Introduction
On 28th August 2017, I received a phone call from a war victims’ representative in Moyo, a district located on the border with South Sudan approximately 470 kilometers northwest of Uganda’s capital city Kampala. He was concerned about the daunting number of people in the district/sub-region living with as yet untreated war injuries sustained during violent armed insurgency over the period 1995-1998. More than twenty years later he still hoped the victims might be assisted to recover and heal from the untreated visible and invisible war wounds.
Two days after receiving the phone call, I headed up to Moyo with a team comprising of psychosocial practitioners and researchers from the Refugee Law Project’s Gulu office. Imagine, in just one location (Obongi trading center, Gimara sub-county in Moyo district) and within a span of only 3 hours, we identified and profiled a total of 23 victims with serious untreated wartime injuries and ailments dating back to the 1995/6 and the operations of the West Nile Bank Front rebel group.
Many presented with unimaginable untreated war injuries/ailments; bullet wounds, body swellings, retained bullets/fragments, fractures, growths on body parts, abnormal painful bullet keloids/scars, chronic body pain, swollen testes resulting from torture, and reproductive health problems for victims of rape. Others complained of abnormal skin problems, believed by the sufferers to be as a result of hiding in contaminated water/swamps from the rebels throughout the insurgency period. Some victims reported being pricked by poisonous grasses and shrubs such as spear grass, black nightshade, witch-weed, thorn apple and sodom apple, plants that caused chronic itches and swelling of different body parts.
The war victims and survivors who were profiled expressed dissatisfaction and disappointment with available health services; although health centers and hospitals are now accessible due to the prevailing peace in Moyo, they felt there was a lack of capacity to address their specific health problems and needs. As a result, some victims told us, they had resorted to visiting witchdoctors and traditional herbalist for healing. Such decisions have boomeranged on a number of affected victims, as exemplified in the following case of a 34 year old man:
"I was not helped at Moyo Hospital where I was referred to from Obongi Health Center IV at the time when I was terribly helpless. I couldn’t bear the pain and because I needed urgent help from anyone, my family took me to a witchdoctor who instead “ate” the money for nothing. I had to sell my goat at 50,000 Uganda shillings to see a herbalist who gave me some painful yellow herbs that I put in my bullet wound. Unfortunately my body reacted badly to the herb and the whole of my leg got swollen as if I had elephantiasis. I never recovered and my wound kept on widening and discharging pus and fluids. I cope by covering it with a piece of cloth. People do not even want to share meals with me because of the smell yet in my family we had developed a tradition of sitting around and eating together. My friends have run away from me and I am always lonely. I feel like committing suicide because I don’t see any hope of healing since the war has made my family poorer’’.
These dilemmas reminded the RLP team of numerous similar cases of healing dilemmas faced by persons we have encountered in Acholi, Lango and Teso sub-regions during different transitional justice engagements including; memory dialogues, community information sessions, family preparatory and trauma counseling sessions, stakeholders’ capacity building on rehabilitation of war victims, memorial prayers and commemorations of massacres, and the different referrals made by partners such as Terra Renaissance and Justice and Reconciliation Project.
Unaddressed wartime injuries are proving to be a serious impediment to post-conflict recovery and development in conflict-affected communities in Uganda because the mental and physical ability of the affected people to actively participate and sustain productivity are often severely constrained. This also hampers trauma healing because the health issues continually trigger trauma symptoms and subject the sufferers to psychological instability and negative coping strategies to deal with associated pain. Plastic surgeries, hip replacement, hypertrophic scars/keloids repair surgeries, chemotherapy, palliative care, and brain scan are among the specialized interventions required. These are generally done at national referral hospitals such as Mulago and specialized private hospitals like Comprehensive Rehabilitation Services in Uganda (CoRSU) which are quite expensive.
When rehabilitation and healing is not prioritized in conflict-affected communities, it can negatively affect life expectancy in the country. Untreated war ailments can continue to inflict suffering, vulnerabilities and premature death on the affected people. It also costs government when such wounds are left untreated for a long period of time even after hostilities ended, as they lead to chronic and complicated cases thus increased visits to health facilities requiring expensive medical procedures which are associated with increases in governmental health expenditures.
