Document - Burundi: Medical Action - Redress for victims of sexual violence

Public AI Index: AFR16/010/2004 ----------------------------

Amnesty International

International Secretariat

Peter Benenson House

1 Easton Street

London WC1X 0DW

United Kingdom

To: Health Professionals’ network

From: Medical Team

Date: 27 February 2004

Burundi:

Redress for victims of sexual violence

"I was going with three children to get water when a soldier stopped us on the road. The children managed to escape, but I fell and he caught me. He took me to a church, which they had turned into some kind of bar with food and alcohol everywhere. The soldier raped me in the church, and he told me I would be blessed because it was a holy place...Another one refused to rape me. The first soldier forced a bottle of beer inside me. I started bleeding and shouting. The soldiers covered me with a military coat and left me outside the church to die." Amélie, aged 30

Summary

On 24 February, AI launched a report entitled Burundi: Rape - the hidden human rights abuse(AFR 16/006/2004). The report focuses on the alarming increase in the number of cases of rape of women in the context of Burundi’s armed conflict; it describes, among other things, how a concomitant increase in HIV/AIDs and other sexually transmitted diseases has affected victims of such violations; how, due to the stigma and fear attached to reporting rape, lack of access to medical care and the lack of systematic recording of cases, many cases go unreported, and suggests that urgent action is required to end the violence against women in Burundi, address its legacy and prevent a recurrence. The report also looks at the way the rape crisis is putting a further strain on the health care system in Burundi, which is already weak and under-resourced and susceptible to pressure from international financial institutions such as the International Monetary Fund and the World Bank to limit provision of free medical care.

Relevant materials for this action

· Report, Burundi: Rape - the hidden human rights abuse(AFR 16 /006/2004) February 2004.

· Action Circular AFR/007/2004, 09 February 2004 (Distributed to Campaign Coordinators and the Medical network, amongst others).

· International press release to coincide with the launch of the report on 24 February 2004.

· Website and online action at: http://web.amnesty.org/pages/bdi-240204-action-eng, available from 24 February.

· Report: It's in our hands - Stop violence against women(ACT 77/ 001/2004), launch report of the SVAW campaign, March 2004.

Please liaise with your section campaign coordinator regarding any publicity and outreach activities.

Background

During Burundi’s 10 year armed conflict women have suffered disproportionately and have been targets of violence and degrading treatment as a result of their gender. Sexual violence is a significant and under-reported element of the human rights tragedy in the country. Rape has become an entrenched feature of the crisis because the perpetrators - whether government soldiers, members of armed political groups, or private individuals - have largely not been brought to justice. Rape has, however, also been exacerbated by widespread discrimination against women and its consequences have been aggravated by poverty, internal displacement and a failing health system.

In 2003, national and international non-governmental human rights and humanitarian organizations, international agencies, and government authorities reported an alarming increase in the number of cases of rape of women in the context of Burundi’s armed conflict.(1) A concomitant increase in HIV/AIDs and other sexually transmitted diseases has affected victims of such violations.(2) It is only recently that information on rape began to be recorded within the criminal justice system. Even now, when the scale of the violence has forced the issue into the open, many cases go unreported due to the stigma and fear attached to reporting rape officially, lack of access to medical care and the lack of systematic recording of cases. Testimonial evidence supports the view that sexual violence has been a significantly underreported element of Burundi’s 10-year human rights crisis.

Even from the limited evidence available, the scale of rape indicates a deliberate strategy in some parts of the country by belligerents to use sexual violence against women as a weapon of war to instil terror among the civilian population and to inflict degradation and humiliation. The perpetrators are largely members of the Burundian armed forces and armed political groups, as well as armed criminal gangs who not only rob but also rape. Rape of young girls (under 12?) is also common - sometimes in the mistaken belief that it will provide protection from, or constitute a cure for, HIV/AIDs. Fear of being raped at home at night is causing whole families to sleep outside and away from their homes, rendering them still more vulnerable to malaria and other insect-borne diseases.

Access to health care

The rape crisis is putting a further strain on the health care system in Burundi, which is already weak and under-resourced as a consequence of years of under-investment.

Interventions by humanitarian organizations have enabled women in some areas to receive this medical care, including free post-exposure prophylactic drugs to prevent HIV infection in the immediate aftermath of rape. However, these services are not available in many provinces, particularly to women who live far from health centres or in areas of conflict. Many people do not know that such sources of care or medication exist. Additionally, the continuing stigma attached to sexual violence and fear of coming forward prevents some victims of sexual violence from accessing these services.

