Document - Rwanda: Medical action: "Marked for death" - rape survivors living with HIV/AIDS in Rwanda

AI Index: AFR 47/11/2004

Distrib: PG/SC

To: Health Professionals

From: Medical Office

Date: 12 May 2004







MEDICAL ACTION:


Marked for death”- rape survivors living with HIV/AIDs in Rwanda.



I was raped by militia…My husband left when he learned I had HIV and he didn’t. He divorced me and left me with three children. Now I have problems paying for rent, school and food. As it is, I live thanks to my friends and neighbours. My six-year-old also has many health problems and never seems to get better. She should be on ARVs1, but I can’t get them for her, and she is allergic to antibiotics. We eat badly…My greatest worry is for my children. What will happen to them if I die? I am trying to get them sponsors abroad so at least I will be able to die in peace.”

Tharcissie, aged 29



Summary


On 7 April 2004 AI launched a report entitled: “Marked for death”- rape survivors living with HIV/AIDs in Rwanda. The report, released on the 10th anniversary of the start of the genocide and armed conflict in Rwanda, describes the situation faced by women survivors of the violence - many of whom continue to die from diseases related to HIV/AIDs, which they contracted through rape - and their families.


The report also describes how the consequences of the violence have not been dealt with adequately by the international community or by the Rwandan government and calls on these to enhance medical care provision and delivery, including psychological support, to establish a compensation fund for survivors of violence during the war and genocide, to translate legal reforms that support women’s rights into reality on the ground, to combat discrimination against people living with HIV/AIDS, to support children of parents living with HIV/AIDS, to increase the access to justice of rape survivors, and to take measures to eliminate ongoing and future violence against women.


This action circular forms a component of the wider action being organized around publication of the report and focuses on chapter 8 of the report, “Access to healthcare.”



Goals


  • To raise awareness of AI’s concerns within the international health professional community;

  • To put pressure on international donors and the Rwandan government to pursue a sustainable, fair and robust policy to assist victims of sexual violence in Rwanda, including those affected with HIV/AIDs during the 1994 genocide and war.


Timing


This action will continue from May to July 2004.


Materials


  • AI report: “Marked for death”, Rape survivors of HIV/AIDS in Rwanda (AI Index number: AFR 47/007 /04

  • Action circular: 10 years on: survivors of sexual violence living with HIV/AIDS, (Index number: AFR 47/004/2004)

  • Press Release: Rwanda: Legacy of 1994 genocide and war yet to be addressed (AI Index AFR47/009/2004, 6 April 2004

  • Website and online action: http://web.amnesty.org/pages/rwa-070404-action-eng

  • AI report: Rwanda: the enduring legacy of the genocide and war (AI Index number: AFR47/008/2004)2


Special Instructions to Coordinators


Please check with your home government lobbyist in your section before carrying out any action directed at your home government, as indicated under letter-writing.


Please note, we are not asking for survivors of sexual violence to be prioritised for receiving anti-retroviral (ARV) treatment. We want to ensure fair access and an infusion of resources, both medical and non-medical, to support survivors of sexual violence and their families adequately, while accepting that there are resource constraints in the country.


Background


Between 250,000 and 500,000 women are estimated to have been raped during the genocide, and subsequent war in Rwanda3. Many of these are now traumatised and living with sexually transmitted diseases, including HIV/AIDS, with little hope of medical care or compensation. According to the association for genocide widows, AVEGA, 70% of the survivors are estimated to have contracted HIV, and up to 80% remain “severely traumatized”.

These women have been dying since then, with only a handful receiving life-prolonging anti-retroviral treatment.

Since the National Commission to Fight Against AIDS (CNLS) was established in 1986, and a first plan for monitoring and preventing HIV/AIDS put in place in 1988, the government of Rwanda, multilateral and bilateral donors and non-governmental organizations (NGOs) have made strides to expand prevention, care and treatment services and the sensitization of the population to the risks of HIV infection. Such initiatives have included provision of anti-retroviral drugs (ARVs), voluntary counselling and testing programs, mother-to-child prevention transmission programs and the forming of local associations of people living with HIV/AIDS to provide moral and psychological support, to educate and to assist those living with the virus and their families. However, a weak healthcare system, which results in many people facing difficulties accessing even basic health care; management problems; stigma surrounding HIV/AIDS (exacerbated by some healthcare personnel); difficulties in changing behaviours; corruption by government and NGO programs related to HIV/AIDS; capacity limitations within the health sector and the existence of a climate of fear curtailing people’s willingness to speak out about their status for fear of being denied services or discriminated against for treatments or services, as well as other forms of intimidation all pose substantial challenges to combating the disease4. In addition, donor contributions of money and technical support have sometimes been uncoordinated, resulting in glaring gaps in services, occasional duplication of efforts and a high concentration of service provision in urban areas


