VI. Discrimination in the Health Care Sector

 

In September 2012, an official at the Ministry of Health and Social Welfare told Human Rights Watch,

The policy is clear: no one is to be denied health services, even if someone may equate [their behavior] with something that is not legally acceptable. Criminalizing it does not amount to denying someone health services. The service side should not be informed by the legal position of our country.[199]

But despite government commitments to equal access to health care, members of key populations experience multiple violations of their right to the highest attainable standard of health. These included outright denial of care, verbal abuse and harassment, and onerous requirements that disproportionately impact marginalized groups. This occurs when hospitals require that those being tested for sexually transmitted infections (STIs) bring in their partner, a requirement with which sex workers and men who have sex with men cannot easily comply, since even if they could convince their partners to come in, they would risk stigma—or require that assault victims obtain a form from the police before being treated, even when victims have been assaulted by the police themselves.

Government agencies and NGOs have undertaken recent efforts to sensitize health workers about the needs of key populations. In Zanzibar, the AIDS Commission and the Zanzibar AIDS Control Programme (ZACP) have taken a pragmatic approach to HIV, providing training on most-at-risk populations aimed at health workers, the police, and the police jamii.[200] An MSM activist in Dar es Salaam told Human Rights Watch that as part of the government-sponsored Tanzania AIDS Prevention Program (TAPP) 

We’re trying to collaborate with Muhimbili [National Hospital] to provide condoms, lubricants, and peer education. At other health clinics you lie in order to get tested—they ask you when you last had sex, and where your girlfriend is. There are Angaza centers [Voluntary Counseling and Treatment Centers (VCTs)] in the districts. I went to one and the woman started preaching to me not to have sex with men. I left, and went to another place. We need a friendlier place to get tested.[201]

TAPP outreach workers are also working with other government hospitals to improve their receptiveness to MSM. Additionally, three NGOs—Engender Health, PSI, and T-Marc—have joined forces in the Husika Project, which seeks not only to conduct HIV outreach to MSM and sex workers, but also to train government health workers in order to reduce stigma.[202] Médecins du Monde has implemented a training curriculum for health workers in Temeke to raise awareness regarding drug use and people who use drugs. So far more than 100 employees working in various hospitals, clinics, and dispensaries have been trained.[203]

Even absent specific training, some health professionals in Tanzania carry out their functions without bias. Christian B., a gay man, went to Mbeya Referral Hospital with a case of anal gonorrhea. He told Human Rights Watch, “They examined my body, including my anus. They did not stigmatize me. They just gave me medication, and I left.” [204] In Arusha, Mt. Meru Hospital has a good reputation for dealing sensitively with people who use drugs. [205] The testimonies below, however, suggest these cases are the exception rather than the norm, and that training and accountability for health professionals is required.

When public hospitals are inaccessible, NGOs often step in to fill the gap. An international NGO with an office in Mwanza, AMREF, has trained staff at VCTs to be attentive to the needs of female sex workers. AMREF advises female sex workers that they can go to these VCTs to get friendly services.[206] In Dar es Salaam’s Temeke district, PASADA, a Catholic-run clinic, is friendly and accessible to key populations.[207] In Zanzibar, ZAYEDESA runs a VCT that is accessible to key populations.

However, most Tanzanians still rely on public dispensaries and hospitals as their primary course of health care. At these institutions, despite slight improvements in recent years, numerous obstacles to the right to health remain.

Denial of Health Care

Some members of key populations face outright denial of health services. A gay man in Dar es Salaam, Collins A., was turned away from a government dispensary in the Tandika neighborhood of Dar es Salaam in December 2011. Collins told Human Rights Watch and WASO, “The nurses said, ‘We can’t give you services here. We can’t treat a person like you. Even the public doesn’t want to see you.’”[208]

When Alex N., a transgender man, sought treatment for an STI at a Dar es Salaam dispensary, a doctor told him, “It’s not possible. What kind of person are you?” and refused to treat him. After asking friends for advice, Alex returned to the dispensary to see another doctor who was known to be more open-minded, and who provided him service.[209]

Lack of care can have serious and even fatal consequences. Human Rights Watch and WASO interviewed the friend of a gay man who died in 2011 after being turned away from Temeke District Hospital. He told us:

I was the one who was taking care of him and who took him to the hospital. He was suffering malaria and had a high fever. At Temeke District Hospital, there was a doctor at the reception who knew we were gay. The doctor said “Go away! There’s no service for people like you.” So we went to PASADA [a Catholic-run health clinic]. He was tested for HIV there. They said, “Come next week for your results.” They don’t have hospital beds, it’s just a VCT. But within the next week, before getting his results, he died. No one went to get his results.[210]

