered, "110."

"And how many could you scale up to operate, if you had additional funding?"

Without missing a beat, Bitshi answered, "160."

Within days, the wheels were set in motion for additional funding to PSND. On a follow-up visit several months later, Johnson was astonished that PSND had scaled up to 160 units so quickly. What Bitshi had not mentioned at the time was the recent termination of the Enterprise project that had assisted private companies to incorporate family planning into the legally mandated health services for employees. Many of these enterprises had already come to PSND, asking for help with training, equipment to insert IUDs, and contraceptives. With extra funds from USAID, PSND was able to incorporate these outlets into its program in record time.

During another of their meetings, Johnson advised Bitshi to give large quantities of contraceptives to the different facilities. Bitshi argued against this idea, citing the possibility of loss or theft. Mr. Johnson replied, "Is someone going to steal something they don't use? Go ahead and give it to them."

It is historical serendipity that four surprisingly detailed accounts exist of the status of the national family planning program as of 1990–91. Consistent with its procedures for large development projects, USAID/Zaïre commissioned an evaluation of the Zaïre Family Planning Services Project – covering both PSND and the Zaïre Social Marketing Project – conducted in October–November 1990. At roughly the same time, the Regional Inspector General's (RIG) office in Dakar, Senegal, carried out an audit of the project from September–December 1990. Independently, the PSND, with technical support from the Population Council, collected data for a Situation Analysis of family planning nationwide in July 1991, providing a detailed snapshot of service provision at the start of the 1990s. In preparation for the extension of the SANRU project, USAID consultants produced a "Project Identification Document" (PID) for the Zaïre Integrated Family Health Project, with rich details about family planning services. In retrospect, the timing of these assessments was eerily prescient, for they captured the family planning landscape in Zaïre before the country would be upended in late 1991.

The first of these assessments – the 1991 evaluation of the Zaïre Family Planning Services Project – analyzed the project's technical accomplishments, institutional arrangements, and management practices for both PSND and the Zaïre Contraceptive Social Marketing Project. The three-person evaluation team reviewed project documents, interviewed key informants, and conducted field visits to project sites.6

The results of the PSND evaluation were mixed. On the positive side, PSND had exceeded expectations in establishing family planning units: 140 in total (by the count of the evaluators), compared to the target of 125. The project had some staff who were well-trained and highly qualified. Two of three regional training centers were operational and had trained large numbers of providers. Financial accountability had improved. And a population policy has been crafted and approved by CONAPO.7

Yet the 1991 evaluation was critical on numerous points. Some of the 140 family planning (FP) units were not functioning or inadequately supplied. The report described the planning process as "ad hoc and top-down." Service providers outside of Kinshasa had no role in setting objectives and were not aware of their existence. PSND's organization of human resources was headquarters-heavy rather than fieldoriented. The number of divisions and bureaus within PSND had proliferated, and the staff had grown from 41 to 89 between 1984 and 1990. The evaluators recommended that "USAID and the major actors in family planning needed to clarify the goals and speci 8 fic objectives of US family planning assistance in Zaïre."

The second assessment – the RIG audit – aimed to determine whether USAID/Zaïre planned, implemented, and monitored the project's inputs as

#### 148 The Fifty Years of Family Planning

required by USAID policy.9 In effect, it was evaluating USAID's performance in ensuring that the project correctly accounted for funds, appropriately planned for contraceptive procurement, monitored the work of technical experts hired to assist the PSND, oversaw training activities, and monitored the government of Zaïre's (GOZ) contribution of counterpart funds as specified in the original agreement. By definition, the audit was far more focused on financial and logistical management than on programmatic accomplishments.

The RIG audit concluded that "While contraceptive social marketing has achieved considerable success in attaining and in some cases exceeding its goals, PSND has been largely ineffective in expanding family planning services in government and private employers' healthcare programs." Part of the report dealt with bureaucratic procedures within USAID/Zaïre, whereas other issues were laid squarely at the feet of PSND: the inability to track service statistics from the clinics in its network; unauthorized use of project vehicles for non-project purposes; failure to act on the advice of the management support unit set up specifically for this purpose. Finally, the audit criticized USAID/Zaïre for inadequately monitoring the government's contribution of counterpart funds to the project.

Charles Johnson, the Director of USAID/Zaïre, fired back at the RIG with an 18-page cable, acknowledging "several accurate criticisms," but rebutting multiple findings from the preliminary report and making several insightful comments.

The third assessment – a Situation Analysis Study of family planning – was conducted in July 1991 by the PSND and the Population Council's OR/TA project. Based on a standard methodology used in multiple African countries, the study provided data on 108 family planning service delivery facilities countrywide.11 Over half, 52%, were supported by PSND, 35% by SANRU, and 13% by AZBEF. The study revealed low levels of family planning activity. The median number of new and continuing clients seen per facility per week was 7.5, less than one client every two working days of the month. PSND facilities saw the highest number of clients per week (16.4 on average), compared to SANRU facilities with the lowest (2.7). These averages masked the fact that a handful of facilities served the vast majority of clients. Quality of care was also an issue: many facilities lacked the equipment necessary to provide quality family planning services and over a third (37%) had not received a supervisory visit in the past six months. The study concluded that PSND would need to address these shortcomings "once political conditions allow it." Unbeknownst to the researchers, that would take another two decades.12

The fourth document, the Zaïre Integrated Family Health Project PID, described family planning in the larger context of primary healthcare and provided valuable insights into the dynamics surrounding this subject. The PID labeled family planning as the "weakest link in Zaïre's primary healthcare program" and foreshadowed the increased emphasis that USAID planned to give to family planning in the follow-on project. Among other background information, it summarized the obstacles facing family planning:

"In Zaïre, major constraints to family planning program implementation stem from the cultural ideologies of many of the political elite and the large proportion of the population. The tendency to view population efforts as a diversion from fundamental structural changes; hostility to all policies affecting change in women's traditional roles; religious opposition to family planning; competing claims by government ministries over the allocation of scant resources; and the lack of motivation and skills needed to effectively implement programs impede advancement. Arguments based on the fact that Zaïre has vast uninhabited tracts of land coupled with the overall low population density continued to fuel pronatalist beliefs. 13 "

The 1991 evaluation and the 1991 audit by the RIG had consequences. Mme. Chirwisa was relieved of her post.14

By late 1990, relations between USAID and Mme. Chirwisa had begun to fray. Chirwisa realized she was in hot water but described it in more political terms. Her deputy director was a close relative of the minister of health, and she claimed that the minister wanted "one of his own" in her position.  One day, a large group came from the MOH to announce that she should leave the PSND. They expected she would resist, but instead she responded, "There is no problem." She signed her mise et reprise (resignation) and exited without fanfare. They were stunned, including the director of the cabinet. As Chirwisa tells it, the onsite search for money began immediately. Mr. Ngoie Mubeya Fidel was named PSND director.

In retrospect, Mme. Chirwisa Chirhamolekwa did a remarkable job spearheading the introduction of family planning into a geographically vast, predominantly Catholic pronatalist country, where the talent pool included few strong managers, and the principles of accountability were foreign. Rick Thornton had been right; she had the grit to steer through these troubled waters. USAID/Zaïre had chosen her specifically because she was an experienced operator within the GOZ system. Yet they had not anticipated her need to remain loyal to the political hierarchy, right up to President Mobutu, whom she knew personally. USAID undoubtedly expected that their multi-million-dollar investment in the PSND would garner a certain loyalty from the chief executive, and Chirwisa initially followed USAID directives closely, working in collaboration with the expat advisers housed at PSND. Yet as Chirwisa became more established in her post, she felt less compelled to heed the advice of the technical experts that USAID had hired to assist PSND in achieving its objectives. This tendency became particularly clear when USAID contracted the Population Council to create a management support unit within PSND, headed by Hervé Ludovic de Lys. The 1991 evaluation gave the unit high marks for its efforts to improve financial and administrative systems within the organization. But it cited Chirwisa's frequent disregard of these advisers.15

Hervé – who was also advising the CECAP (Cellule d'Etudes et d'Accompagnement des Activités de Population) of the Ministry of Plan – remembers the day that his Zairian counterpart at CECAP called him into his office. "You are trying to address certain management issues at PSND, but there are 100 people who are pulling in the other direction. And guess who is going to win?" Thirty years later – with experience in other turbulent environments (Mali, Côte d'Ivoire, Venezuela, and Afghanistan), he offered piercing insights into the situation at PSND. "Chirwisa had good intentions but little margin to maneuver as she struggled to reconcile the efficient resource management for family planning service delivery with the higher political motives of the ruling party (Mouvement Populaire de la Révolution)." As director, Chirwisa complied with most USAID directives. But to survive in the government system, her first loyalty had to remain to the political power structure. (Several high-ranking physicians working in HIV/AIDS allegedly lost their lives for disrespecting the demands of the hierarchy.) Within those circles, her power came not from increasing contraceptive use in the country (the objective of USAID), but from adhering to the party line and sharing resources (e.g., the occasional loan of vehicles) if asked. When the advice from technical experts provided by USAID did not align with her priorities, she followed her instincts. USAID/Zaïre had chosen her because of her tenacious management style, but they had not reckoned with her role within the larger political apparatus.

Thanks to PSND, SANRU, the Social Marketing Project, and AZBEF, by the early 1990s the Zairian population was far more knowledgeable about contraception and had far better access to family planning services than a decade earlier. Consistent with the vision of USAID to establish a national family planning program, tremendous strides had been made and technical capacity strengthened to put contraception within reach of potential users in many urban and rural areas.

Yet the adage "build it and they will come" did not apply to family planning in the early 1990s. Demand for modern contraception for birth spacing – much less birth limitation – remained low. Anecdotes abound about the cases of women with eight or ten children, desperate to put an end to childbearing. Yet for the majority, the deep-seated norms and practical realities still favored having large families. Too many obstacles remained: fear of side effects, husband's opposition, community disapproval, religious beliefs, costs, and lack of knowledge about contraceptives and where to get them. Ironically, the felt need for contraception was most apparent later in the decade when obtaining contraceptives, even in Kinshasa, became all but impossible.

