Communal violence in Gujarat, India: impact of sexual violence and responsibilities of the health care system.

Abstract: Situations of chronic conflict across the globe make it imperative to draw attention to its gendered health consequences, particularly the violation of women's reproductive and sexual rights. Since early 2002 in Gujarat, western India, the worst kind of state-sponsored violence against Muslims has been perpetrated, which continues to this day. This paper describes the history of that violence and highlights the mental and physical consequences of sexual and gender-based violence and the issues that need to be addressed by the police, the health care system and civil society. It draws upon several reports, including from the International Initiative for Justice and the Medico Friend Circle, which documented the reproductive, sexual and mental health consequences of the violence in Gujarat, and the lacunae in the responses of the health system. The paper calls for non-discrimination to be demonstrated by health personnel in the context of conflict and social unrest. Their training should include conflict as a public health problem, their roles and responsibilities in prevention, treatment and documentation of this "disease", and focus on relevant medico-legal methodology and principles, the psychological impact of sexual assault on victims, and the legal significance of medical evidence in these cases.

Keywords: conflict and crisis settings, communal violence, sexual violence, gender-based violence, reproductive and sexual health, India

Resume

Les situations de conflit chronique dans le monde obligent a attirer l'attention sur les consequences sanitaires differentes pour les hommes et les femmes, en particulier la violation des droits genesiques des femmes. Depuis le debut 2002 au Gujarat, en Inde occidentale, la pire sorte de violence parrainee par l'Etat a ete perpetree contre les musulmans et se poursuit a ce jour. Cet article retrace l'histoire de cette violence et met en lumiere les consequences mentales et physiques de la violence sexuelle et sexiste, et les questions que la police, le systeme de sante et la societe civile doivent aborder. Il s'inspire de plusieurs rapports, notamment de l'Initiative internationale pour la justice et du Medico Friend Circle, qui ont enquete sur les consequences de sante genesique et mentale de la violence au Gujarat, et sur les lacunes des interventions du systeme de sante. Dans ce contexte de conflit et d'instabilite sociale, l'article demande aux soignants de ne pas faire de discrimination. Leur formation doit etudier le conflit comme probleme de sante publique, leur role et leurs responsabilites dans la prevention, le traitement et la documentation de cette << maladie >>, et se centrer sur la methodologie et les principes medicaux-legaux pertinents, l'impact psychologique de la violence sexuelle sur les victimes et la signification legale des preuves medicales dans ces cas.

Resumen

Debido a las situaciones de conflicto cronico mundialmente, es imperativo senalar las consecuencias para la salud de las mujeres, particularmente la violacion de sus derechos sexuales y reproductivos. Desde principios de 2002 en Gujarat, en la India occidental, se ha perpetrado el peor tipo de violencia patrocinada por el estado contra musulmanes, la cual continua hasta la fecha. En este articulo se describe la histona de esa violencia y se destacan las consecuencias mentales y fisicas de la violencia sexual y basada en genero, asi como los problemas que deben tratar la policia, el sistema de salud y la sociedad civil. Se basa en varios informes, como los de la Iniciativa Internacional por la Justicia y el Circulo de Amigos Medicos, que documentaron las consecuencias de la violencia en Gujarat para la salud reproductiva, sexual y mental, y las lagunas en las respuestas del sistema de salud. Se hace un llamado al personal de salud para que no demuestre discriminacion en el contexto de conflicto y descontento social. Su capacitacion debe abarcar el conflicto como un problema de salud publica, sus funciones y responsabilidades en la prevencion, el tratamiento y la documentacion de esta "enfermedad", y centrarse en metodologia y principios medico-juridicos pertinentes, el impacto psicologico de la agresion sexual en las victimas y la importancia juridica de la evidencia medica en estos casos.

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THE effects of sexual violence in Gujarat resemble those seen in other situations of conflict, including particularly the physical impact as well as the psychological and social effects of rape upon the victims, their families and the community. Women experience trauma to reproductive organs, deaths in childbirth, miscarriages and difficulties giving birth, a rise in and dangers of illegal abortions, sexually transmitted infections, possibly leading to HIV infection because of tears in genital tissues and the resultant bleeding, especially due to gang-rape. The psychological and social effects of rape are devastating. Terrified of being divorced, ostracised, infected with H1V or abandoned by their families, survivors cope as best as they can with their mental health problems in silence and isolation. Despite its particular history and continuing social conditions, the Gujarat case raises questions about the responses of health systems to these patterns of violence that are applicable to many similar situations.

Conflict and war have existed through history, and rape and other kinds of sexual violence have always been used as weapons to subjugate the "other". However, in the post-colonial period, because of majoritarian nation-state building, violent struggles and military repression have increased in multi-cultural and multi-ethnic countries of the world. (1) Resurgence of conflicts over ethnicity and nationality, politicised religion, globalisation-driven economic policies, revolutionary class struggles, separatist and autonomy struggles and the general failure of the democratic agenda, have all contributed to radicalised politics. Smaller groups are asserting their right to cultural survival and political power, and seriously challenging the state as the sole source of legitimate political power, along with the concept of the state as a neutral umpire.