Recently, activists providing support to the MSM community in Temele met with district hospital officials to sensitize them about MSM health issues. The activists expressed optimism that treatment may improve following this initiative.[211]

Jamal P., a 28-year-old gay man in Zanzibar, told Human Rights Watch that in March 2012, he went to Mnazi Mmoja Hospital to be treated for an STI. Jamal said,

The doctor examined me and told me it was gonorrhea, but then refused to treat me. He said “You already have sex with men, now you come here to bring us problems—go away.” He told me he wouldn’t treat me because I’m MSM. I came back home and my mom took me to a private hospital.[212]

The following month, however, Mnazi Mmoja Hospital initiated a groundbreaking program in which a doctor, trained specifically to address the needs of key populations, is available to provide services two days a week.[213] LGBTI rights activists in Zanzibar were optimistic about opportunities for improved services under this program.[214]  Mnazi Mmoja personnel have proactively informed key populations of the services available: when they realized that few people were accessing their services, they began sending out peer educators and partnering with community organizations in order to conduct outreach, a model that could be replicated elsewhere in Zanzibar and on the mainland.[215]

Verbal Abuse, Harassment, and Violations of Confidentiality

Human Rights Watch and WASO documented a number of cases in which health workers verbally abused and harassed individuals, deterring them from seeking services in the future. Lester F., an 18-year-old gay man in Arusha, is effeminate and sometimes wears make-up, and is often identified as gay. He told Human Rights Watch and WASO,

Once I was discriminated against when I went to test for HIV. I went to the Angaza (VCT) as usual. After the test, I was waiting for the results. When the results came, the doctor looked at me and said, “I know what you’re doing. Stop what you’re doing, it’s very bad.” I just took the results and said, “Thank you,” and left to avoid problems.[216]

 

Carlos B. developed an anal STI and went to Mwananyamala Hospital (also known as Kinondoni District Hospital) in Dar es Salaam. Despite Carlos’s efforts to mask his sexual orientation, the doctor verbally abused him:

I was afraid to tell the doctors about my sexual orientation because of the stigma and discrimination in society, so I created a fake story to convince the doctor to listen to me. I said, “Three days ago, I was drunk, I passed out somewhere, and people raped me. So I think I got anal STIs.” The doctor started to insult me, saying, “You are a man, why are you doing this? It’s not right for a real man to do something like this.” I said “I’m not a gay, it wasn’t my fault, it just happened.” The doctor said, “Next time, don’t do something like that, you are a man, you should not drink so much alcohol so that you let something like this happen, you have to have a limit.”[217]

Treatment varies widely from one medical professional to another. Ismail P., a sex worker, told Human Rights Watch and WASO he frequently caught STIs, in part due to the large number of clients who refused to use condoms. He said,

When I got STIs and went to the hospital, some doctors treated me well, others mistreated me—it depends on the doctors who are there for that day. Some treat me like any other patient. Others say, “I’m not feeling comfortable to treat you, let me call another doctor.” Some say, “You know, my religion doesn’t allow this,” or “The law of the country doesn’t allow this.” [218]

Many LGBTI people resort to paying high fees at private hospitals in order to avoid discrimination at public hospitals. Mohamed R. said, “I once had an STI in the anus. I went to Temeke District Hospital, and I was mistreated and not even checked on. But I was treated well in a private hospital, where I brought my lover and he got treated too.”[219]

Men who have sex with men also experience harassment and abuse when they seek treatment for problems other than sexually transmitted infections. Peter E. also went to the hospital after being beaten because of his sexual orientation. He explained to the doctor the circumstances under which he had been attacked. He said, “When I was open to a doctor about my sexual orientation, the doctor started to call others, saying ‘Hey doctor, come here!’ and told them I was gay…. You feel inhuman to be there.”[220]

Ismail P. told Human Rights Watch and WASO that he was also attacked in the street because of his effeminate appearance. He was beaten unconscious and woke up in the hospital. There, he experienced varying treatment:

Some doctors were treating me well, but others were abusing me, insulting me, saying, “These people, it was his fault, he’s supposed to be beaten. You shouldn’t give him a treatment, just leave him. Why do men come and do such things? Why is he a gay? Why’d he decide to be a gay? It’s his fault. It’s good for people to beat him.” And others were saying “No this is unfair, this is also a human being, he is not supposed to be beaten.”[221]

Hayat E., an intersex person born with both male and female sexual organs, told Human Rights Watch that at public hospitals, “They begin to point fingers at you, and I can hear them talking. They call each other to see me, and then the other patients also begin to wonder about me…. I get scared to attend hospitals.”[222]

People who use drugs, too, are humiliated and mistreated by medical professionals, perhaps largely because they are assumed to be “thieves.” As described in Section II above, after January H. was attacked in Dar es Salaam by a mob of Sungu Sungu who cut him on the face with pangas, Temeke Hospital staff called him a “thief” and refused to use anesthesia while stitching him up.