#### Mobutu faces increasing opposition with fast-dwindling support from the West

The 1990s started poorly for President Mobutu. With the fall of the Berlin Wall in 1989 and the dissolution of the Soviet Union in 1991, the Cold War was over. The West no longer needed Mobutu as a counterweight to countries with Communist sympathies.16

Five months into the new decade, trouble was brewing on the campus of the University of Lubumbashi, the second-largest city located in the wealthiest province, Shaba. Students were protesting for larger study grants, better conditions, and Mobutu's resignation. To quell the unrest, on May 11, 1990, a squad of Mobutu's elite commandos – Les Hiboux (the Owls) –descended on the campus and massacred at least 50 students.17 A US official would later comment, "the security forces which used to be the glue that held Zaïre together are now themselves the cause of deepening instability. 18 "

In response to this brutal incident the European Community (now European Union, EU), the United States, and Canada suspended non-humanitarian aid to Zaïre. Western support for Mobutu's regime was nearing its end.19 An already tense political climate became more incendiary, as actors in all sectors feared what might come next.20

After 25 years of tolerating Mobutu's abuses of power, violations of human rights, and pilfering of the country's mineral resources, the international community pressured Mobutu toward a more democratic approach to governance.21 In 1990, Mobutu took a fact-finding trip to different parts of the country to gather feedback from the population on his regime; people were even allowed to express their grievances. At the first hearing in Goma, Mobutu listened as person after person ranted against the evils of his regime. They were angry that wages were low, that living conditions were abysmal, and that the military created such an oppressive environment. Mobutu was shocked, hurt, and outraged to learn the extent to which the population had turned against him, and he refused to attend the remaining sessions in person.22

US support for Zaïre was rapidly declining. Whereas in 1989 Zaïre was sub-Saharan Africa's largest recipient of US economic assistance, in November 1990 the US Congress imposed restrictions on economic aid to Zaïre, barring any further military assistance.23 On June 1, 1991, Zaïre hit the 12-month mark for failure to repay its debt on loans under the Foreign Assistance Appropriation Act, triggering the Brooke sanctions that halted further development assistance. US foreign assistance dropped from \$643M in 1989 to an estimated \$250M in 1991, leaving only PL 480 food aid operative.24

#### 152 The Fifty Years of Family Planning

Mobutu appeared to bend to the international pressure in October 1990 by allowing for a proliferation of political parties, while trying to buy loyalty from several of them.25 He announced that the country was entering the Third Republic. In a gesture toward power sharing, he called for a National Conference – a dialogue among a range of individuals, from powerful party leaders to representatives of associations and churches. Some 2,800 delegates from across the country descended on Kinshasa for the National Conference, which began on August 7, 1991.26

Citizens dared to hope that this conference might bring about a new start, that it would mark the end of Mobutu's rule, but the cagey leader found ways to cling to power. His forces went into high gear to buy off representatives to the conference with cash and gifts, but many would not have it. Mobutu named a Chair for the conference who was so closely linked to him that the participants booed him off the stage when he tried to speak. Yet within a week, the conference dissolved over accreditation disputes and political in 27 fighting.

Mobutu could not have been disappointed that the National Conference collapsed. Yet within weeks, he was faced with a new form of protest, this time from his own soldiers. On September 23, 1991, his disgruntled, unpaid military showed its wrath by ransacking the entire city of Kinshasa, an event that has gone down in infamy as the pillage. 28

#### Kinshasa erupts in violence and destruction: the pillage of 1991

The blow that would cripple the country for more than a decade came in September 1991. Military personnel – disgruntled by their low wages – mutinied in Kinshasa. Starting in the predawn hours they shut down the control tower at N'djili airport and ransacked a supply depot. From there they drove the military vehicles 15 miles to the main boulevard of Kinshasa, 30 Juin, and laid waste to storefronts, pharmacies, and gas stations.29 By 10 am the city had descended into chaos. The rampage expanded to other parts of Gombe, where the villas constructed during the Belgian Congo era became fair game. They completed their path of destruction by moving up the hill to Binza, where well-to-do Zairians and expat families lived in spacious houses. Soldiers were eager to régler les comptes (settle accounts).

The looting began with anything that was portable: merchandise, foodstuffs, alcohol, TVs. From there, the soldiers continued tearing out the plumbing, light fixtures, metal grating, wiring, and paneling. Caught up in the frenzy of protest, ordinary citizens joined the soldiers in plundering the city, able for the first time to express their rage against government oppression and a lifetime of injustices. The rampage spread to Lubumbashi, Kisangani, and other major cities, laying waste to them as well.30 Some 30–40% of businesses in Kinshasa were destroyed, 70% of small retailers were ruined, some 117 people were killed and 1,500 injured.31

Mobutu did nothing to quell the rioting that was instigated by his own troops, nor did he ever discipline them for their actions.32 Some speculated that Mobutu may even have provoked the rampage to derail the National Conference. According to observers on the scene, he delighted in seeing the city torn apart, leaving citizens with nothing. "That's what they deserved for turning against me." He hoped that this apocalypse would demonstrate once again that he, and only he, could bring order to the chaos. He is famously quoted as saying, "après moi, le deluge," (After me, the deluge).33

The Western embassies reacted swiftly to ensure the safety of their citizens. Within 48 hours, Belgians and French troops brought in planes to evacuate foreign businessmen, missionaries, diplomats, development staff, and Peace Corps volunteers to the safety of Brazzaville (across the river from Kinshasa), where they could temporarily hold up or find airline connections out of the country. Within a week, the US embassy had evacuated almost all its personnel. Many expats who had lived in Kinshasa for years were forced to pack up in a matter of hours, clutching their passports and whatever belongings fit into a few suitcases. An estimated 10,000 expats fled the country, closing their businesses and causing some 100,000 "middle-class" Zairian workers to lose their livelihood.34

The International Committee of the Red Cross and the Belgium Médecins Sans Frontières (MSF) were first responders to this pillage, arriving with surgical teams and emergency medical support. The UN considered that they had no mandate to coordinate the response of the international donor community. No other international donors came to the rescue.35

The pillage gutted the local economy.  Expat owners of companies fled the country, disgusted that they had believed in Mobutu's ability to maintain stability.36 Technicians of every stripe – factory workers, mechanics, carpenters – could not get work. Civil servants returned to their jobs, but most offices had ceased to function. As reported in Brooke Wind-up Plan, from the end of October to the end of November 1991, average house rents quadrupled, school costs increased ten-fold, and bus ticket costs increased by 200%. By year's end, the banking system had collapsed as a result of loan defaults, lack of deposits, and the non-availability of Zairian currency in the system.37

Unemployment rose to 80% in the wake of the pillage.38 For families already living on the edge of poverty, the loss of employment was catastrophic. The disruption of markets caused the price of goods to skyrocket. Families were reduced to eating one meal a day, consisting largely of high starch, low nutritive fufu. 39 Residents of Kinshasa, already adept at hustling for additional income in the informal sector – sought any means possible to bring in a few zaires. Except for those with special job qualifications or political connections, the informal sector became the major source of survival.40 Some attribute the phenomenon of street children in Kinshasa to the pillage, where parents no longer had the means to take care of their children and left them to fend for themselves in the streets.

Retail stores, shops, and pharmacies lost much of their inventory to looting. Small neighborhood markets around the city continued to function, but the scarce goods commanded high prices. A few private pharmacies still carried some contraception but at exorbitant prices. One type of commercial activity thrived: the sale of looted merchandise in sidewalk markets that sprung up around military camps.

#### 154 The Fifty Years of Family Planning

The devastating effects of the pillage reached well beyond Kinshasa. Companies in the Interior providing raw materials to factories in Kinshasa such as cotton for UTEX or palm oil for soap production at Lever Brothers (through their subsidiary Plantations Lever au Zaire) overnight lost the market for their products.41 Businesses providing foodstuffs to Kinshasa found that the urban population could no longer pay for their goods. Once a top producer of coffee and cotton, Zaïre never regained the market.42 The pillage ruined business in both urban and rural areas.

Likewise, the flow of goods from Kinshasa to the Interior slowed to a trickle, as retail stores and pharmacies in Kinshasa had little to sell. Fuel, too, became more expensive, making the cost of shipping products to and from Kinshasa exorbitant.

The pillage inflicted economic misery on the population of Kinshasa and beyond. Mobutu reacted to the economic crisis in a familiar fashion – by printing more money, resulting in hyperinflation: 205% in 1990, close to 10,000% in 1991. The value of one dollar US dropped from 459 zaires at the end of 1989 to over 60,000 zaires per dollar by the end of November 1991.43

As Kinshasa smoldered in the ruins of the pillage, the political intrigue continued. Mobutu named his archrival Étienne Tshisekedi as prime minister on September 29, only to dismiss him within a week for failure to sign a pledge of allegiance to the president.44 The following month the Sacred Union formed a parallel government. And the beat went on.

#### International donors halt development assistance

In response to the pillage, most international donors abruptly halted aid to Zaïre. The executive team of USAID/Zaïre regrouped in Washington, DC, and operated as a "Mission in exile." Within three months, the dollar funding for PSND, SANRU, and the Zaïre Social Marketing Project was cut off, as well as support to centrally funded contractors working in Zaïre on population and health. Wheat shipments under PL 480 were allowed to continue to Zaïre as scheduled in October and December 1991, the proceeds of which would be used to close out program activities.45

Because of the Brooke sanctions that took effect before the pillage, the US government had already assembled a team to oversee this drawdown of funding. Following the pillage, the team's mandate was expanded to include all US development assistance. The Brooke Wind-up Plan outlined what was to happen with each of the US government projects.46 Annexed to the document are barely legible cables sent back to Washington during the period, providing a window into the thinking of this team.

Given the chaos, uncertainty, and general unrest, the Western embassies evacuated personnel and their families through Brazzaville within three days of the pillage. All USAID dependents and most staff left.47 Ray Martin, head of the Health, Population, and Nutrition Office, stayed on in case USAID decided to resume some health-related humanitarian work. But even he, the mission director, and a few others left before the end of 1991 when it appeared obvious that continuing any development work would be futile. Linda Gregory, USAID's Administrative Officer, however, remained at her post to finish various administrative details and to maintain a minimal US presence.

The USAID offices in the Mobil building at the end of 30 Juin were not attacked, but the looters had emptied the depot in downtown Gombe.

USAID retained a staff of nine foreign service nationals, Zairians who had worked for USAID for many years and earned the trust of the leadership. Their primary job was to assist in closing out projects and closing down the office.48 In October 1992, they emptied the Mobil building – furniture, computers, office supplies – and transferred everything to a USAID depot near the Ndolo airport, in preparation for a future resumption of operations. They moved their own offices – along with a mountain of files – into the GAO (Government Accountability Office) building, near the Mobil building.

Since UNICEF had decided to remain open, operating with a skeleton staff, USAID arranged to pass unspent funds – one million dollars from PSND and three million dollars from SANRU – to UNICEF to procure and distribute essential medicines and contraceptives to health zones, to the extent possible. This allowed USAID to continue to contribute to the humanitarian relief effort without any in-country presence.

