What does circumcision mean to you? While circumcision is a religious practice for some, for others it is a technique proven to reduce HIV infection and Sexually Transmitted Infections (STIs). For some surgeons in Bugisu, it is the reason they will be coercively tested for HIV this year, a violation of their rights.

In advance of the inaugural Imbalu ceremony on August 11, the Ministry of Health and the cultural institution Inzu Ya Masaba have announced that over 1,000 surgeons will have to undergo HIV tests in order to “safeguard those to be circumcised.” It is not clear what will occur if surgeons are found to be HIV positive. Will they be barred from participating? Will their privacy be protected? It is not clear whether surgeons who are living with HIV will lose business or their livelihood. And it is particularly unclear why they are being forced to get tested for HIV at all, given that no part of the Imbalu ceremony involves surgeons sharing blood or bodily fluids with the boys they will operate on.

Building strong policy at the intersection of health and cultural practice can be complex. According to Article 37 of the Ugandan Constitution, Ugandans have the right to culture, to practice and enjoy cultural languages and traditions. At the same time, according to the International Convention on Economic, Social, and Cultural Rights (ICESCR), Ugandans have the right to the highest attainable standard of health. These two rights are not in opposition to each other: programs promoting health rights can and should be integrated with cultural practices. In the example of Female Genital Mutilation (FGM), FGM was found to be a severe threat to health and women’s rights, and was banned in Uganda in 2010.[1] In enforcing this ban, the Ugandan government found that attempting to eradicate FGM only pushed the practice underground and led to backlash. Instead, preserving the rite of initiation while ending the most violent aspects of the practice was a more effective and sustainable strategy to reduce violence against women.[2] Such strategies allow communities to maintain cultural cohesion along with a high standard of health. They are most effective when paired with strong community engagement and health education, giving community members the tools to make informed choices about their own health.

In the case of Imbalu, the tradition has undergone shifts in the last decade related to the HIV/AIDS epidemic. In 2012, New Vision reported that growing numbers of Bagisu boys were getting circumcised in health centers, in order to reduce the risk of HIV transmission, instead of in the Imbalu ceremony.[3] Circumcision does reduce the risk of HIV transmission, but it does not remove the risk entirely, which the government failed to communicate fully: the same year, the Center for Health Journalism reported that individual Bagisu men were forcibly circumcising non-Bagisu men, convinced that they were spreading HIV and STIs to Gishu women.[4] This is a strong example of the value of health education. With an incomplete understanding of HIV transmission, people can draw incorrect conclusions around the stigmatized topic of HIV transmission and commit violence based on them.

Since 2012, there have also been initiatives in place to clean and sterilize knives used in the Imbalu, and a “one knife, one candidate” policy.[5] The “one knife, one candidate policy” drove up the cost of knives, but is an excellent example of a minimal intervention into the Imbalu ceremony that allowed communities to continue a cultural practice in a safer form. This policy is a type of harm reduction, where policymakers make small interventions to an existing activity rather than attempt to drastically change behavior patterns or criminalize whole practices. The Ugandan Harm Reduction Network (UHRN) has advocated for needle and syringe sterilization programs for Injectable Drug Users (IDUs), programs that save lives and money.

If surgeons are careful to operate with clean, sterilized equipment and ensure that they themselves do not have any open wounds, there is no risk of HIV transmission. HIV is transmitted through specific bodily fluids: blood, breast milk, sexual fluids, and mucus.[6] It absolutely cannot be transmitted by a person performing surgery with sterilized surgical tools. The decision to test surgeons is based not in science or best practices in public health, but instead on the stigma surrounding people living with HIV. Once again, it is crucially important to engage in health education to reduce this stigma, the idea that people living with HIV are dangerous or risky.

In truth, it is this stigma that is dangerous. If people associate fear, confusion and discrimination with HIV, they are less likely to seek effective care, protect against HIV transmission, and treat people living with HIV with dignity. People living with HIV are members of our community, and Ugandans everywhere should have the tools to protect against HIV transmission without demonizing people who live with it. HIV tests should be voluntary and consensual, with full assurance of privacy and confidentiality. Surgeons who test positive should be counseled on treatment options and free to continue their work without discrimination, as established by the 2005 Equal Opportunities Commission Act and the 2006 Employment Act in Uganda.