Mwajuma P. said she believed women who use drugs were particularly stigmatized: “At Temeke Hospital and Muhimbili Hospital, I’ve been stigmatized. Drug users in this country, especially women, are not valued….  At Muhimbili sometimes the nurses say, ‘These are drug users,’ and they call others. At Temeke they also do this.”[223]

In both Dar es Salaam and Tanga, NGO-run drug treatment programs provide beneficiaries with cards that identify them as participants in treatment programs, which assist them in accessing hospital care. Those who participated in such programs reported a lower level of stigma.[224] A representative of a Tanga community-based organization explained, “Without a card, it’s hard to get service, because of stigma from providers. The providers think they might steal something, or just don’t like the way they look.”[225]

Requirement to Submit Police Form Number 3 (PF3) before Treatment

Tanzanian hospitals require that assault victims submit a form known as Police Form Number 3 (PF3) prior to being treated.[226] The purpose of the form is to ensure that police have a record of all assaults, and that crimes can be investigated and perpetrators prosecuted.[227] Hospitals will occasionally admit a patient without a PF3 if their situation is judged urgent, but in other cases, patients without PF3s are sent to the police station before receiving treatment.[228] Victims told Human Rights Watch and WASO that private hospitals were more likely than public hospitals to waive the requirement, but most Tanzanians cannot afford private hospitals.  

The PF3 requirement impedes access to health. For those who have been assaulted by the police themselves—or who are reluctant to go to the police for fear of facing repercussions—treatment is out of reach, either because police outright refuse to provide the form or because victims are afraid to request it. Medical treatment in the aftermath of any assault, including sexual assault, should not be linked to or dependent on criminal proceedings.  Victims should be able to seek and receive medical care, regardless of whether they choose to report the crime.

Suleiman R., suspected of robbery because of his drug use, was assaulted with a hot iron by a police officer in Temeke district in December 2011 (see Section III, above). After he was released from custody, he went to Chang’ombe police station with his mother in order to get a PF3 and seek treatment:

My mother explained, “He was beaten by the police and needs to go to the hospital.” A corporal at the station refused and said “If we give you a PF3, you will accuse the police in court.”

Suleiman had to go to a private hospital, where he paid Tsh 35,000[about $20] for treatment.[229]

Susan N., a sex worker, went to a public hospital in 2011 after a client forced her to have anal sex, but she could not get treatment without filing a police report:

When I went to the hospital on that night with a bruised anus they refused to treat me unless I reported to the police first. This made me decide to go home and seek medical attention the following day at a private hospital. It cost a lot of money but at least I got the service I required.[230]

Some members of key populations lie to police or hospital staff in order to acquire a PF3 or to evade the requirement to have one. This may lead to inadequate treatment: if patients cannot be forthright about the causes of their injuries, health workers may not know what to look for. Walter S. has invented stories in order to get a PF3 on the several occasions that he has been beaten by neighbors because of his drug use: “Sometimes you go and make a fake story to the police that you fell or something like that to get the PF3. You do not want to tell them that you were beaten because you are a drug user. So you say, ‘I had an accident with a motorbike.’”[231]

Mwamini K., a sex worker in Dar es Salaam, lied to hospital staff in order to get treatment after being beaten by police officers in Kinondoni District in 2011:

They were three police officers. They beat me with their hands, and kicked me. They were saying, “What are you doing here, you’re a prostitute, a dog, you are a pig”…. I went to the hospital because they had hurt me badly.  I had damage on my skin. My whole body was hurting. I told the doctor that I fell down the stairs. If I had told them what really happened, they would need a PF3. I was afraid to go to the police to get forms because they would ask me many questions and they would want to arrest the person who beat me—and if those police [officers] were arrested, they would say that I was a sex worker.[232]

Others simply self-medicate or do not get any form of treatment because of the PF3 requirement. Jamila H., a sex worker, was gang-raped in February 2012 and went to a public hospital, but was told she needed a PF3. She told Human Rights Watch, “They said I should go to the police, but I couldn’t because I was a sex worker.” Two of her rapists had not used condoms, but absent access to hospital services, she did not get tested for HIV.”[233] Denied hospital treatment, Jamila bought basic medicines at the pharmacy.