At the time of the 1991 pillage, UNFPA had recently promoted Dr. Hans DeKnocke to UNFPA country director; until then UNFPA had functioned under UNDP (United Nations Development Program). He rapidly evacuated, leaving two Zaïrois – Mr. Sébastien Mutumbi Kuku and Mr. Mpoyi Mankonda – in charge. The absence of a country representative from 1991–97 and the ongoing socio-political crisis made it impossible for UNFPA to enter into an agreement with the Zairian government for new programs. However, UNFPA did contribute with the intermittent purchase of contraceptives benefiting the few services still open during the 1990s.49 In its own report, UNFPA called it "ten years of floating." In 1996 UNFPA brought in an expat representative, Mme. Tamany Safir, an Algerian, who remained at the post until 2001.

One organization that stayed open and active was the Order of Malta, a lay Catholic religious organization that historically has specialized in medical services and other humanitarian aid in countries worldwide. Operating a full-service operation for philanthropic reasons, it worked with the Catholic Church in Zaïre to procure medications. Although run by the Catholics, the services were intended to benefit the entire population. Given the emergency measures taken, the situation for procuring medications became marginally better within four to five months of the pillage, though the scarcity of products continued throughout the medical supply chain.

#### The 1991 pillage leaves the PSND barely functional

The PSND offices at Kintambo had escaped the worst of the pillage. The main offices and adjacent warehouse had not been attacked or looted. The inventory of contraceptives, audio-visual materials, spare parts for the vehicles, and other goods were largely intact. However, a fleet of ten vehicles, numerous motorcycles, and bicycles housed at the USAID depot awaiting shipment to the Interior were gone. Staff in the communication division who had been working in offsite offices lost all their equipment.

USAID cut off its dollar funding to the PSND in December 1991.50 With the pillage came the sudden realization of the disparate employment status of PSND staff. Over half (47 out of 87) were government employees, with a quasi-lifetime contract but a meager salary. The remaining 40 staff were hired with USAID project funds, at far more attractive salaries. To close the gap, MOH employees received both their government salary and a prime (bonus) that brought them to the same level as their co-workers. Often the prime was much larger than the government salary itself. In the period immediately following the pillage, the government still had access to counterpart funds, which were used to pay government salaries. But in the months and years that followed, salary payments became irregular and sometimes failed to arrive.

The pillage brought to light a related problem. The PSND was a USAIDfunded project, which had never obtained official status as a government program. Official documentation labeled it as an organization "officially designated to promote GOZ family planning activities. 51 " As such, "project staff" were not entitled to earn a government salary. With the withdrawal of USAID funding, all salary support – including the primes – stopped abruptly. Half the PSND staff lost their jobs; the other half lost a major chunk of their salary.

The drastically reduced take-home pay left staff hard put to feed their families. Anyone who had a salary – however meager – became a magnet for the extended family, desperate for access to any resources. Following the Mobutu slogan of débrouillez-vous, people sold household possessions and hawked whatever skills they could offer.52 Bitshi – a health administrator and trained nurse – reopened his welding business to produce anti-theft covers for exterior lights. Mbadu Muanda went back to teaching because parents with money wanted to keep their children in school. Mme. Virginie Kangololo fled to Angola where she started a restaurant.

The PSND remained open but hardly functional. Staff stopped coming to work every day. Initially, it had contraceptives in the Kintambo warehouse but there was no project funding to ship them to the clinics elsewhere in the country. Staff from the Interior had to pick them up in Kinshasa.

Over time, PSND's stock of contraceptives dwindled, until there was nothing left to distribute to partner clinics. Bitshi explained that he gradually stopped coming to work, entirely demoralized that he had nothing to offer. "The matrones from Sona Bata came to us, offering to pay for contraceptive products, and we had nothing to give them."

Entrepreneurs jumped into the void. They went to neighboring Angola to get oral pills, returning with a brand previously unknown in Zaïre. Others brought them back by ferry from Brazzaville. The churches used other channels. An evangelical church (église du réveil) had a connection in Nigeria and brought in a suitcase full of Depo-Provera. The ECZ (Church of Christ of Zaïre) managed to obtain a shipment of Noristerat (an injection). These efforts reflected the felt need – at least for a small portion of the population – to use contraception.

Whereas international donors had withdrawn funding from large-scale projects on the ground, they were willing to send promising young professionals for training outside the country. Those who benefited from the training became wellknown names in family planning circles in subsequent decades. In 1993–94, Emmanuel Buhendwa received a ten-month training at the University of Montreal on demography, MCH, and management. In 1994–95, Mr. Bitshi traveled to Mauritius for a diploma in human resources management and training at the local School of Public Health. In 1995, the WHO supported the travel of Mbadu Muanda and Prof. Yanga Kidiamene to Togo for a 3-week course in epidemiological research. And in 1996, with funding from the World Bank, WHO sent Mbadu Muanda and Lina Piripiri for a three-week training in operations research in Benin.

#### SANRU struggles after the pillage

At the time of the pillage, SANRU was riding high. The project had avoided the Brooke sanctions. USAID had argued that the project was managed by ECZ, a private voluntary organization (PVO). Moreover, discontinuing its funding would result in significant losses in healthcare coverage and an increase in infant mortality in rural health zones, because government services were weak or non-existent.53 The SANRU II project was scheduled to end in 1992, but SANRU staff were working with USAID on the design of the follow-on project entitled the "Zaïre Integrated Family Health Project," to be implemented through ECZ, PSND, and PSI.54

The pillage of 1991 brought those plans abruptly to a halt, disrupting the momentum – built up over a decade – for developing primary healthcare throughout the country. Franklin Baer tried to stay on with a small team at USAID to coordinate possible emergency assistance, but the US embassy vetoed that plan. By March 1991 USAID had discontinued its dollar funding to SANRU.55

The ECZ continued to operate as a PVO with a small local staff through June 30, 1992, using its counterpart funds and donations from churches back in the United States to provide a minimal level of support to the health zones. Dr. Sambe Duale resigned as director of SANRU in February 1992 and moved to Washington, DC, where he and Frank Baer continued as informal advisers from afar. Dr. Nkuni Zinga, director of the ECZ medical office since 1985, assumed a second title of director of SANRU to oversee the final months of the project close down. From there, USAID redirected three million dollars of unspent SANRU funding through UNICEF to provide limited assistance – primarily medicines and contraceptives – to health zones.56

In February 1991 (before the pillage), the World Bank authorized the \$30.4M Social Sector Project (PASS), designed to meet the basic needs of the population in health, population, nutrition, and education. Among its aims was to increase access to family planning for five million people. ECZ – one of the recipient organizations 57 – began to receive funding in 1992. The minister of plan balked at giving the funding directly to the ECZ, preferring to manage financial transactions themselves. It became a moot point when in November 1993, the World Bank ended the PASS project because of Zaïre's inability to pay its debts.58 Less than a half-million dollars from this project was ever disbursed to ECZ.

#### ASF and Johnny Loftin operate social marketing on a shoestring

The Zaïre Social Marketing Project was also a casualty of the abrupt halt to USAID funding in Zaïre.59 PSI's (Population Services International) office and vehicles emerged unscathed from the pillage. Its warehouse containing 20 million condoms and cartons of Graine spermicide remained intact. Shortly after the pillage, PSI headquarters recalled its expat director to Washington and dismissed him, presumably for reasons unrelated to the pillage.

USAID suspended PSI s funding in November 1991.60 ' By then, PSI was working with a local NGO, Association de Santé Familiale (ASF), which had been created by Professor Payanzo Nsomo and colleagues in response to the HIV epidemic. Under their arrangement, PSI obtained project funding from USAID contracts and multiple other sources. ASF became the implementing partner for much of this work. Although operational, ASF's status as a fully registered NGO remained in legal limbo.61 USAID authorized ASF to continue the social marketing of condoms and contraceptives through a self-liquidating scheme, whereby it could finance its operations from the sales of existing stock – until the supply was exhausted.62

PSI had a vested interest in Zaïre, which was its first and highest-profile condom social marketing project in Africa; it became the model for similar PSI projects in other African countries. To this end, PSI used corporate funds to "perch" – maintain some presence in the country for a period of time until conditions improved and funded project work could resume.63

Although most Americans fled Kinshasa after the pillage, one who remained was Johnny Loftin. Married to a Zaïroise and with three children in The American School of Kinshasa (TASOK), Loftin opted to stay in Kinshasa, where he and his colleague Wally Herzog assisted USAID to evacuate the personal effects of expats who had abruptly left the country. Although new to HIV/AIDS prevention work, in 1992 he became a consultant for ASF, assisting them with logistics, finances, donor reporting, and small fundraising activities. Initially, PSI hired Loftin to work a few days a month to oversee its operations and finances, but it quickly evolved into a near fulltime job "that put my three kids through TASOK," quipped Loftin.

From a multi-million-dollar project before the pillage, the social marketing operation shrank to three local staff, two guards, and Loftin. Max Kibondo Kilongozi was the lead administrator; Claude Disuemi ran sales, production, and marketing; and Mami Batonda did the admin/bookkeeping. To pay salaries and rent, they set to work selling the 20 million condoms and stock of Graine spermicide that they had. Eventually they ran out of the colorful wrappers with the Prudence logo used to repackage the generic condoms provided by USAID, so they fabricated a paper pouch locally that lacked pizzazz but kept them in business. They also had a large stock of plastic shopping bags with the imposing panther from the Prudence logo, which they had previously given away as a promotional item. They realized the potential value of these bags when they found them being recycled and sold in local markets, so soon they, too, began selling these shopping bags to bring in extra revenue.

Despite their best efforts, ASF was operating hand-to-mouth. Loftin helped with fundraising. Because the expat community had contracted so drastically, Loftin found himself golfing with ambassadors and the few remaining businessmen in town (it was only men at the time). As secretary-treasurer of the American Business Association, he recruited speakers for the monthly luncheon meetings and exposed his expat colleagues to the ASF social marketing model. Soon, he began obtaining donations for ASF: Oxfam gave two separate grants of \$7,000 and \$14,000. The Dutch chipped in \$5,000. DFID/British embassy donated audio-visual equipment. The Koreans purchased a vehicle for ASF. The World Bank gave \$15,000. "These were small grants, but they helped," Loftin explained. "These donors were more interested in helping a local NGO than one based in the US."

By 1996, with no consistent source of support for family planning and no further stock of Graine, ASF focused entirely on condom use for HIV/AIDS and pregnancy prevention.

Life in Kinshasa in the mid-1990s, especially after the second pillage, was grim. Services were not available, large sections of the city experienced electrical blackouts and shortages of water, and soldiers circulated throughout the city with impunity.64 At a time when most development workers had long since departed, Johnny Loftin was viewed as the lone ranger, carrying on the good fight to make condoms available in Kinshasa. His Zairian deputies also deserve a great deal of credit for keeping the lights on.

#### AZBEF's financial irregularities further hinder the organization

Even before the pillage, AZBEF had lost much of its stature as a family planning agency in Zaïre. The creation of PSND in 1982 ate into the monopoly that AZBEF had in service delivery and IEC. The departure of Dr. Miatudila Malonga for the World Bank in Washington, DC, in 1989 left a leadership void from which AZBEF never fully recovered.