Requiring Imbalu surgeons to be tested for HIV is a counterproductive, discriminatory, and disruptive approach. The Ministry of Health should instead act to promote health rights within cultural practice, scale up programs that ensure clean and sterilized surgical equipment, and encourage comprehensive health education.

All Ugandans have the right to move through the world with privacy, dignity, culture, and the highest attainable standard of health. The young people preparing for the Imbalu in Bugisu deserve to be safe, healthy, make choices about their own bodies, and participate in cultural rites. Similarly, and the surgeons preparing for the ceremony deserve to navigate their HIV status in comfortable and consensual ways. As Uganda navigates the complex challenges of establishing a sound HIV policy in a culturally diverse environment, a focus on human rights, education, and non-discrimination is both sound and humane policy to carry out cultural practices in safe and healthy ways.

Written by Sagaree Jain – Research & Grants Associate at CEHURD

[1]https://ulii.org/ug/legislation/act/2015/5-5

[2]http://www.fahamu.org/mbbc/wp-content/uploads/2011/09/Tamale-2007-Right-to-Culture.pdf

[3]https://www.newvision.co.ug/new_vision/news/1311410/imbalu-surgeons-abandon-risky-practises-hiv-surges

[4]https://www.centerforhealthjournalism.org/2012/07/19/culture-and-male-circumcision-clash-mbale-uganda

[5]https://www.newvision.co.ug/new_vision/news/1311410/imbalu-surgeons-abandon-risky-practises-hiv-surges

[6]https://www.avert.org/learn-share/hiv-fact-sheets/hiv-transmission

According to the 2014 Global Initiative for Economic, Social and Cultural Rights; A Rights-Based Approach to Participation. A GI-ESCR Practitioner’s Guide, Every person and all peoples are entitled to active, free and meaningful participation in, contribution to, and enjoyment of development in which human rights and fundamental freedoms can be realized. READ MORE

By Sheila Akandinda

Access to health care is a Human right guaranteed under the international instruments. The International Covenant on Economic, Social and Cultural Rights (ICESCR), recognizes the right of everyone to “the enjoyment of the highest attainable standard of physical and mental health”. “Health” is this sense should not be looked at a right to be healthy, but as a right to control one’s own health and body (including reproduction), and be free from interference such as torture or medical experimentation. States including Uganda, thus, must protect this right by ensuring that their citizens have access to the underlying determinants of health. These include, but not limited to, clean water, sanitation, food, nutrition and housing, and through a comprehensive system of healthcare, which is available to everyone without discrimination, and economically accessible to all.

It’s also a requirement that governments take specific steps to improve the health of their citizens, including reducing infant mortality and improving child health, improving environmental and workplace health, preventing, controlling and treating epidemic diseases, and creating conditions to ensure equal and timely access to medical services for all. These are considered to be “illustrative, non-exhaustive examples”, rather than a complete statement of State obligations.

The above requirement extends to the protection of Women’s reproductive rights. Thus, governments are required to respect such by among others not limiting access to contraception or “censoring, withholding or intentionally misrepresenting” information about sexual health. They must also ensure that women are protected from harmful traditional practices such as Female genital mutilation. It is unfortunate however that when it comes to access to health care especially for women of reproductive age, health commodities are always reported, either insufficient, out of stock or never supplied. This hinders access to services.

Basic commodities like essential drugs, books where health workers write the patients’ medical prescriptions, basic family planning services like female condoms, blood transfusion services, on top of low staffing of health centers among others, leave a number of patients unattended to.

In rural remote areas, the situation is even worse. While the few health service provider over work to ensure access to health care for all, some conditions put for one to access a service leave out many. For example, or lack of better means for record keeping, health facilities require any patient to have an exercise book to allow workers record medical prescriptions. This requirement however, leaves out a big number of those that can hardly afford the books from accessing the service. The enquired book is worth three hundred (300/-) Uganda shillings but many cannot afford it.

One would then pause a question to the Ugandan government on whether the three hundred Uganda shillings is worth the life of many people dying each and every day that passes just because they cannot afford books, whose role and mandate is it to ensure that facilities have enough stationery to cater for the very poor people to allow them access basic health care? It’s such a saddening situation that Uganda as a country needs to critically think about.
Despite Uganda having one of the worst healthcare records in the world, a decision to develop local facilities, and proper installment of drugs and training of volunteers will bring life-saving services to thousands of people and related realization of an access to health care dream.