When war victims find that governmental health facilities cannot provide adequate treatment and rehabilitation, they are left with limited options including; visiting private health facilities which are often very expensive and resorting to herbalism/traditional healers or church/spiritual option. All the above options come with costs as described in the example given above. Yet we know, from our experience working with such cases, that it is possible to see a positive turnaround for many such victims, even years after an injury occurs. Why is it then that despite the availability and decentralization of healthcare delivery systems in Uganda, health concerns and problems continue to be daunting in post conflict communities?
Uganda’s health system should aim at achieving and sustaining good health for its entire people. The strategic evolution and creativity within Uganda’s Ministry of Health by instituting a decentralized health service delivery framework at all levels should fully accommodate both generic and specialized care and treatment for its citizens. In addition to integration of mental health into primary health care, the burden of physical and psychological rehabilitation needs in conflict-affected communities should have been reduced considerably. Stakeholders need to identify the right diagnosis and appropriate treatment within the national health care systems in the country to ensure inclusive and comprehensive health care and treatment and reduced health burdens in war ravaged communities across the country.
The strategic health reforms by the Ministry of Health in Uganda in March 2001 that abolished cost sharing in first level government health facilities is a manifestation of good political will in the sector. Sadly, however, the needs are overwhelming; RLP’s 2014 Compendium of Conflicts in Uganda documented 125 conflicts, the majority of which were armed conflicts whose unaddressed legacies and consequences need to be identified and acted upon, and these remedies need to be reflected in national budgets and policies.
As our recent visit to Moyo shows, there are significant number of war victims grappling with serious war related health burdens that require specialized care and treatment that the primary level governmental health facilities are unable to address.
Recognising the huge psychological and physical rehabilitation gaps in the greater northern Uganda region in the post-conflict period, and that these are compounded by a narrow focus on physical infrastructural development, the Refugee Law Project began in 2013, with support from Democratic Governance Facility (DGF), to actively contribute towards individual and community healing.
To date, we have successfully profiled over 3,000 victims living with serious untreated war ailments, and offered psychotherapeutic and medical treatment to over 1,500 victims through the specialized services offered by St Mary’s Hospital, Lacor in Gulu. Our experiences indicate that many of the war injuries and wounds can heal provided there is appropriate treatment and resources. Furthermore, the beneficiaries of both psychological and physical repair attest to the fact that their functionality levels have improved drastically and many have been happy to rejoin their families and the community in productive livelihood, development and peace building initiatives. Beneficiaries of medical recovery often advocate for extension of continuous rehabilitation support to other war victims who have not yet accessed healing support. In light of their own experiences, they often condemn wars and preach the gospel of “Never Again”.
Victim’s demand for rehabilitation and healing of untreated wounds is very real in post-conflict communities. Current prevailing peace and the absence of physical fighting offers a good opportunity to realise sustainable peace. Sustainable peace building can best be achieved by addressing root causes of conflicts as well as identifying and addressing wide range of war ruins and damages inflicted on affected rural populations so that individual and community healing is achieved.
The government should embark on strengthening and consolidating health sector reforms and policies that directly address the health needs of war victims and survivors across the country given the history of armed insurgencies in Uganda. The country must strive towards successful implementation of sustainable development goals, especially goals number one (“End poverty and all its forms everywhere”) and three (“Ensure healthy lives and promote well-being for all at all ages”). The government and her development partners should be ready to sharpen health budgets – the alternative is to develop huge contingency plans to address the increased dependency level and food insecurity exhibited by affected individuals, households and unproductive war victims who continue to live with serious untreated war injuries.
Emphasis needs to be put on localizing specialized care and treatment for citizens, and the poor victims who cannot afford to be flown abroad for treatment just like government ministers and other government officials/diplomats who have the privileges, besides their financial capabilities.
There is an urgent need to conduct national health surveys in post conflict communities in Uganda to map out related health burdens, generate authentic statistics of victims of wars living with war related injuries/ailments and resultant disabilities to inform pragmatic and inclusive public sector health policy reforms.