As of 1990, AZBEF continued to receive modest funding from IPPF/Nairobi to cover salaries and service delivery costs. It supported FP units in clinics in Kinshasa, Katanga, Bas Zaïre, and Equateur, for which UNFPA and IPPF/Nairobi provided contraceptives.

None of the AZBEF offices suffered physical harm from the 1991 pillage. Rather, the damage it sustained was self-inflicted, resulting from its inability to manage its finances. A series of audits showing financial irregularities caused IPPF/Nairobi to discontinue its support of AZBEF between 1991–95. UNFPA continued to provide contraceptive products to AZBEF, but the organization was largely inactive for several years.

AZBEF was struggling. Despite having plans and ideas, AZBEF suffered a chronic lack of funds. It had 26 staff and 100 volunteers, but according to the 1991 Work Plan, most of its central-level staff had been placed on "administrative leave. 65 " The 1991 evaluation of the Zaïre Family Planning Project spoke of the need to revitalize AZBEF and recommended placing an expatriate adviser at the deputy director level.

Prior to the first pillage, the evaluation team saw potential in AZBEF and recommended that USAID allocate a greater proportion of its family planning resources to this private non-profit organization for several reasons: lower salary and overhead costs, fewer cumbersome bureaucratic procedures, experience in working at the grass roots level, and fewer political constraints in promoting the still controversial topic of family planning. Yet this recommendation never got serious consideration, as the donors pulled out of Zaïre in 1991.

Surprisingly, at a time when the city of Kinshasa was on life support, AZBEF received its official designation as a non-governmental organization on March 14, 1992. It is unclear that this designation changed anything in the day-to-day routine of the organization, but it was useful for AZBEF to have clarified its legal status.

#### The Kinshasa School of Public Health loses its primary source of funding

After a successful start, USAID approved a second five-year contract to continue its support of the Kinshasa School of Public Health (KSPH). In the months between approval and signature, the city of Kinshasa erupted into violence during the pillage of 1991. KSPH became yet another casualty of the pillage, as USAID withdrew funding for all development projects in Zaïre. Only those students receiving support for their doctoral studies at foreign universities were allowed to finish.

In contrast to many other institutions of higher education, KSPH kept its doors open. The first generation of Congolese professors, recently returned from their doctoral studies abroad, received less than \$200/month in salary – if they were paid at all. Personal security became an issue, as did the widespread scarcity of food.

In the face of these disastrous conditions, Professor William Bertrand found a solution that would allow the KSPH to keep the lights on. He created a US-based foundation – Support for the Kinshasa School of Public Health – and obtained a modest grant of \$30,000 a year from the Rockefeller Foundation's Schools of Public Health Without Walls project.

Despite the untenable conditions in the DRC, the school was able to continue operations with funding from the Rockefeller Foundation and small private donations while the rest of the university was shut down. Some of the training was moved to Nairobi. Of note, all but one of the PhD students who trained overseas returned to work in the country or region, indicating a satisfactory working environment at KSPH and a commitment on their part to give back to the country.

#### The second pillage (1993) wreaks further havoc on the country

In January 1992, the newly appointed Prime Minister Nguza reopened the National Conference, only to close it down two days later. In an attempt to bring pressure to bear for its reopening, the Catholic clergy organized a March for Hope on February 16, 1992. It devolved into yet another blood bath, first in Kinshasa, then in other major cities. Over one million people participated in what was the largest mass march in the country's history, many holding Bibles and rosaries. Mobutu brought out his troops to confront the marchers, leaving more than 50 people dead.66 Mobutu had allowed his troops to use napalm on his own citizens for crowd control.67

Following this bloody massacre, Mobutu was further pressured to reopen the conference. In April 1992 the National Conference reconvened, renaming itself the Sovereign National Conference. A new constitution was drafted and plans were made for elections. Its newly elected chairman, Archbishop Laurent Monsengwo Pasinya subsequently proposed a Transitional Act, intended to curb Mobutu's interference in the proceedings. On August 15, Etienne Tshisekedi was elected prime minister of the transitional government, which Mobutu accepted without acknowledging the Transitional Act. One of Tshisekedi's first acts was to try to curb inflation, by then over 4,000%, by taking measures that would block Mobutu from printing more money to cover government expenses. But Mobutu foiled these attempts with countermeasures. Despite the exuberance of the delegates over the prospect of Tshisekedi's ascent to power, the opposition leaders lacked the vision and strategy needed to carry their victory over the finish line. The Sovereign National Conference ended in early December 1992, with mixed results. There were still no concrete plans for new elections.68

With the economy in shambles and the population in turmoil, Mobutu resorted to his time-honored practice; he printed more money. In December 1992, his government introduced five million Zaïre banknotes worth about two dollars each, which he used to pay the salaries of his army. Tshisekedi in his position as prime minister opposed this move as unlawful and urged shopkeepers not to accept them. When the military tried to change these bills, the local moneychangers refused. This time it was not rank and file solders but Mobutu's Presidential Guard (the DSP) that sought revenge.69

On January 28–30, 1993, the elite forces (DSP) began a violent rampage through Kinshasa, murdering rank and file soldiers, tearing through businesses, terrorizing the population, and ransacking public and private property. Nuns in the district of Limete were reportedly raped. An estimated 2,000 people were killed, including the French ambassador. French troops swept in and carried some 1,300 foreigners to safety. Belgian troops – denied entry into the country by Mobutu – evacuated foreigners from Brazzaville.70

Many described the second pillage as worse than the first. What little remained of the country's infrastructure and functioning businesses was further destroyed, causing a new flight of expats and wealthy Zairois to leave.  Rioters broke into the USAID depot near Ndolo airport, making off with a hundred vehicles. What they could not steal, they destroyed. Kinshasa was in chaos; smoldering vehicles were strewn across the city. With guns coming in from the east, business people and government officials armed themselves. As the economic situation worsened, people were reduced to eating wheat bran, previously fed only to animals. Women went back to preparing manioc as they had in the village. Less than 15% of the population had access to healthcare.71 Despite the widely touted unity of the African family, even those with jobs struggled to feed their own children.

After the 1993 pillage, USAID reduced its staff of Zairians from nine to four. Any hopes that USAID could resume operations were shattered.72 Instead, the US Office of Foreign Disaster took the lead for the US government in directing its humanitarian assistance. Relief agencies flocked to the country. MSF, Catholic Relief Services, Action against Hunger, Handicap International, and others had set up operations in the country.

International observers monitored the disintegration of the country that Mobutu had decimated with his violent acts and personal greed. The US government officials surmised that Zaïre "still does not have a functioning government, there is no consistent control over the military, the economic catastrophe continues, and the threat of national disintegration looms larger every day. 73 " As US officials contemplated their options, they realized that the country risked an even more dire future of civil war, famine, and national disintegration. If the president could not reach a compromise with his political foes, they envisioned the destruction of the country's infrastructure, with waves of refugees that would destabilize the region and require a massive humanitarian relief effort from the international community.74

While Zaïre teetered on the brink of collapse, an even greater catastrophe struck across the border in Rwanda: the 1994 genocide. The Rwanda Civil War began in 1990 when the Rwandan Patriotic Front (RPF), consisting largely of Tutsi rebels invaded the country. For several years, tensions escalated between the ethnic group in power, the Hutus, and the minority group, the Tutsi. President Juvenal Habyarimana sought to bring the war to a peaceful conclusion by signing the Arusha Accords in August 1993. Yet on April 6, 1994, the aircraft carrying President Habyarimana and Burundian president Cyprien Ntaryamira, both Hutu, was shot down by surface-to-air missiles, killing both.75 This event triggered the genocidal killings that would last close to 100 days, when majority Hutu soldiers, police, and militia killed over 500,000 Tutsi and moderate Hutus. The genocide sent shock waves through the international community, though no country attempted to intervene to stop the killings.76 When the Tutsi-led RPF seized control of Kigali, two million refugees fled to neighboring countries, many to eastern Zaïre. In the face of this human tragedy, the international community once again courted Mobutu to provide a temporary safe haven to these refugees. For a time, the calls to depose Mobutu were muted, and he maintained his faltering grip on power.77

In 1995, a new scourge emerged in Zaïre: the Ebola outbreak. In May, Dan Fountain's son Paul made a call to Larry Sthreshley, then working with the ECZ medical office, to report the emergence of an unknown disease in the town of Kikwit (in the province of Bandundu). Dan reported that everyone involved in an operation on a patient with this unknown disease had died unexplainably, and there were more patients with the same symptoms in the hospital. Larry scrambled to put together \$5,000 and took it to the Indian businessmen to buy personal protective equipment. The next day Mission Aviation Fellowship flew the drugs and materials to Kikwit as first responders. Larry borrowed a friend's phone to call the Centers for Disease Control and Prevention (CDC) in Atlanta, providing a detailed description of the dire situation on the ground. The CDC responded the next day with a 40-page fax, identifying the outbreak as Ebola. In a meeting back in Kinshasa, several high-level officials in the international community met to discuss how best to quell the panic that threatened to escalate. The head of the EU approached Larry and said, "the only way this is going to get under control is if you [the Americans] take the lead." Larry went to the US ambassador who gave him \$50,000 to cover immediate expenses. Within three days, CDC experts were in-country, working out of the ECZ offices. Larry became the official local representative, attending strategy meetings, receiving Department of Defense flights at the airport, and warehousing materials from the US. Within 11 weeks, the outbreak was contained. The ECZ medical office gained street cred as an organization able to operate effectively in a crisis, despite poor communication systems and minimal resources.78

Given the downward spiral of the country, in March 1996 USAID further reduced its in-country staff – to a single individual: Mr. Victor Mandingula. A UStrained Zairian economist who had worked for USAID for over 15 years, Mangindula moved to a small office in GAO, where he was the only employee in the building. He helped health experts visiting the country for different outbreaks to get into and out of the country, and he regularly shipped human and animal specimens from the Kikwit region to labs in Atlanta/CDC, Germany, and South Africa via DHL.

For those familiar with the mammoth USAID operation in a large country with extensive development programming, the idea of a single individual holding down the fort for USAID for two years defies imagination. When a surveillance survey conducted in 1996 showed that Ebola was under control, Victor feared that USAID might no longer need him. As political events unfolded in 1997, he need not have feared for his job.

#### Box 6.2 The military had wives, too

Almost all accounts of Mobutu's military describe the elite forces and regular soldiers as heartless brutes, bordering on savages, as they carried out orders to terrorize civilians and massacre students. Dr. Gilbert Wembodinga, a practicing Ob-Gyn with a clinic in Kisangani in the 1990s, might not disagree, but he experienced first-hand their humanity on several occasions.