By Irene Abenakyo

Global estimates published by WHO indicate that about 1 in 3 (35%) of women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in there. Gender based violence has been broadly defined as a significant well-recognized threat to public health and human rights It include any act that results in or is likely to result in physical, sexual, or psychological harm or suffering, whether occurring in public or private life. Such acts may include Female infanticide; child sexual abuse; sex trafficking and forced labor; sexual coercion and abuse; neglect; domestic violence; elder abuse; and harmful traditional practices such as early and forced marriage, “honor” killings, and female genital mutilation/cutting.

GBV is wide spread in Uganda and it affects all people irrespective of their social, economic and political status. It occurs in families, communities, workplaces and institutions. According to the Uganda Police Force’s annual crime report, gender-based violence cases that were reported and investigated increased by 4% (from 38,651 to 40,258 cases) between 2015 and 2016. The 2016 Uganda Demographic and Health Survey further revealed that up to 22% of women aged 15 to 49 in the country had experienced some form of sexual violence. The report also revealed that annually, 13% of women aged 15 to 49 report experiencing sexual violence. These statistics leave a number of questions relating to realization of rights. If the state can broadly write about these violations, one wonders what has been put in place to protect women and girls from such abuse.

The Center for Health, Human Rights and Development (CEHURD) in collaboration with the International Law Development Organization (IDLO) implemented a DREAMS Innovation Challenge project titled; Integrating Legal Empowerment and social accountability for Quality HIV Health services for AGYW in the district of Mukono and Gomba.(LE-SA+). One of the achievements of this project was to uncover the GBV cases within districts. We realized a number of challenges in accessing justice for survivors of gender based violence. First, during the initial stages of the project, communities had lost hope in the judicial law and order sector actors for their continued corruption and perhaps insufficient knowledge in what to do in case such case are received. CEHURD worked tirelessly to revive this hope and indeed at the end of the project in October 2018, many had seen light in the sense of accessing justice.

• The most troubling question though is whether government’s failure to provide shelter for such survivors of violence is in itself a violation of rights.
  NFM (pseudo acronyms) a 16 year old was defiled on her way home by a boda boda cyclist, she endured the pain and sought medical attention- the beauty is that the health service provider who attended to her had been trained by CEHURD- he did his best and forwarded her to police- investigations took on and the case is pending before Court.
• NBJ (pseudo name) a 14 year old was defiled by a school, football coach, and who is living with HIV. NBJ sought medical attention and was brought to CEHURD’s attention during one of our community awareness campaigns. CEHURD took over and case is pending before Court of law
• FM (pseudo name) is presumed to have been defiled by her step father when her mother was away and impregnated. She did not have an opportunity to receive PEP neither emergency contraceptives. Her step father did what he could to ensure this girl is aborted. The case is up for police investigations.

The stories are many but that not my point today. My question is, where all these girls and many more go after surviving such violence. CEHURD’s intervention on this subject has proved that once abused, women and girls are left to get back to their communities without receiving any psychosocial support or prepared to get back to the communities. The country lacks such a one stop center that is ideal in the realization of rights of these women and girls.

While there are private institutions like Wakisa ministries, working hand in hand with government, the restrictions are to take on girls who survive violence and become pregnant at such tender ages. CEHURD’s efforts under this project were geared towards ensuring that such girls do not get pregnant and has worked with health institutions to readily avail them with emergency contraceptives and PEP. It thus becomes a great challenge that the government of Uganda has not put in place any of its owned shelters that can cater for each and every survivor

The lack of such a shelter comes with violations of a number of rights. Once the girls are defiled they go through a lot of psychological torture and necessitate rigorous counselling to ensure their right to health and life is not violated. However with lack of a shelter, they face numerous discriminations and stigma including community and self-stigma. Some have opted to run away from their communities while others drop out of schools for the stigma they face. Homes have become a center of abuses yet communities are not prepared to receive such abused girls back. Privacy, nondiscrimination and equality before the law remain in the Constitution as rights but not observed in such scenarios.

In the end, there seems to be no hope for such girls and as a country, we are most likely never going to report a total reduction of teenage pregnancies and hopefully unsafe abortions. .

These and many become pertinent for the government to put in place a shelter, which is accessible to all survivors, which will help the victims/ survivors seek medical help at no cost but also be provided with security from the perpetrators and be reached by police in cases of evidence collection.