Chapter 8 of AI’s report highlights:


  • How women survivors of the 1994 genocide and war remain scarred, traumatized and often marginalized, with scant access to healthcare and open to further abuses, including sexual violence, or pressure to resort to transactional sex (i.e. sex in exchange for food, goods or money);


  • How some survivors of rape are stigmatized by their families and community once these have learned of the incident;


  • How, despite efforts made by medical personnel, the government, business and NGOs, which have improved the situation, stigmatization remains one of the most painful elements of HIV infection for many Rwandese. Many women with HIV/AIDS and their families are stigmatised and marginalised because they are seen as being infectious even through casual contact, “marked for death”, unproductive and possibly immoral.


  • Some Rwandese do not realize that children of people living with HIV/AIDS are not necessarily infected with the disease, and thus treat family members of HIV positive women with the same disdain as the person herself. Because of this stigma, HIV positive women may suffer numerous forms of exclusion, including losing their employment, being denied bank loans or credit and losing status in their communities.


  • How many people prefer to remain silent about their HIV status rather than risk suffering the stigma attached to discriminatory attitudes. As a result, many women are discouraged from seeking medical advice and treatment.


  • How children left alone after the death of parents become extremely vulnerable and may face great difficulties finding sufficient food, shelter, going to school, asserting inheritance rights and meeting basic needs. Many such children are particularly vulnerable to sexual assault and may be forced by circumstance to trade sex for food and material goods or to enter into prostitution. Some are themselves infected with HIV. Hospital staff report that is it nearly impossible to administer ARVs to street children or children living alone because they cannot ensure that the child will take the medication consistently.


AI’s recommendations, specifically aimed at the international community and the Rwandese government, include:

• Increasing access to healthcare for women who have been victims of rape or other gender-based violence, including by ensuring transparent and fair access to and delivery of services;

• Compensating victims and survivors of violence during the genocide and war for the abuses they suffered. This fund should compensate victims of all ethnic groups for abuses in a non-discriminatory manner.

• Expanding community-based activities to reduce stigma and ignorance around violence against women and addressing underlying discrimination against women, particularly in customary law.

• Expanding community-based activities to reduce stigma around HIV and AIDS and to educate people about how to support people living with HIV/AIDS.

• Pursuing investigations and prosecution of the crime of rape, whoever the perpetrator by devoting necessary resources and political commitment to investigations and prosecutions.



RECOMMENDED ACTIONS


LETTER-WRITING


Please write letters in French or English, in your own words on professional headed paper if you use this in your work. Use the following points as guidelines:


1 To the Rwandan authorities (Minister of Health and Minister in Charge of AIDS and Other Infectious Diseases):


  • Introduce yourself as a health professional concerned with human rights issues, saying that you are writing in connection with AI’s report about survivors of rape with HIV/AIDs in Rwanda.

  • Welcome Rwanda’s efforts in combating HIV/AIDS and in taking concrete steps to eradicate violence and discrimination against women.

  • Inform them that you are writing to the international community to ask them to support, financially and technically, the recommendations outlined in AI’s report.


  • Urge them to consider and implement AI’s recommendations and in particular to:


- enhance the provision of medical care to survivors of sexual violence, including taking steps to ensure that equal access to anti-retroviral treatment is provided to the greatest possible number of persons suffering from HIV/AIDSwhich should address the needs of both rural and urban populations.

- ensure that women and girls who have been victims of sexual violence have access on a voluntary basis to counseling and testing for HIV/AIDS and other sexually transmitted diseases.

- expand psychological counseling programs for rape survivors and ensure that these constitute an integral part of the health care system.

- ask whether they have yet proceeded in putting into place a program of post-exposure prophylaxis drugs (PEP) for survivors of violence to reduce the likelihood of HIV transmission. If not, ask when this initiative is likely to start.

- ensure that all decisions and policies concerning the provision of health care are consistent with Rwanda’s obligations under the International Covenant on Economic, Social and Cultural Rights, to which it is a state party.

- ensure that resources are efficiently and fairly allocated to people living with HIV/AIDS in need of assistance, without discrimination of any kind. Suggest that the affected people and their families should be consulted on their needs and views and these should be taken into account in the formulation of government programs and strategies, at both national and local level.