In the early 1990s, a soldier knocked on his door, begging him to care for his wife who was experiencing life-threatening pregnancy complications (placenta previa). The University Hospital and another clinic had turned them away because he did not have the money to pay. Dr. Wembodinga agreed to operate on her and managed to save her and the baby's lives. All in a day's work. Several years later, during the pillage of 1993, soldiers destroyed much of the infrastructure in Kisangani, including stores, pharmacies, and clinics. Yet to Wembodinga's surprise, his clinic had been spared. He traced it back to the actions of the man he had helped, a major named Yelima, who had deterred other soldiers from attacking the clinic.

Several years later, Dr. Wembodinga had a narrow escape with Mobutu's soldiers. In 1997, he was living in the professors' quarters at the University of Kisangani. One night, well after the military-mandated curfew, he heard a knock on the door. A panicked husband beseeched Dr. Wembodinga to care for his wife, who was in labor with a breached birth. Violating curfew, he took her to the hospital.

En route, a band of soldiers jumped out to arrest him.

But Dr. Wembodinga protested, "I have to save this woman's life." The soldiers took mercy on her situation, and two military were assigned to escort them to the hospital. The story ended happily.

In 1997, as the population in Kisangani waited anxiously for the war, life became uncertain. Military personnel would enter private homes without warning. Outside of Kisangani in the Tingi Tingi forest, groups of Rwandan refugees (Hutus) were camped out in squalid conditions, many dying of malaria and diarrhea. A UN rescue team came for Wembodinga and escorted him to the refugee camp, where he spent a week ministering to the ailments of this destitute population. He came back a second week with a truck filled with humanitarian supplies. The third week, a military escort came to his home to suggest that he "rest" that week, making an oblique comment that "we are only two and we can't protect you against a larger group." That week the Rwanda army descended on this community in the Tingi Tingi camp and killed hundreds of the refugees.

Thanks to the warning from the military, Dr. Wembodinga was spared.

#### Resuscitating family planning in Zaïre

By the mid-1990s, the situation for family planning had reached new lows. The PSND, though functional, received only enough money from the government to pay salaries, with little or no funding for operations or programmatic activities. ECZ received small amounts of funding from different sources, barely enough to keep it afloat. ASF and Johnny Loftin were struggling to keep condoms on the market, with modest support from PSI. Already marginalized by the growth of PSND and the Social Marketing Project, AZBEF struggled with chronic funding shortages.

But 1995 marked a turning point for reviving family planning work in Zaïre. In 1994, the landmark International Conference on Population and Development (ICPD), held in Cairo, Egypt, revolutionized the field of international family planning. Government officials from 179 countries participated in the official conference, with a parallel conference attended by some 4,000 participants from international NGOs, women's groups, donors, and advocates. A major outcome of the conference was the rejection of the demographic thrust of family planning programming. Country programs needed to look beyond "women as breeders" and consider a wider range of their health and social needs. Gender equality was seen as pivotal to women being able to take their rightful place in society and to have the autonomy necessary to control their own fertility. The Cairo Programme of Action was highly client-centered, rather than working to achieve the demographic objectives of a country. At the international level, donor funding spiked in response to the enthusiasm over this new direction, only to succumb to the greater urgency of the HIV/AIDS epidemic shortly thereafter.79 The tumultuous political situation in the DRC did not allow for the country to benefit from the new-found interest in a broader definition of reproductive health until the end of the decade.

In 1996, the government recognized the need to convert its family planning project to a government program, both to underscore its importance to the public health and development of the country and to engender a greater sense of country ownership. On February 20, 1996, the PSND was renamed the Programme national de Naissances Désirables (PNND) through Ministerial Decree No. 1250 / CAB / miniSP / 0096. The acronym became PNND or PND. But many continued to refer to the organization as PSND, despite the official name change.

Some project staff who had lost their jobs after USAID withdrew funding in 1991 were able to obtain a matriculation number that authorized them to receive a government salary; others were less fortunate or did not follow through on the tedious administrative process.

In 1997, Mr. Ngoie stepped down as the director of PNND for health reasons. The following three years would see rapid turnover in the leadership of PNND, with varying levels of dedication and competence. Dr. Lusikila Samba Chantal held the post for one tumultuous year (1997–98), accused by her senior staff of bad governance. She was replaced by Mr. Tambwe Yelumba, who passed away while in office in 1999. Mr. Kwanzaka Izanza took over as interim director from 1999–2001. If the pillage had started the PSND/PNND on a downward spiral, these few years further accelerated the decline.

PSND staff did play a role in the expansion of service delivery, in collaboration with ASF/PSI and Pathfinder. Using a social marketing approach, the project distributed condoms, pills, and spermicides to pharmacies, as well as to selected clinics. Mr. Mutombo Yatshita, former director of training at PSND, recruited personnel who had been trained by PSND to train clinical providers and pharmacy personnel in family planning, thus expanding access to contraception in Kinshasa, Lubumbashi, and Bukavu.

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The ECZ also benefited from an infusion of funds in the mid-1990s that allowed it to revive its work in family planning. In 1995, the EU awarded the ECZ the PATS I project, a \$1.32 M two-year general support contract (Appui Global) to maintain primary healthcare including family planning in six health zones in Kinshasa and five in Kasaï.80 With this funding, the ECZ continued to distribute whatever contraceptives it had until its stocks were depleted or the products expired.

In 1996, the ECZ received an additional \$107,000 contract (\$65,000 from the World Bank, \$42,000 from the Presbyterian Church/USA), specifically for family planning work. Dr. Nkuni, director of the ECZ medical office, was keen to revitalize family planning in Kinshasa. The ECZ staff who worked under this agreement attributed it to Ray Martin, who in mid-1992 left USAID and was hired by the World Bank. With this funding, the ECZ established a Cellule de population (population unit) within its medical office and recruited Drs. Dick and Judith Brown to return to Kinshasa for what would be their third tour of duty for family planning in Zaïre in three decades. When they arrived, they found Mme. Yvette Mulongo, trained in community health and behavior change communication, already working at ECZ.

The population unit focused on integrating family planning into existing health facilities in Kinshasa. With this funding, the ECZ set up a depot to house the contraceptives brought into the country by UNFPA. Because of frequent stockouts of methods requiring resupply, the Browns chose to train providers in counseling and insertion of the IUD.

With a pickup truck and local driver provided by the ECZ medical office, the Browns and Yvette made the rounds of largely church-supported clinics in Kinshasa, determining which ones were providing services and had contraceptives. Papa Lukoki, the driver, would use his network to identify trouble spots to avoid (unrest and burned tires were big clues). They made schedules day-by-day, depending on where they could go.

A survey conducted in 1996 yielded a mixed picture of family planning operations in the city. The Browns ran into a number of nurses whom they had previously trained, who were still on the job, but many lacked equipment or had no contraceptives in stock. They also surveyed the local markets, where they found large quantities of oral pills, Depo-Provera, and spermicides for sale. They checked pharmacies, some of which had products for sale. "Where are they getting these supplies?" The answer: Brazzaville, Nairobi, and Zambia. The Browns came away with two conclusions: there was a demand for contraception in Kinshasa, and anything they could do to retrain people and resupply them with contraception would be a plus.81

The ECZ adopted four strategies in revitalizing family planning: work with viable institutions that had survived the political crisis, concentrate on providing clinical services, emphasize long-term methods, and build in cost-recovery schemes for all levels of providers. They succeeded in re-establishing family planning services in some 30 health centers and hospitals in Kinshasa. Yet they were acutely aware that the momentum for family planning had been lost. The population was now less knowledgeable about contraceptive methods than in previous years. Moreover, many women were simply too poor to pay for contraceptive services. They concluded that revitalizing family planning services in a disrupted country would require highly personalized, labor-intensive efforts. Even then, contraceptive use would be slow to return.82

In 1996–97 refugees from the civil war in Brazzaville started pouring into Kinshasa, squatting in makeshift housing near N'djili airport. With authorization from the ECZ medical office, the Browns and Yvette set up a temporary service delivery point in the area where they gave counseling and delivered IUDs and condoms to this refugee population. In 1996 they had set up a similar temporary refugee service on the grounds of the campus of the University of Kisangani for refugees flowing into the country from the east.

At the end of their two-year term, the Browns packed their belongings for one final time, departing Kinshasa in 1998. ECC had received additional funding of \$730,000 from the EU83 for a PATS 2 project, including family planning.

According to Ray Martin, the World Bank had operated on the principle that "what countries needed was finance; they could implement the projects." But by 1998, even the World Bank decided it did not make sense to continue to support projects in this chaotic environment and closed its development assistance to Zaïre.

In the mid-1990s, the tides also turned for ASF/PSI. In 1995, the European Union Development Fund contributed \$40,000 to ASF to procure condoms. This funding provided a bit of a lifeline until they got their major break.

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However, the EU funding came with strings attached. The EU project officer insisted that ASF/PSI conduct quality testing on its existing stock of condoms. He did not accept the results of local testing; it had to be done overseas. The PSI condoms did not fail the overseas test, but the results were inconclusive. To Loftin's disbelief, at a time of great scarcity of goods in Kinshasa, the EU project officer ordered ASF to destroy the entire lot. With the threat of losing the funding if they failed to comply, Loftin and the ASF team borrowed a truck from the US embassy and loaded their entire stock of condoms onto it. En route to Matadi, they found a dirt road off the highway, drove to an abandoned lot, and dumped the entire load, creating a mound of condoms five feet tall and twenty feet in diameter.  From ten miles away, they could still see the plume of black smoke on the horizon. It took another three to six months for the new lot of condoms to arrive.

In 1998, PSI was part of the winning consortium for the USAID centrally awarded AIDSMARK project, operating in multiple countries including DRC.84

ASF had kept the condom social marketing operation afloat during the lean years after the first and second pillages, with support from PSI.85 When PSI returned in 1998, with funding for the AIDSMARK project, they operated as a single entity.86 The donor funding flowed through PSI to ASF, and expat staff worked for PSI. Yet in DRC, they operated as ASF or ASF/PSI.87

AIDSMARK was an HIV/AIDS prevention project targeting vulnerable youth, commercial sex workers, and people living with HIV/AIDS. It promoted the ABCs, widely used in USAID-funded projects of that era: Abstinence, Be faithful, or Condom use.88 The same year PSI launched the Zaïre AIDS Mass Media project, which worked hand-in-hand with AIDSMARK. The approach to behavior modification included peer education, mass media information dissemination, and social marketing of the condom Prudence. PSI brought in market research experts to conduct focus groups and pretest ads for different market segments.