The past ten years of insecurity have taken their toll on the health of the population in a number of ways: problems caused by war-related injuries; degraded health due to diminished access to fields and markets, and to insecurity and pillaging of food stocks; vulnerability to disease aggravated by sleeping outdoors, often in the cold or rain, repeated displacements, fatigue, malnutrition and, for refugees and internally displaced persons (IDPs), poor sanitation; destruction of health centres and inaccessibility to health care due to insecurity; looting of pharmaceuticals; widespread sexual violence and the attendant transmission of HIV/AIDs and other diseases.

At the same time, incomes in Burundi have fallen, leaving a destitute population unable to afford medical treatment or even examination. Only one to two state doctors serve each province(3) and are responsible not only for treating patients but also for providing administrative oversight. The population has reportedly resorted to traditional healers for several reasons: these healers may be cheaper, the population’s faith in the health services has diminished and health centres may be located in areas of insecurity.

International human rights obligations and health care

Burundi, like many countries dependent on foreign aid, is under pressure from international institutions such as the International Monetary Fund and the World Bank to limit provision of free medical care. In 2002, during a period when the Burundian population has been most in need of adequate and affordable healthcare, the government of Burundi instituted policies of cost-recovery in the health centres - that is, patients had to pay for the cost of medical services delivered. As a result, very few Burundians are now able to afford services provided by state health centres. If it were not for the assistance provided by humanitarian organizations, many Burundians would have no access to health care whatsoever. Women about to give birth are often required to pay a deposit before they will be admitted to health centres - this is to cover the eventuality that they may need a caesarean section - and may be effectively imprisoned in the health centre until they pay their bills, sometimes by resorting to selling their family plots of land. The available evidence concerning the impact of cost-recovery policies on access to health care for impoverished sections of the population raises questions concerning whether or not the government has acted in accordance with its obligations under the International Covenant on Economic Social and Cultural Rights (ICESCR) that everyone has the right to the "highest attainable standard of physical and mental health" without discrimination of any kind(4).

In its General Comment 14, the Committee on Economic, Social and Cultural Rights notes the provision of the Covenant for progressive realisation of the right to the highest attainable standard of health and the resource constraints faced by States Parties, but clearly states "health facilities, goods and services must be affordable for all. Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households."(5)

General Comment 14 also states clearly the international obligations of states parties to "recognize the essential role of international cooperation and comply with their commitment to take joint and separate action to achieve the full realization of the right to health. In this regard, state parties are referred to the Alma-Ata Declaration(6) which proclaims that the existing gross inequality of health status of people, particularly between developed and developing countries, as well as within countries, is politically, socially and economically unacceptable and is, therefore, of common concern to all countries...Similarly, States Parties have an obligation to ensure that their actions as members of international organizations take due account of the right to health. Accordingly, State parties which are members of international financial institutions, notably the International Monetary Fund, the World Bank, and regional development banks, should pay greater attention to the protection of the right to health in influencing the lending policies, credit agreements and international measures of these institutions."(7)

AI’s recommendations

Among other things, AI is urging the Burundian government:

· to acknowledge sexual violence against women to be a major social and justice issue;

· to develop an action plan to control such violence;

· to evaluate, with the help of UN agencies and other experts as appropriate, how it can better medically assist victims of sexual violence;

· to ensure that women and girls in all areas have free access to testing and treatment for sexually transmitted diseases including HIV/AIDs, as well as to the provision of emergency contraception and post-exposure prophylactic drugs within 72 hours of rape to prevent HIV infection;

· to develop other training programs to ensure more counselling is available and is an integral part of the health care system;

· to ensure that all decisions and policies concerning the provision of health care are consistent with its obligations under the International Covenant on Economic and Social and Cultural Rights (ICESCR) to provide the highest attainable standard of health for all.

· To bring the perpetrators of abuses to justice.

AI is also making separate recommendations to the leadership of the CNDD-FDD(8) including to:

· issue immediate public instructions to CNDD-FDD forces to end human rights abuses, including rape;

· ensure that CNDD-FDD forces cooperate with any investigations into allegations of human rights abuses committed by the CNDD-FDD;

· investigate allegations of human rights abuses against members of the CNDD-FDD to determine responsibility for any such abuses and ensure that those responsible are prevented from committing further human rights abuses against civilians, and are excluded from the new Burundian security forces; [are we asking for prosecution?]