-Suggest that, in consultation with international organizations, national non-governmental organizations, associations of people living with HIV/AIDS, religious communities and independent media, they should give greater priority and resources to developing, supporting and promoting education programs for the public and community leaders on the importance of not stigmatising women victims of violence or women living with HIV/AIDS and allowing them to speak openly about their situation and to seek help. Suggest that these programs should include a particular focus on male partners and family members of women living with HIV/AIDS.

- Urge them to address the problem of stigmatization of people living with HIV/AIDS by including information about how to care for affected people and their families and assurances that HIV cannot be contracted through casual contact, in all government information about certain risk behaviours and the consequences and symptoms of HIV infection.

- Urge them to establish programs that provide care for children who risk being orphaned or have been orphaned by HIV/AIDS.

- Urge them to ensure that material is available informing people of their rights, what health care is available and how to proceed if they or members of their families are victims of sexual violence.

- invite a response.

.

To President Kagame


  • Introduce yourself as a health professional concerned with human rights issues, saying that you are writing in connection with AI’s report about survivors of rape with HIV/AIDs in Rwanda.

  • Welcome Rwanda’s efforts in combating HIV/AIDS and in taking concrete steps to eradicate violence and discrimination against women.


  • Inform him that you are also writing to the international community to ask them to support, financially and technically, the recommendations outlined in AI’s report.


  • Urge him to consider and implement AI’s recommendations and in particular:



- Urge him to ensure that the particular needs of families living with HIV/AIDS are taken into account, in accordance with Rwanda’s obligations under the ICESCR to respect, protect and fulfill the right to food and ensure that everyone has the right to the highest attainable standard of health.


- Urge him to ensure that resources are efficiently and fairly allocated to people living with HIV/AIDS in need of assistance, without discrimination of any kind and to consult and take their needs and views into account in the formulation of government programs and strategies, at both national and local level.


- Urge him to enforce anti-discrimination provisions in the Constitution and other legislation by taking action against employers who discriminate against PLWHA by refusing to hire them, by requiring HIV tests prior to hiring or by firing them once they learn the employee’s HIV status. Suggest also that the Government should likewise prevent banks, and credit agencies from discriminating against people because of their serological status, or government and religious officials from refusing to marry individuals with HIV/AIDS.

- Urge him to give meaningful assurances that people living with HIV/AIDS who peacefully exercise their right to freedom of expression will not be subject to denial of services or discrimination in receiving services or treatments, or other forms of intimidation.

- Urge him to make provisions for the children of people living with HIV/AIDS - before the children are left orphan - to ensure the protection of children’s rights, including the right to adequate food, clothing, housing, education and the highest attainable standard of health. Suggest that the government should also provide assistance in claiming inheritance and other rights, and reliable adult support in managing the household if needed. Children already living on the street or in

precarious conditions should benefit from special assistance in this regard.


- Invite a response.

In addition, you may also use one or more of the following points:

  • Urge him to continue to take a strong public stance on gender-based violence by sending a clear message that it is neither inevitable nor acceptable and that those responsible will be brought to justice. Suggest that the government should compile statistics, conduct research on violence against women and permit other organizations working in Rwanda to document and publicize the results of their research.

  • Urge him to ensure that material is available informing people of their rights, what health care is available and how to proceed if they or members of their families are victims of sexual violence.

  • Urge him to ensure that material is available informing people of their rights, what health care is available and how to proceed if they or members of their families are victims of sexual violence.

Please send copies of any letters you write to President Kagame to:

- the Minister of Justice.

- Mr. Christophe Bazivamo, Minister of Local Government and Social Affairs.

Include a covering letter, acknowledging that, while the Ministry of Local Government and Social Affairs is not necessarily wholly in charge of implementing the recommendations AI makes to the Rwandese government, AI is addressing concerns to him as he would participate in any implementation process. In the cover letter also ask the Minister to make the various prefectures5aware of AI’s report and recommendations.

  1. To your own government

Please check with your home government lobbyist in your section before carrying out any action directed at your home government.


  1. To Ministers of Foreign Affairs in Belgium, Canada, France, Germany, Ireland, Italy Netherlands, Sweden, Switzerland, United Kingdom and United States (these are either involved in bilateral discussions on Rwanda or are donors).


  • Introduce yourself as a health professional concerned with human rights issues.