By Lilian Aguti

GBV is an umbrella term used to describe any harmful act that is perpetrated against a person’s will on the basis of unequal relations between women and men, as well as through abuse of power. In Uganda sexual and physical violence is widespread and mainly committed against women and girls and it affects all people irrespective of their social, economic and political status.

Global estimates published by WHO indicate that about 1 in 3 (35%) of women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in there. Gender based violence has been broadly defined as a significant well-recognized threat to public health and human rights. It includes any act that results in or is likely to result in physical, sexual, or psychological harm or suffering, whether occurring in public or private life. Such acts may include Female infanticide; child sexual abuse; sex trafficking and forced labor; sexual coercion and abuse; neglect; domestic violence; elder abuse; and harmful traditional practices such as early and forced marriage, “honor” killings, and female genital mutilation/cutting.

According to the Uganda Police Force’s annual crime report, gender-based violence cases that were reported and investigated increased by 4% (from 38,651 to 40,258 cases) between 2015 and 2016. The 2016 Uganda Demographic and Health Survey further revealed that up to 22% of women aged 15 to 49 in the country had experienced some form of sexual violence. The report also revealed that annually, 13% of women aged 15 to 49 report experiencing sexual violence.

My experience working with the communities, fear is among the contributing factors to committing GBV. Often times, survivors of violence give up to report or follow up on cases due to fear of wrangles, hatred by the family of the perpetuator or even threats of death. In the communities people believe that witchcraft is real and because of this, there is a tendency to fear that they will be bewitched or killed because of following up on cases that end up with imprisonment as a punishment of the perpetrator. At the same time, girls fear to report cases of sexual violence with the assertion that they will be embarrassed, they would rather conceal the information to themselves instead of seeking for support. This is because, in the Ugandan setting, sexuality is considered private and not for public consumption. Through the norm of “Eby’omunju tebitottolwa” literally meaning that what whatever happens in the home should never be a consumption of the public, the young women are culturally taught to conceal any information that is related to their marriage to the extent that even when the husband batters her, she is to keep it to herself.

The fear still goes an extra mile that even the local council members to whom support could be sought from, fear to handle such cases because they feel they will end up losing their positions in the subsequent elections as a result to taking to jail an offender.

All these have been fertile grounds for GBV to prevail in the communities as the perpetrators run away with it and commit similar offences. Much as the fear is at the forefront, we cannot also run away from the fact that there other drivers fueling GBV prevalence in the communities. These include negotiations at the village /community level, poverty, illiteracy levels, weak enforcement of laws on violence, corruption among others. As a result of all these, some parents have been forced to accept bribes from perpetrators which has hindered cases from being forwarded to court. When someone insists that the case be taken forward to court, in some instances the parents of the survivor stand up to say “Is the defiled child yours?”

It is also a common practice for people in the community to tell the parents of the survivor that “At least you get something, agree and negotiate with the perpetrator but if you don’t, then it’s going to be a total loss on your side”. Such comments are usually tagged to the long Court processes and delays at police. As if that is not enough, there is a practice of charging fees at almost every center for one to successfully report a GBV case. For example facilitating the movements to court, to the health facility, to police then later to court and the fees for filling in the police form3. Sometimes the police also need to be facilitated to go and arrest the perpetrator or to visit the crime scene and collect evidence. This facilitation may not be available to most of the survivors so they end up abandoning the cases.

My interaction with the communities also made me know that community members have low confidence in the justice systems. Police has been cited as one such an institution. A number of voices within communities noted the high levels of corruption within the police that sometimes the police are paid off to suppress cases. They connive with parents of the perpetuator to convince the victim’s family that they will not get justice in court but rather they should seek monetary compensation from the perpetrator and sometimes they hide the files and make the cases disappear.

The community members have now developed a belief that perpetuators target poor families of people who cannot proceed anywhere with the cases. Whereas as perpetrators are able to bail themselves out scot free.
Thanks to the Center for Health Human Rights and Development (CEHURD) interventions in the communities of Gomba and Mukono under the Determined Resilient Empowered, AIDS free Mentored and Safe (DREAMS) innovation Challenge project which has and will continue empowering the communities on their human and health rights through the trainings.

CEHURD has also trained Adolescent Girls and Young Women (AGYW) as Community Health Advocates. This continue to empower the communities on their human and health rights. This sensitization trainings have been an eye opener and communities are now able to report cases of violence. The elected local council members have also been trained on their role in handling the GBV cases and there is hope that there is some light at the end of the tunnel.