Recommended Actions

Letter-writing

Please write letters in your own words in French, English or your own language, and on your professional headed paper if you use this.

1 National lobbying:

To your Ministry of Financeor equivalent using the following points as guidelines:

· Say that you are writing, as a concerned health professional about AI’s report: "Burundi: Rape - the hidden human rights abuse";

· Urge them to help alleviate the plight of Burundian women victims of rape by supporting AI’s recommendations and in particular to infuse the necessary resources to revive the health sector in Burundi and ensure that access to health care is in line with Burundi’s international obligations to provide the highest attainable standard of health for everyone under the International Covenant on Economic, Social and Cultural Rights. This should include reviewing relevant aspects of the health care policy of international financial institutions, notably the International Monetary Fund and World Bank and ensuring that these do not impede these obligations;

· Invite a response from them.

2 To the President of the World Bank and the International Monetary Fund using the following points as guidelines:

· Say that you are writing, as a concerned health professional about AI’s report: "Burundi: Rape - the hidden human rights abuse";

· Urge them to help alleviate the plight of Burundian women victims of rape by supporting AI’s recommendations; in particular urge them:

o to establish clear commitments to politically and financially support free access to medical treatment and counselling to victims of rape or other sexual violence in all areas in the country;

o to infuse the necessary resources to revive the health sector and ensure that agreements with Burundi ensure that health care is in line with Burundi’s international obligations under the International Covenant on Economic, Social and Cultural Rights which provides that the highest attainable standard of health should be provided to all;

o to do nothing which may undermine the obligations of the Burundian government under international law to provide the highest attainable standard of health to everyone.

o Invite a response from them.

3 To President Domitien Ndayizeyeusing the following points as guidelines:

· Say that you are writing, as a concerned health professional about AI’s report: "Burundi: Rape - the hidden human rights abuse"

· express concern at the fate of thousands of women who have been victims of widespread and systematic sexual violence during Burundi’s armed conflict and who have little prospect of obtaining redress and appropriate medical care;

· Urge him to consider and implement AI’s recommendations, in particular urge him:

o to ensure that potential members of the military, now being reformed under provisions in recent political accords, are screened to ensure that they are themselves not perpetrators of sexual violence and receive extensive training to ensure that they uphold and protect the rights of women;

o to give greater priority and resources to developing, supporting and promoting education programs targeting the public and community leaders on the importance of not stigmatizing women victims of violence and allowing them to speak out and seek help;

o to ensure that the government of Burundi adheres to its obligations under international law concerning health care which state that health care should not be discriminatory and the highest attainable standard of physical and mental health should be available to everyone;

o to ensure that women and girl victims of sexual violence in all areas are given free access to counselling, testing for STDs and HIV/AIDS, as well as emergency contraception and prophylactic anti-retrovirals within 72 hours of possible exposure to HIV to prevent infection;

o to abandon the policy of arming the population which increases the risk of violence against women within communities. Urge him to take swift action to work with international bodies to implement high-quality disarmament, demobilisation, and reintegration programs and set up programs of collection and destruction of small arms;

o State that AI will continue to lobby the relevant components of the international community to support the government of Burundi in achieving greater respect for human rights, including addressing the points raised above and:

- to establish clear commitments to politically and financially support free access to medical treatment and counselling to victims of rape or other sexual violence in all areas in the country;

- to infuse the necessary resources to revive the health sector and ensure that agreements with Burundi ensure that health care is in line with Burundi’s international obligations under the International Covenant on Economic, Social and Cultural Rights which provides that the highest attainable standard of health should be provided to all;

- to do nothing which may undermine the obligations of the Burundian government under international law to provide the highest attainable standard of health to everyone.

· Invite a response from him.

4 To the CNDD-FDD leader

To Minister and CNDD-FDD leader, Pierre Nkurunzizausing the following points as guidelines:

· Say that you are writing, as a concerned health professional about AI’s report: "Burundi: Rape - the hidden human rights abuse"

· Express concern at the fate of thousands of women who have been victims of widespread and systematic sexual violence during Burundi’s armed conflict and who have little prospectrs of obtaining redress and appropriate medical care;

· Urge him to address the prevention of sexual assault, the provision of care and treatment for victims and the accountability of perpetrators as a priority.