  • Explain that you are writing regarding AI’s report about Rwanda. Ask about their activities in Rwanda on the issues of HIV/AIDS and violence against women. Urge him/her to support AI’s recommendations and in particular to provide funding and technical support to Rwanda for measures that will:

    • assist the government of Rwanda in establishing free access to medical treatment and counselling to survivors of rape or other sexual violence in all areas of Rwanda and make HIV/AIDS services more widely available;

    • enhance the health, nutrition, education and financial conditions of people living with HIV/AIDS and their families, including including taking steps to ensure that equal access to anti-retroviral treatment is provided to the greatest possible number of persons suffering from HIV/AIDS which should address the needs of both rural and urban populations and programs that provide care for children who risk being orphaned or have been orphaned by HIV/AIDS.


  • Provide appropriate support so that Rwanda fulfils its obligations under the International Covenant on Economic, Social and Cultural Rights, that everyone has the right to the highest attainable standard of health. In this regard, urge them to review relevant aspects of the health care policy and impacts of international financial institutions and international trade regimes.


  • Assist the government of Rwanda in devising, supporting and promoting education programs targeting the public and community leaders on the importance of not stigmatising women victims of violence and allowing them to speak out and seek help.

  • Make provisions for the children of people living with HIV/AIDS who risk being orphaned or who have been orphaned.

- Invite a response.



Please send copies of any letters you send to your Minister of Foreign Affairs to your Minister for Development/Aid, with a covering letter asking them to support AI’s recommendations.

  1. To Ministers of Foreign Affairs in other countries:

Please check with your section home government lobbyist.

Please send copies of any letters you send to your Minister of Foreign Affairs to your Minister for Development/Aid, with a covering letter asking them to support AI’s recommendations.



Outreach

Bring AI’s report to the attention of Medical Associations in your country – particularly to committees working on women’s health issues or international affairs. Medical Associations in those countries which are directly involved in assisting Rwanda (see previous page) could be asked to approach their Ministers of Foreign Affairs urging them to:

  • Assist in the strengthening of the medical sector in Rwanda.

Please send copies of any letters you write to your national medical associations to the World Medical Association.

Publicity



  • Bring AI’s report to the attention of health professional journals in your country, focussing on the ongoing hardship on survivors of sexual violence during the genocide and war and the need to improve healthcare provision, particularly to women survivors of rape living with HIV/AIDS and their families.

  • Write articles for medical journals etc



ADDRESSES



  1. Government Addresses


President Paul Kagame

President of the Republic of Rwanda

P.O. Box 15

Kigali

Rwanda

Fax: +250 572431

Salutation: Dear President / Monsieur le Président de la République



Dr. Abel Dushimiyimana

Minister of Health

Ministry of Health

B.P. 84

Kigali

Rwanda

Fax: +250 576853

Salutation: Dear Minister / Monsieur le Ministre


Dr. Innocent NYARUHIRIRA

Minister of State in Charge of HIV/AIDS and Other Infectious Disease

Ministry of Health

B.P. 84

Kigali

Rwanda

Fax: +250 576853

Salutation: Dear Minister / Monsieur le Ministre



Minister of Justice

Me. Edda Mukabagwiza

Minister of Justice

Ministry of Justice and Institutional Relations

B.P. 160

Kigali

Rwanda

FAX: +250 86509

Salutation: Dear Minister/Madame la Ministre

Mr. Jean de Dieu Mucyo

Prosecutor General

BP 1328

Kigali

Rwanda

Fax: +250 514114

Salutation: Dear Prosecutor General/Monsieur le Procureur Général



Mr. Christophe Bazivamo

Minister of Local Government and Social Affairs

Ministry of Local Government and Social Affairs

BP 3445

Kigali

Rwanda

Fax: +250 82228

Salutation: Dear Minister/Monsieur le Ministre


  1. Other addresses



World Medical Association

13, ch. du Levant

CIB - Bâtiment A

01210 Ferney-Voltaire

France

Fax: +33 4 50 40 59 37

e-mail: wma@wma.net



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.



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



1 Anti-retroviral drugs.

2 This report, released on 6 April, examines the extent to which the current government has over the past decade addressed points of tension that led to the heinous crime of genocide in 1994.

3Report of the UN Special Rapporteur, 1996.

4 For example, journalists have reported being afraid to report extensively on the issue for fear that they may be retaliated against by the government, among others.


5 Prefectures are essentially states; provincial officials represent the level of administration just below the national-level administration. There are 12 prefectures in Rwanda.


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