PSI hired Loftin as chief of party for AIDSMARK. Having stretched every penny for years, Loftin was now confronted with a different challenge: spending the vast sum of money now available for programming. He opened an office on Boulevard du 30 Juin and built a studio to produce audio and video spots onsite. He worked with various local musicians who remained in the country including keyboardist/producer Alfred Nzimbi, composer/vocalists Lokito and Nzaya Zaidio (from Lipua-Lipua), guitarist Felix Mbetu (from Zaiko Langa-Langa), and other personalities. ASF/PSI would provide the messages that the musicians would then incorporate into their songs.89

Within a year, the ASF/PSI staff grew from five to 75. They were once again "everywhere" – in the capital cities of all the provinces. In addition to the conventional media and educational songs, they staged other attention-grabbing activities: parades with horses, and showy exhibitions at the annual International Fair. They connected with at-risk populations through their Soirée de Prudence (an Evening with Prudence). After obtaining permission from the owner of a bar or nightclub, their youthful staff would take to the stage for some 10–15 minutes. A dynamic MC would introduce the idea of protection against HIV, then move into a game-like format, shouting out questions about HIV/AIDS and handing out prizes for the right answers: a T-shirt or baseball cap with the Prudence logo. From there, members of the team would circulate among the tables, offering condoms (at low prices) for the clients, all as Congolese music pulsated in the background.

Although ASF/PSI worked almost exclusively in HIV/AIDS prevention, not family planning, this work resulted in high levels of awareness of condoms among the general public. The presence of ASF/PSI in Kinshasa and their ability to reach large numbers of people in cities nationwide gave them a first-mover advantage when family planning funding returned in the 2000s.

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AZBEF, too, experienced a change of fortune. Starting in 1996–97, IPPF/ Nairobi again began to fund salaries and small projects for AZBEF. They were able to fully reengage in service delivery and demand creation work, starting in Kinshasa. They then opened regional coordination offices in Matadi and Lubumbashi, and shortly thereafter in Bandundu and Equateur. This funding from IPPF/Nairobi supported training for service providers, contraceptives, equipment, and supplies.

Prior to the 1991 pillage, AZBEF did not have its own clinics. Rather, it signed partnership agreements with private health centers and clinics to incorporate family planning services, which became known as Unités de Naissances Désirables. AZBEF signed similar agreements with the health centers of public and private companies (including ONATRA, Gécamines, and REGIDESO). With the influx of funds from IPPF/Nairobi, in 1997 AZBEF established its own clinic, Bongisa Libota in Kinshasa, first in N'djili then in several other locations before ending up in Kazavubu. Then later they established another clinic in Matadi. The two Kinshasa facilities would go on to become among of the most frequented family planning clinics in the decades that followed.

AZBEF also used these funds to develop programming for youth and adolescents, starting in 1997–98. Mr. Jules Luanga, who had begun as an administrative secretary in 1991, took charge of this activity. AZBEF trained young people to serve as peer educators who visited schools, churches, youth clubs, and other areas where youth would congregate. These peer educators provided counseling about contraception, distributed condoms, and referred interested persons to nearby facilities for other methods. They did not receive a salary but would get small monetary remuneration when they submitted reports during monthly meetings. At a time when PNND had yet to reengage fully, AZBEF played a useful role in providing services in several key cities, especially to youth. Luanga recalled the period from 1996–2000 as some of the organization's best years.

In 1997, AZBEF changed its name to ABEF-ND (Association de Bien-Être Familial–Naissances Désirables, the Association of Family Wellbeing – Desirable Births). With the change in the name of the country, it was no longer appropriate to retain the Z (for Zaïre). The obvious choice would have been to change AZBEF to ACBEF, but that name was already claimed by the IPPF affiliate in Congo-Brazzaville, leading to the decision in favor of ABEF-ND. Often, the "ND" was dropped, and the organization became known simply as ABEF.

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There was even relief for some research activities. In 1995, Mme. Sokifuani was named minister of health. She learned of the work of a young demographer named Mbadu Muanda, and soon thereafter established the Cellule de recherche en santé de la reproduction (CRESAR, the research unit on reproductive health). Others joined: Chirwisa Chirhamolekwa, Dr. Nguma Monganza, Dr. Yanga Kidiamene (a gynecologist), Lina Piripiri (a doctoral student at Tulane), and Bolie Nonkwa (from the Ministry of Gender, Family, and Children). They received \$25,000 to complete their first assignment: a literature review of all research in Zaïre/DRC completed between 1980–95 on sexual and reproductive health. They compiled their findings in a booklet and presented it to WHO. Seeing the promise of this group, WHO began to support further capacity development at CRESAR, sending these individuals to train outside the country. Upon their return, WHO awarded them a grant to identify indicators for MCH. From CRESAR, Mme. Chirwisa would be recruited to work with WHO/DRC, Lina Piripiri with USAID/DRC, and Mbadu Muanda with his subsequent leadership positions in reproductive health.

For the Kinshasa School of Public Health, the slow return to normalcy in Zaïre in the late 1990s coincided with the PEPFAR-driven rise in funding for HIV/AIDS worldwide. KSPH was well-positioned to receive funding in this area, given its previous experience with HIV/AIDS research, and to expand into other areas of public health research.

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#### 170 The Fifty Years of Family Planning

The cadre of US- and European-trained PhDs became the cornerstone to developing a thriving educational institution as well as reinforcing the public health infrastructure of the country as it recovered from two pillages and endless armed conflict. Four of these PhD graduates would go on to become deans of the KSPH (Paul Lusamba, Antoinette Tshefu, Patrick Kayembe, and Mukoko Munyanga). Lina Piripiri would become a senior adviser at USAID overseeing maternal child health. Prof. Ngo Bebe and Paul Lusamba would work in Africa regional offices of the World Health Organziation. Emile Okitolunda would manage major PEPFAR intervention and research programs. Ali Mapatano would hold a senior position within the MOH. Almost all became well-published researchers in their respective fields.

#### Protestant missionary work evolves by the late 1990s

The Protestant hospitals had been pioneers in introducing family planning, dating back to the 1970s. During the 1980s, many sites became the reference hospitals for the health zones supported by SANRU I (starting in 1982), which included family planning as one component of primary healthcare. As of 1980, 95% of the MCZs (the chief district medical officer) were missionaries, making up for the complete absence of Zairian doctors posted to the Interior.

Well before the pillage, the number of expat missionaries began to drop. In the early 1980s more Zairian doctors and nurses began to occupy posts in churchsupported hospitals, which were able to provide them with housing, schooling, and a garage to maintain their vehicles.90 Also, the government authorized doctors to take a portion of the proceeds from the operating room as a salary. As local doctors more willingly accepted these rural posts, the rationale for using expat physicians became less compelling.

By the end of SANRU II (in 1991), only one health zone had a missionary expat MCZ.

The landscape for church-supported hospitals changed markedly during the 1990s for multiple reasons. The destructive pillage of 1991, followed by the more violent pillage of 1993, caused missionaries in some locations to pack their bags and leave the country for good.91 In other locations, the missionaries felt sufficiently isolated from the political turmoil to continue their work in health, education, and religious teaching. In both situations, financial support from the churches back in the US and Europe began to dwindle over time, in many cases to nothing. The boarding hostel at TASOK which had housed missionaries' sons and daughters attending high school in Kinshasa closed in 1993 and was converted to the MPH Guesthouse.

In well-known sites such as Karawa, Kimpese, Nyankunde, Tshikaji, and Vanga, expat missionary personnel evacuated after the pillage of 1991, when their personal safety could no longer be assured, and the country appeared on the verge of collapse. Some did trickle back, but as Dr. Duale recounts for Karawa, those returning tended to be religious leaders (pastors), not medical personnel. He readily admits, "Karawa today is not the Karawa of the 1980s." Thanks to fundraising in the memory of Dr. Paul Carlson (killed in 1963), Karawa continues to benefit from external support. Not all sites are as fortunate.92

Other church-supported hospitals – in locations more isolated from the political turmoil of the 1990s and/or with stronger sources of external support – continued their work with a combination of expat and Congolese health providers. Some denominations chose not to cut their ties; they valued the direct interaction and continued to send missionaries, either for healthcare service delivery or development work.93

Since church-supported hospitals represented 38% of the hospitals in Zaïre at the time of the pillage, the continuation of this external support was a lifeline for many health zones. With donor-funded programs closed, the church-supported outposts scattered across this vast country became islands of refuge for the local population. Still today, in numerous locations the church tries to make up for many deficiencies of the government, although its presence is far less marked. As of 2022, Vanga still had an American and a German doctor.

The final nail in the coffin came in 1997, with the First Congo War (described below). The insecurity that gripped the country during the transition between Mobutu and Kabila was the final straw for most of the remaining expat missionaries in the country.94 According to Larry Sthrestley, who grew up in a missionary family in Zaïre and then worked for faith-based organizations, some missionaries left after the 1991 pillage and did not come back, but at least a third did return. After the 1993 pillage, more left, and then the war took the number down even further.

Dr. Thibaut Mukaba (currently Family Planning and Reproductive Health Adviser for USAID/DRC) recounts his own experience. Because of the pillage, the University of Kinshasa closed for two years, delaying his opportunity to take the test that would allow him to become a doctor. When he finally took and passed the test in 1993, he left to become a doctor at a German-financed Catholic hospital in the health zone of Kingangu, province of Bandundu. With no disruption in the German missionary funding, the health zone became a "development pole" in the region, with ongoing training and community agents who counseled on nutrition. Although the government could no longer purchase medications, the Church set up procurement through its own depot in Kinshasa. To attract young doctors, such health zones provided them with a house with electricity six hours a day, a refrigerator, and regular access to a vehicle to get provisions and medications.

By contrast, in church-supported health zones where the expat personnel fled and funding was discontinued in the wake of the pillage, the story was much different. Dr. Théophile Nemuandjare was the MCZ in the health zone of Nyanga, province of West Kasaï (Kasaï Occidental) in Zaïre, supported by the Mennonites. He was in Kinshasa to visit the bank and purchase medications and supplies for the health zone the day the pillage began in 1991. He was shocked by the destruction of property that he witnessed and the total chaos of his surroundings. Soon thereafter, it became difficult to find medicines, even soap, in Kinshasa. Shortly after the pillage, the American and Canadian missionaries in Nyanga held a meeting with the local personnel. "We have trained you. Now it is your responsibility to carry on." By 1992 the missionaries had left; the funds they sent back slowed to a trickle. The local community did not resent their departure, but they greatly regretted it. The hospital staff struggled to maintain the quality of services and slowly it began to decline. They could not give their patients the right care, and the patients could not pay. "All of today's problems date to the 1991 and 1993 pillages," observed Dr. Nemuandjare.