· Urge him to consider and support the reports recommendations, in particular:

· Issue immediate public instructions to his forces to end human rights abuses, including rape;

· Ensure that his forces cooperate with any investigations into allegations of human rights abuses committed by the CNDD-FDD;

· Investigate allegations of human rights abuses to determine responsibility for any such abuses and ensure that those responsible are removed from any position in which they may commit further human rights abuses against civilians, and excluded from the new Burundian security forces;

· State that AI will continue to lobby the relevant components of the international community to support the government of Burundi in achieving greater respect for human rights, including addressing the points raised above;

· Invite a response from him.

Publicity

Bring AI’s report to the attention of health professional journalsin your country, write articles for journals etc.

Outreach

Bring AI’s report to the attention of Medical Associationsin your country - particularly to committees working on women’s health issues or international affairs.

Urge them to approach the Burundian government to:

· Express their concern at the fate of thousands of women who have been victims of widespread and systematic sexual violence during Burundi’s armed conflict and who have little prospectrs of obtaining redress and appropriate medical care;

· Urge the government to ensure that women and girl victims of sexual violence in all areas have free access to counselling, testing for STDs and HIV/AIDs, as well as emergency contraception and anti-retrovirals to prevent infections.

· Urge the government to adhere to its obligations under international law concerning health care which state that health care should not be discriminatory and the highest attainable standard of physical and mental health should be available to everyone.

Contact professional or activist groups working on women’s health rights issues in your country and inform them of AI’s campaign.

Copies

Please send copies of the letters you write to President Ndayizeye to the Ministers of Health, Finance and State in Burundi.

Addresses

Son Excellence

Monsieur Domitien NDAYIZEYE

Président de la République

La Présidence

Burundi

Faxes: + 257 21 26 70

Telegrams: President, Présidence, Bujumbura, Burundi

Salutation: Monsieur le Président de la République / Your Excellency

Dr Jean Kamana

Ministre de la Santé Publique

Bujumbura, Burundi

Faxes +257 22 91 96

Salutation: Monsieur Le Ministre de la Santé Publique

Monsieur Athanase Gahungu

Ministre des Finances

Bujumbura, Burundi

Faxes : +257 22 38 27

Salutation : Monsieur Le Ministre des Finances

Monsieur Pierre Nkurunziza

Ministre d’État chargé de la Bonne Gouvernance

c/o Monsieur Onésime Nduwimana

Ministre de la Communication et

porte-parole du gouvernement

Bujumbura, Burundi

Fax : +257 21 63 18

Salutation : Monsieur le Ministre d’État

James D. Wolfensohn

President

World Bank

1818 H Street, N.W.

Washington, DC 20433 U.S.A.

Fax: (202) 477-6391

Salutation : Dear Mr Wolfenshon

Horst Köhler

Managing Director

President

International Monetary Fund

700 19th Street, N.W., Washington, D.C. 20431

USA

Fax: (202) 623-4661

Salutation : Dear Mr Köhler

Please send any replies you receive to the medical team at the IS as soon as possible (medical@amnesty.org)

If you do not receive replies within two months of your original letters, you may send a follow-up enquiry, referring to your first communication. Please check with the medical team before doing so.

Please send any replies you receive to the medical team as soon as possible.

Thank you for any activities you are able to organise around this action.

********

(1) A number of cases of male rape - previously limited to prisons - have also been reported.

(2) Not all HIV and other sexually transmitted diseases are contracted through rape. However, for many of the women infected, medical tests after rape or other sexual violence may be the first time they learn of their HIV status.

(3) There are 16 provinces in Burundi: Bubanza, Bujumbura, Bururi, Cankuzo, Cibitoke, Gitega, Karuzi, Kayanza, Kirundo, Makamba, Muramvya, Muyinga, Mwaro, Ngozi, Rutana, Ruyigi..

(4) Burundi acceded to the ICESCR in May 1990.

(5) Committee on Economic Social and Cultural Rights. General Comment 14 (2000) on the right to health. Paragraph 12(b). UN Document E/C.12/2000/4, 11 August 2000. See: http://www.unhchr.ch/tbs/doc.nsf/385c2add1632f4a8c12565a9004dc311/40d009901358b0e2c1256915005090be

(6) The International Conference on Primary Health Care, which met in Alma-Ata (now Almaty) on 12th September, 1978, expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world. The declaration from the conference stated that "the attainment of the highest possible level of health is a most important world-wide social goal". See: http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

(7) General comment 14, para. 38.

(8) The National Council for the Defence of Democracy--Forces for the Defence of Democracy (CNDD-FDD), one of the armed political opposition groups in Burundi.