Some police take advantage of the vulnerable position of key populations in order to extort money from them in exchange for a PF3. Maureen B., a sex worker in Dar es Salaam, was beaten by a client in 2010:

I was taken to the hospital by another girl, but first they wanted a PF3. We had to go to the police station to get the document and because they realized I was a sex worker, they made me pay Tsh 20,000.[234]

Others paid bribes to medical professionals rather than the police. Dalili S., a sex worker, said, “When I get injured when working, I have to bribe some of the night doctors so that I can receive service without going through the process of obtaining a PF3.”[235]

In December 2011, the Ministry of Health and Social Welfare launched national guidelines on gender-based violence that would allow victims of sexual and gender-based violence to receive medical services before acquiring PF3 forms from police stations.[236] Such guidelines are an excellent initiative, but experiences such as that of Jamila H., above, suggest that as of 2012 the guidelines were not being uniformly implemented. Additionally, because they only apply to sexual and gender-based violence cases, they only provided limited relief: those who are victims of police torture or who are attacked by angry mobs due to their presumed sexual orientation or drug use would not benefit from such waivers.

Requirement to “Bring Your Partner”

Some Tanzanian health workers refuse to treat patients for sexually transmitted infections unless they bring their partner. Human Rights Watch and WASO were unable to determine whether this requirement is based on an official policy or law, and the Ministry of Health and Social Welfare did not respond to written inquiries regarding the nature of the requirement. While such a requirement may derive from a desire to ensure treatment of all people infected or affected by HIV and other STIs, it is counterproductive when it comes to sex workers and LGBTI people who may be unable to convince partners to seek treatment, even if they themselves are willing to do so and only serves to drive patients underground. Mwamini K., a sex worker in Dar es Salaam, recounted her experience going to Mwananyamala Hospital to seek treatment for a fungus:

They normally ask you to bring your partner. I told them the truth, “I don’t have a partner, I’m a sex worker, and I got this STI in my work.” The nurse refused to treat me. She said “I can’t treat you without getting your partner.” I left and went to a private hospital.[237]

Pili M. had a similar experience at Sinza Hospital in Dar es Salaam. When she went for STI treatment and said she could not bring in her partner, according to Pili,

 [The nurse] said “Do you do sex work or what? You are a liar. Because this STI is very bad”… She refused to treat me, saying “I can’t treat you until you bring your partner.”[238]

This requirement is not uniform. According to Melissa L., a sex worker in Arusha, “It’s OK when we explain that we can’t bring our partners. Even at government hospitals, they understand. They don’t judge us, but give us advice to use condoms.”[239] In Zanzibar, organizations working with sex workers said testing was not conditioned on bringing in a partner.[240]

These models should be adopted across Tanzania, given that the alternative is that vulnerable populations go without testing and treatment.

Lack of Access to Lubricant

The use of water-based lubricant is an important protective measure during anal sex. Condoms are more likely to tear when sexual partners engage in anal sex without lubricant, or when they use oil-based lubricants such as Vaseline. Unfortunately, in most of Tanzania, water-based lubricant is unavailable or prohibitively expensive.  Almost all the MSM interviewed by Human Rights Watch and WASO said they did not know where to get water-based lubricant or could not afford it; several did not know the benefits of water-based lubricant or did not know what it is. The few who did have access to water-based lubricant relied on Dar es Salaam’s HIV/AIDS organizations that serve MSM, which themselves sometimes have an irregular supply.

Access to water-based lubricant appears most severely limited outside of Dar es Salaam. According to Lester F. in Arusha, “It’s easy to get condoms, but not lubricant. You might go to five stores asking for it without getting KY. So I’m using Vaseline.”[241] Lester was aware that Vaseline posed the risk of damaging condoms, but did not see an alternative.

In Mbeya, Christian B., a sex worker, told Human Rights Watch he had only once tried water-based lubricant, when a client brought it from Dar es Salaam. On other occasions, he used oil-based lubricant. Christian B. knows he takes risks, but he has never been tested for HIV; he said he is afraid to know his status because he does not know where he will get support if he finds out he is HIV-positive.[242]

A 19-year-old MSM in Tanga that did occasional sex work told Human Rights Watch and WASO that he had never heard about lubricant, either water-based or oil-based; he only used saliva for lubrication during anal sex.[243]