Dr. Felix Minuku recounts a similar story in Sona Bata, where an American doctor named Glen Tuttle built the Protestant hospital in 1925. From 1975 to 1986, the hospital was run by several Dutch doctors. Dr. Minuku arrived in 1977 as the first Zairian doctor to work at this hospital. Dr. Minuku credits the Dutch missionaries with helping to build or rehabilitate most of the health centers and maternities in the neighboring communities, as well as providing equipment for many health facilities in the region. They also helped to build a new nursing school in Sona Bata. For many years, the hospital in Sona Bata, along with other Americansupported Protestant hospitals in the provinces of Bas Zaïre and Bandundu, received linens from the Overseas White Cross (supported by the American Baptist Women's Ministries), as well as cans of corned beef to feed indigent patients and malnourished children. Sona Bata was considered to be one of the best hospitals in the region and attracted patients from as far away as Kinshasa (over 80 kilometers away). But by 1986, the last of the expat missionary doctors had departed Sona Bata. The local community was very favorable toward the missionaries but had grown to depend on them. The church had never tried to make the operation selfsufficient, and the staff did not learn to use local means to maintain their services. Dr. Minuku laments in relation to Sona Bata today, il n'y a plus rien sinon des bâtiments en ruine et un personnel soignant abandonné à lui-même. (There is nothing left but buildings in ruin and service providers abandoned to their own means.)

Dr. Albert Mudingayi had similar reflections about the missionaries. He had worked at the Presbyterian-supported hospital in Tshijaki, "the best in the province." Along with other primary healthcare services, they had a well-organized family planning program. "They never had stockouts." His mentor, American Dr. Walter Hull had taught him "what we didn't learn in medical school." The operative principle was to save a person's life without considering the money. When Dr. Hall succumbed to cancer, he was long remembered by the many people he had helped in the community. The population appreciated the sacrifices that the missionaries made to live in remote locations and serve populations that had so little. Yet people came to imagine that this assistance would go on forever. Many missionary groups did not have an exit strategy; they had not prepared their local counterparts to take over these services. "It would have been better to have a transition, say ten years, to train business managers," reflected Dr. Mudingayi. Most patients were not able to pay for their care, in a society where wealth was measured in terms of the number of goats and chickens. "But one chicken cannot pay for a Cesarean." The Presbyterians did send some Zairians for training overseas, but a number failed to return. Under the circumstances they had little choice; there was nothing to return to. Concluded Dr. Mudingayi, "The pillages killed off the missionary system."

The ECC survived the turmoil of the 1990s and continued well beyond as a vibrant actor in healthcare delivery, in addition to religious teaching. But the days of large mission stations – oases in remote areas with electricity, running water, and other amenities – drew to a close, as hospitals and health centers were increasingly turned over to the state to run. Locally trained physicians, many with an MPH, assumed their rightful positions as MCZs in the healthcare system.

#### Kabila brings an end to the Mobutu reign

By 1996, Mobutu's regime was politically and financially bankrupt. The population was restless, seething with resentment at Mobutu's chaotic repression, and economically devastated by the two pillages. Mobutu's military was in shambles, and his government was losing whatever control it still had over the population. The 1994 genocide in Rwanda had further destabilized eastern parts of the country, where long-lasting regional conflicts festered. Besides, Mobutu was terminally ill.95

In September 1996 Rwandan soldiers led by Laurent-Désiré Kabila's Alliance of Democratic Forces for the Liberation of Congo (AFDL) invaded Zaïre to root out the remaining perpetrators of the genocide. They progressively took control of major Zairian towns.96 Neighboring African countries jumped into the fray, in what became the First Congo War (1996–97). Although Mobutu's army put up resistance, it was easily quashed. The forces of Laurent-Désiré Kabila began a long march overland, hindered primarily by the dreadful state of Zaïre's roads. In the process, hundreds of thousands were killed in ethnic violence, and the already destitute country was further destroyed.97

On May 17, 1997, the ADFL captured Kinshasa. From Lubumbashi where he was located, Laurent-Désiré Kabila declared himself head of state. He promised to form a transitional government, ordered the military under his control, called for calm, and promised elections within two years (that never occurred).98

The Congolese population was jubilant to see Mobutu deposed. They took to the streets, welcoming Kabila's arrival as liberation, chanting and shrieking with cries of joy.99 Early in his administration he gained favor with the population by paying soldiers, teachers, and public servants; cleaning up garbage and sewers; and sprucing up the halls of ministries. But his popularity was short-lived.100

The Western powers also looked to Kabila's administration with great hope for clean management after decades of kleptocracy.101 It was not to be.

Mobutu fled first to his jungle palace in Gbadolite, then sought exile in Morocco. Through years of perfecting the practice of embezzlement and corruption, he had gained a fortune estimated between \$5–10 billion. Mobutu – who had bankrolled literally thousands of family members and acquaintances for decades – found himself alone with his wife when he succumbed to advanced prostate cancer on September 7, 1997.102

Kabila dispensed with the name Zaïre for the country, river, and currency, replacing it with the Democratic Republic of the Congo, the Congo River, and the Congolese franc. Under the new government, Kabila retained the existing ministries but installed political appointees in high places; civil servants continued their work. Initially, the economy appeared to improve, and petty theft subsided. Both international observers and common citizens dared to hope that the country was moving toward stability.103

Although Kabila had been brought to power with assistance from Rwanda, Uganda, and Burundi, he felt threatened by their continued presence in the country and sought to expel their military units. His efforts to secure their departure triggered the Second Congo War in 1998, which eventually drew in the armies of three more African nations. The First and Second Congo Wars ravaged the country's economy, further reducing the government's output and revenue, and increasing the external debt. The influx of refugees after the Second Congo War made a poor country even poorer.104

According to UNFPA reports from the time, Kabila's administration saw the link between economic development and population growth. In a speech in May 1998, the minister of plan insisted that slowing rapid population growth from 3.2% to 2.5% a year within two decades was essential to sustainable, equitable economic growth.105 Yet efforts in this direction were overwhelmed by the political turbulence of the day.

#### The US government reengages with DRC

The US had been watching the situation in Zaïre closely and anticipated the fall of Mobutu. A month after Kabila's forces triumphantly entered Kinshasa and declared victory on 17 May 1997, the USAID Bureau of Humanitarian Assistance (BHA) sent in a team to assess the prospects for re-engaging with the new leadership at multiple levels and in key provinces. The team issued a report in August 1997 that highlighted the dynamic nature of the transition as well as the ambiguities. Against a backdrop of enthusiasm for change, elite leaders, civil society, and the population at large had serious reservations about the legitimacy of the new political leadership (largely composed of expatriate Zairians), and its ties to neighboring powers.106 Most of those involved in the armed takeover had been living abroad and had little direct understanding of the country's complex dynamics.

The BHA team concluded that the new central government was still in flux, but that the US should move forward in bringing aid to support positive change where it was occurring. In the summer of 1997 USAID decided to take a dual approach of initiating stabilization activities and support to local confidencebuilding initiatives through its Office of Transition Initiatives (OTI), while laying the groundwork for reopening the mission.107

OTI sent in a team of eight expatriates with extensive in-country experience, headed by Willet Weeks, to reopen offices in the Mobil building and set up three regional offices in Katanga, Lubumbashi, and Bukavu.108 Max Walton, a highly respected USAID executive officer ("admin guy") who had worked previously in Kinshasa, joined the OTI team to put the necessary physical and communications infrastructure in place. The team reconnected with Victor Mangindula, the Congolese national who had kept the lights on for USAID during the hiatus in operations.

OTI recognized that much of the functional state had collapsed under Mobutu; government services in the provinces had been largely privatized. Where they were operational, they depended on community leadership and financial support. OTI would work to support such operations with a series of small grants, bypassing the still-embryonic central state. With these grants, OTI supported local public-private initiatives, for example, cleaning up the trash from the streets of Lubumbashi, rebuilding bridges in the Kasaïs, creating youth activities to absorb former child soldiers in South Kivu, and promoting peacebuilding activities and provincial-level development planning processes in the provinces where it was present.109

In parallel, the USAID Africa Bureau began moving to reinstate a full-scale mission. In January 1998, USAID Senior Foreign Service Officer John Grayzel, who had years of experience in francophone Africa, deployed to Kinshasa as the new mission director.110 For a period of months, the city bustled with activity by day but was eerily quiet at night. Everything worth stealing had already been taken. Ironically, it was a period of relative prosperity, aided by the de facto dollarization of the economy that ended previous inflationary cycles. Grayzel joined Walton and other Westerners who lived and worked out of the Intercontinental Hotel (later renamed the Grand Hotel, then the Pullman), which was also the de facto seat of government and locus of much intrigue. Fellow hotel guests included countless official and non-official Rwandans who had entered Kinshasa with Kabila's troops. Daily life was fluid. If someone needed legal services, they would go to a government office and pay for a trial. No one was sure what was happening and how things would go.

Across the Congo River in Brazzaville, a violent civil war was raging. The sounds of artillery fire shook Kinshasa, stray shells fell on the city (including on the Intercontinental Hotel), and helicopters could be seen bombarding neighborhoods across the river. Tensions within rebel groups led to frequent clashes and brief exchanges of fire, particularly at night. The city was under a strict night-time curfew.

The director's office had been virtually untouched since 1991, a thick layer of dust blanketing the furniture and an empty pizza carton on a side table. On the advice of a colleague who had served in another post-conflict country, Grayzel immediately called for an audit to identify problems already in existence before he took over. However, he found that French-speaking auditors were not eager to travel to Kinshasa during those turbulent times, and in his two years of tenure, no audit ever occurred.

In August 1998, the Second Congo War broke out, ensnaring eight neighboring countries and some 25 armed rebel groups in the conflict, though fought mostly on Congolese soil.111 It was a terrifying period for those Americans caught in the crosshairs. At one point the embassy asked Americans to gather at the Marine-protected General Services Warehouse compound, only to find Congolese soldiers forcing entry by scaling the wall. Fortunately, they were looking for Rwandan soldiers, not Americans, and left after seeing that none were being harbored there. Given the persistent danger, the US embassy evacuated all US personnel. By December 1998 the city had stabilized enough for US personnel to return, and USAID was able to officially reopen with no dependents allowed.

#### 176 The Fifty Years of Family Planning

Grayzel approached his job by asking "What had worked before that is still around" and "How can we revive it?" He had authorization from Washington to buy into existing centrally funded projects and to make small grants without most of the usual USAID paperwork. "If we had had the normal USAID controls in place, nothing could have happened." He opened up several sectors: environment and democracy first, followed closely by health.112

Health was a high priority. Diseases that were somewhat controlled before the pillage had returned with a vengeance: polio (in Mbuyi Mayi), monkeypox (Sankuru), measles (multiple locations), and by far the most insidious: malnutrition (that pervaded the country).113 Grayzel authorized \$4M to UNICEF as part of a multi-donor polio vaccination effort and recruited Dr. Reggie Hawkins, seconded from CDC, to coordinate this effort. It was a perilous environment for health programming, with the presence of rebel forces in four provinces in the east blocking all access to these populations. Eventually, those involved established a de facto truce that permitted the vaccination teams to proceed with the work, often with members of the armed groups helping with logistics.

Two organizations in the health sector fit the criteria of "previously successful and still operating." The first was the Kinshasa School of Public Health. One day Grayzel made an impromptu visit to the UNIKIN campus. To his amazement – against the backdrop of total disfunction in public services in Kinshasa – he found professors at work teaching public health classes to students from both the Congo and neighboring countries. The institution, with substantial assistance from Tulane University under the direction of William Bertrand, had not only survived the pillages but, according to the CDC analysis, was the only African institutional capacity, other than in South Africa, capable of adequately monitoring outbreaks.

The second was ECC (Church of Christ in the Congo, renamed from ECZ when the name of the country changed), which had been highly effective with SANRU. Grayzel discovered communities where village self-help committees – originally established by the SANRU project – were now operating as critical de facto community governance bodies to manage health, schools, and water in response to the total breakdown of official functioning government services. The ECC would go on to play a key role in reinforcing new health services countrywide.114

USAID/DRC worked to reengage with the Kabila's central government. With the continuing war of aggression by neighboring countries using proxy Congolese forces and the DRC divided into zones of control, OTI was for a time able to resume some activities in the Kasaïs and parts of Katanga while maintaining remote contact with its Bukavu office (from which expat personnel had been evacuated), with travel in and out via Nairobi. As its original mission wound down in 1999, the OTI became involved in supporting crossline communications between civil society actors, convening off-shore dialogues on national reconciliation, and channeling US support to the Lusaka Accords that would bring an end to the Second Africa War. OTI eventually handed off its work to USAID as it reopened in Kinshasa.115 President Kabila would eventually quash these efforts for expanded democratic participation in orienting the country's future.

Family planning was only a small part of USAID's development work in the DRC. Yet USAID was the dominant player in introducing family planning to the DRC in the 1980s before all assistance was halted in 1991. With reason, for those in the family planning community, all eyes were on USAID with the dawn of a new decade and century.

#### Reflections on the 1990s

Thanks to the multiple agencies and projects working in family planning in the 1980s, the decade of the 1990s opened with a sense of progress and optimism for continued growth. PSND had expanded access to contraception in urban areas, despite managerial shortcomings. SANRU and the Zaïre Social Marketing Project exposed millions in both rural and urban areas to the concept of birth spacing and the use of condoms for preventing both HIV transmission and pregnancy. The stated objectives for the Zaïre Family Planning Project included increasing the contraceptive prevalence rate, although the target number varied by document. In the absence of any mechanism to measure contraceptive prevalence at the national level, the exact rate was a moot point. Despite recommendations by evaluators to conduct a national health survey that would measure contraceptive prevalence, no plans were on the books to do so. One can only speculate that the USAID/Zaïre leadership did not consider it a worthwhile investment of funds (millions of dollars) to determine that modern contraceptive prevalence in Zaïre was still in single digits, probably no higher than 5% nationwide, if that.

The pillage of 1991 paralyzed development work, including family planning, for over a decade. The pillage of 1993 brought further devastation and hopelessness to the country. Although PSND/PNND had kept its doors open for the entire decade, it accomplished little, devoid of leadership, contraceptives, and funds to operate a national program. As a local NGO, the ECZ/ECC also remained open with a skeletal crew but insufficient funds to operate effectively. Modest support from PSI headquarters allowed ASF/Johnny Loftin to stay afloat but barely.

By the mid-1990s, several grants breathed new life into family planning, albeit on a limited scale. UNFPA continued to fund PSND with occasional projects.116 The EU awarded ECZ a large two-year grant for general support in rural health zones (including family planning); shortly thereafter the World Bank gave ECZ funding to revive family planning in Kinshasa, primarily in facilities supported by Protestant churches. ASF/PSI – by now distributing condoms only (no other contraceptives) – reestablished a very successful social marketing activity under the USAID-funded AIDSMARK project. But these activities were trifling in comparison to the portfolio of family planning work in the 1980s.

Did the pillage and Mobutu's demise have a long-term impact on contraceptive use in Zaïre/DRC? Yes, in multiple ways. The momentum built up during the 1980s through the PSND, SANRU, the Zaïre Social Marketing Project, AZBEF, and the operation research projects came crashing to a halt when USAID and other donors withdrew their funding in the wake of the 1991 pillage. Moreover, the political and economic upheavals in every decade since Independence in 1960 left the population traumatized and defeated. If Zaïrois had previously lived day-to-day, the effects of the pillage were to further undermine any sense of normalcy. How could one worry about the future when it was unclear where the next meal would come from?

Among the few individuals who wanted to practice family planning, the pillage left two indelible marks that remained until recent years. First, DRC is one of the few countries in sub-Saharan Africa where the condom has been the leading modern method among married women in every major study conducted from the 1980s to 2017.117 Anecdotal evidence would suggest that couples do not like to use condoms, which they consider inappropriate in the context of marriage (condoms imply infidelity; one uses condoms outside of marriage, with prostitutes or the deuxième bureau). Is the use of condoms as the favored method the result of its being one of the few methods available – often free of charge – in the post-pillage period?

The DRC is only one of five countries worldwide in which the percentage of married women using a traditional method (rhythm or coitus interruptus) is higher than for modern methods (pills, implants, IUDs, injections, condoms, among others). Even in Kinshasa, where access to modern contraception expanded dramatically in the 2010s, the percentage of users remains similar for modern versus traditional methods. This practice is often attributed to the deep-seated fear that modern contraception will jeopardize future fertility for the woman (unfounded but widespread).118 Yet some speculate that the widespread use of natural methods in the period after the pillage – for lack of any alternatives – left its mark on this population.

#### Notes

#### 180 The Fifty Years of Family Planning

### 7 The 2000s

Family Planning – Like the Country – Inches Back to Normalcy

#### Armed conflict grinds on despite efforts to wind down the war

As the new decade – not to mention the new century – began in the DRC, much remained unchanged from the end of the 1990s. The Second Congo War continued unabated in the eastern provinces of Orientale, North Kivu, South Kivu, and Maniema, despite multiple accords and agreements for a ceasefire. Violence of all types had become commonplace: massacres, kidnapping, rape. Boys who should have been in school were instead recruited as child soldiers. President Kabila continued his autocratic rule, though he only controlled the seven provinces in the Western region of the country; rebel groups had commandeered the east. The war had devolved from a struggle for political control to an outright gold rush for the minerals in the provinces neighboring Rwanda (Ituri) and Uganda (the Kivus). The rush intensified when global demand spiked for a new mineral, coltan, over 80% of which is found in the DRC. Rwanda and Uganda continued to exploit Congo's mineral resources at mind-boggling levels. Rwanda, a country with no diamonds of its own, sold \$40M of diamonds annually on the world market.1

If the outside world had disengaged from the relentless bloodshed in the Congo, a front-page article in the New York Times on June 9, 2000, refocused attention on the plight of the country: "Death Toll in Congo's Two-Year War is at Least 1.7 Million, Study Says."2 (By its end in 2006, it would become the deadliest conflict since World War II, with an estimated two to five million deaths.)3 Peace treaties and accords were negotiated to put an end to the violence, but none succeeded.

The DRC population had grown to nearly 50 million, with just over one-third living in urban areas. Men and women struggled to earn a living, largely surviving thanks to the informal economy in urban areas and subsistence agriculture in rural areas.

Shock waves rocked the country when on January 26, 2001, Laurent-Désiré Kabila was assassinated in his office at the Palais de Marbre (Marble Palace) in Kinshasa. Within days, members of parliament elected his son Joseph to replace him. To avert unrest, the United Nations Organization Mission in the DRC (MONUC) sent peace keeping forces to the rebel-controlled provinces of the east and later into government-controlled provinces of the west.4 Initially viewed as weak and inexperienced, Kabila fils soon showed his metal in discussions with

DOI: 10.4324/9781032718897-9

Rwandan counterparts and extolled the virtues of peace, national unity, and international cooperation.5

With the help of international intermediaries, in 2002 the DRC signed a peace agreement between DRC and Rwanda in Pretoria; a similar agreement was then signed between the DRC and Uganda in Luanda. In the same year, a UN panel documented that the governments of Burundi, Rwanda, and Uganda were plundering the natural riches of the DRC: gold, diamonds, timber, and ivory.6

With the help of international advisers, President Kabila brokered the Accord Compréhensif et Inclusif (Global and All-Inclusive Agreement of Transition) designed to create a new transitional government. Building on this new government, the Sun-City agreement (2003) was formed to combine all past agreements and fully rid the Congo of both Rwandan and Ugandan soldiers, as well as militia groups. This agreement marked the formal end of the Second Congo War.7

The Accord stipulated a transitional period of two years, beginning in 2003. It called for "one + four" governance: one president plus four vice presidents, representing different regions and interests.8 Realizing that the transitional period would be timebound, those in positions of power lost no time in plundering state funds. According to a 2004 audit, within a year a half billion dollars had been embezzled, leading to the dismissal of six ministers. Some \$13 billion – intended for investment in health, education, and infrastructure – "disappeared. 9"

The Accord Compréhensif et Inclusif brought no end to the political unrest in the east. The final phase of the Second Congo War began in late 2004 when President Kagame of Rwanda announced his intention to send troops into Congo to root out Hutu militants, whom he feared could threaten his government.10 With no end to armed conflict, MONUC increased the number of peacekeeping troops.11

The year 2006 brought changes to the country that allowed both the international community and the average Congolese to cautiously anticipate a better future. It began with the adoption of a new constitution approved through a popular referendum.12 The government also introduced a new flag with the now familiar colors of turquoise, yellow, and red.13

Yet the signature achievement of 2006 was the first multi-party democratic presidential election held since independence in 1960. The event had great symbolic importance, including to the average Congolese. For many, it was their first opportunity to vote. The international community invested a half billion dollars in this exercise in democracy, the most ever expended on a national election at that time.

In what external observers concluded was a generally fair election, Joseph Kabila emerged as president. In his inaugural speech, he pledged to reconstruct five sectors: infrastructure, water, and electricity, education, employment, and healthcare. Again, the West hoped this would bring a new dawn to a country decimated by war, political intrigue, and corruption. For a short time, he enjoyed new popularity among the populace.

Yet as Van Reybrouk observes, "How then could the West expect that particular method to magically transform a deep, rooted culture of corruption and clientelism into a democratic constitutional state in accordance with the Scandinavian model? And then in a region that, during its pre-colonial, colonial[, and] post-colonial eras had known almost nothing but forms of autocratic rule. 14 "