Technology and the strategy of annihilation have resulted in wars not simply being fought on the "front" and among combatants, but with increasing severity in spaces and methods that target ordinary civilians. Sites of confrontation with the "other" are the marketplace, the school, the community well or the water tap. Institutions of the State (such as the police and to some extent even the lower judiciary in India), are subverted to further the divisive agenda of the State. The objective is to destroy the social fabric of society, and the strategy is to create institutional terror, to permeate social relations and psychologically demoralise the community by creating suspicion and hatred.

Analysis reveals that conflict and violence in several parts of the Asian region are initiated and sustained by a nexus of, usually, rightwing fundamentalist forces and their agents at various levels. (2) Here, I do not mean fundamentalism in just the religious sense. I define fundamentalism to denote dogmatic, rigid world views, intolerance of the "other" and construction of an entire framework, not often amenable to reason, and a certain system of (il-)logic to legitimise a world view.

History of communal conflict in Gujarat

Historians have documented violent incidents between Hindus and Muslims in India as far back as 1850. (3) The overt reasons for communal clashes have centred on religious festivals and places of worship. However, below the pattern of hurt religious sentiments, several economic and political forces have accentuated and aggravated the divide between the two communities. These have included divisive British colonial policies, economic sanctions against Muslim textile workers in the 1930s, and other forms of economic competition pre-dating partition. The worst post-independence communal riots occurred in 1969 and saw the beginning of the partisan role of the state and the emerging nexus between political leaders and criminals. This was also the first time the unwritten norm that the lives of women would be spared was broken. After demolition of the 16th century Babri Masjid mosque in 1992, the city of Surat witnessed heinous violence. Around 190 persons died, and women were gang-raped in front of their family members.

By the mid-1980s, electoral politics contributed an additional factor to the Hindu-Muslim divide in Gujarat. The Bharatiya Janata Party (BJP), the political front for Hindu nationalist forces, began consolidating its position in Gujarat and wooing the Dalits and other Backward Castes to join the holy war to protect Hinduism from the threat of Muslims. The Hindu nationalist organisations, collectively referred to as the sangh parivar (or "family" of Hindu nationalist groups), also tried to consolidate their social base through a series of symbolic yatras (travelling campaigns across India) through the decade 1980-90. Each of these yatras left behind a trail of communal clashes. By 2001 the current Chief Minister was in place with his dreams and visions of making Gujarat into a "Laboratory of Hindutiva".

Gujarat in 2002

The violence in Gujarat began after a carriage of a train carrying Hindu activists was set on fire in Godhra on 27 February 2002. Several theories circulate as to who set the train on fire. The dominant version is that following an altercation between the Hindu activists and a Muslim tea seller on the Godhra railway platform, and possibly the attempted molestation of the tea seller's young daughter, a Muslim mob set the train on fire. Fifty-eight people were killed, many of them women and children. The activists were returning from Ayodhya, a north Indian town, where they supported a campaign led by the Vishwa Hindu Parishad (VHP) and allied organisations, to construct a temple of the Hindu God Ram on the site of the mosque destroyed by Hindu militants in 1992. The VHP claims that the mosque was built on a site that was the birthplace of Ram.

Between 28 February and 2 March 2002, a three-day retaliatory killing spree by Hindus left hundreds dead and thousands homeless and dispossessed. The looting and burning of Muslim homes, shops, restaurants, and places of worship was also widespread.

The Gujarat government chose to characterise the violence as a "spontaneous reaction" to the incidents in Godhra. Findings of several independent human rights groups indicate that the attacks on Muslims throughout the state were planned well in advance of the Godhra incident and organised with extensive police participation and in close cooperation with officials of the BJP state government. In the weeks that followed, an estimated 2,000 Muslims were killed and around 200,000 displaced.

Immediately after the outbreak of violence, people fled to areas where their own community was in the majority, to safe public spaces, mostly dargahs, madrassas and some schools, and sought refuge there. These locations were converted into relief camps, largely supported by the various Jamaats (community groups). New camps were set up by the state government later, as the violence continued. Two months after the outbreak of the violence there were more than 100 camps all over Gujarat.

Drawing upon the extensive documentation by citizens' groups in the months following the Godhra train burning, I analyse below the gender dimensions of the conflict, how women's sexual and reproductive rights are affected in such situations, and the role the health system can and should play.

Violence against women

Sexual violence

The sexual violence perpetrated against Muslim women and young girls was unimaginable. Many women were killed after being raped and mutilated. Those who survived report that sexual violence consisted of forced nudity, mass rapes, gang-rapes, mutilation, insertion of objects into bodies, cutting of breasts, slitting the stomach and reproductive organs, and carving of Hindu religious symbols on women's body parts. Fact-finding reports of several citizens and other groups documented the nature of the violence experienced by women in various parts of Gujarat. The Concerned Citizens' Tribunal * referred to the use of rape "as an instrument for the subjugation and humiliation of a community". Testimony to the tribunal included the following:

"A chilling technique, absent in pogroms unleashed hitherto but very much in evidence this time in a large number of cases, was the deliberate destruction of evidence. Barring a few, in most instances of sexual violence, the women victims were stripped and paraded naked, then gang-raped, and thereafter quartered and burnt beyond recognition ... Tire leaders of the mobs even raped young girls, some as young as 11 years old ... before burning them alive ... Even a 20-day-old infant, or a fetus in the womb of its mother, was not spared." (4)

The International Initiative for Justice in Gujarat, a group of international feminists who visited Gujarat in December 2002, documented the following cases: (5)

"Saleem, from Ahmedabad, testified that Hanifa, his 20-year-old daughter died on 7th March in hospital ... On 28th February, police took her to the hospital and on 4th March, he came to know about it. He met his daughter at the hospital who told him that XYZ, a Hindu man, had raped her. She also told him about two other girls who were raped by ABC And DEF. The name of one of the two girls was changed to a Hindu one in tire hospital record. They also showed her age as 35 years. She gape her statement to the police and doctors before dying. Her father said that he had seen people who had suffered burns and that, comparatively, his daughter WAS less burnt. He therefore suspects that she was not allowed to live ...

There were many women bleeding, injured, naked. Many women had bite marks on their breasts ... We cleaned all these women's wounds after removing all the objects inserted in their bodies." (Tayabba and Gulabi, who worked in a relief camp, Ahmedabad)

The unprecedented bestiality of" mass violence against women is also recorded in heart-wrenching testimonies in the report The Survipots Speak. (6)([dagger]) Sultani, for instance, escaping from a mob in her village, speaks of how she "fell behind as I was carrying my son, Faizan. The men caught me from behind and threw me on the ground. Faizan fell from my arms and started crying. My clothes were stripped off by the men and I was left stark naked. One by one the men raped me. All the while I could hear my son crying. I lost count after three. They then cut my foot with a sharp weapon and left me there in that state". A mother, Madina, from the same village testifies that two villagers pulled away her own daughter. "My mind was seething with fear and fury. I could do nothing to help my daughter from being assaulted sexually and tortured to death. My daughter was like a flower, still to experience life. Why did they have to do this to her? What kind of men are these? The monsters tore my beloved daughter to pieces." (Madina's testimony resulted in the conviction of 11 people on charges of killing seven Muslims in Eral village in December 2007.)

A majority of the Muslim survivors did not register rape complaints with the police. This is hardly surprising, given the hostility of the police and the wrong recording of even the simpler First Information Reports. The police were hardly going to encourage the registering of sexual crimes. Additionally, deeply internalised notions of shame and honour prevented women from registering their complaints. So while there are no official figures of the number of women subjected to sexual crimes, women's groups estimate that a minimum of 350 women must have been assaulted and raped. The following testimony by Taslima is an indicator of the number of women who suffered.

"I have interviewed more than 100 women, 55 of whom were gang-raped. There are many more that I know who have not recorded their testimonies as the community did not want me to talk to them because many were unmarried ... Each woman you speak to would tell you another eight to ten cases who were gang raped in front of her. So the number of gang rapes goes much higher." (5)

Genocide and births (5)

In genocides, births of the targeted community have been prevented through mass sterilisations and forced abortions. Developments in international law through judgments of ad hoc tribunals and the Rome Statute of the International Criminal Court now recognise that the definition of genocide includes "imposing measures intended to prevent births within the group" (Rome Statute of the International Criminal Court, Art. 6). Causing serious bodily and mental harm to women and humiliating and stigmatising women are ways of rendering women incapable or ineligible to participate in the reproductive life of the community, or of forcing them to bear the offspring of the "other" group's men.

On 1st March 2002, I left my home at 1 pm in the afternoon. At that time, a mob of 20-25 men surrounded me. They said: 'She's really pretty and good to look at, she cannot be left alone.' I begged them to leave me. They grabbed my son from me and threw the child thrice in the babul bush. I begged them to leave my child but they began beating me. One man said: 'We shouldn't beat up someone so beautiful, she should be laid on the ground and we enjoy her body.' They were saying: 'We will make you deliver a Hindu child.' After that three people raped me." (Rubina, from a village, Anand)

On 1st March 2002, we left our village at around 6 pm and were going towards another village. We were surrounded by a mob on the way.., we were eight women. There were eight men with us including my husband, father-in-law and my nephew. The mob hit the men with iron rods till they lost consciousness. My father-in-law was threatened with a sword (dhariya) "hum tumko kaat dalenge" (we will cut you). They took us to the fields and started shouting dirty abuses at us. 'We will make you conceive and deliver Hindu children.'" (Rehana, from a village, Anand)

The incidents described above illustrate how multiple masculinities are lived out. The hegemonic masculinity of the superior Hindu males and their violent coercive male sexuality not only overpowers the Muslim female bodies but also threatens the "weaker" masculinity of Muslim men. We see also the bond between men and weapons (iron rods and swords) and the links with violent notions of masculinity. "The threat of or actual use of weapons is an intrinsic part of violent, militarized models of masculinity." (7)

Violence against pregnant women

Many reports refer to violence against pregnant women. In the words of Saira Bano, reported in Survivors Speak: "What they did to my sister-in-law's sister Kausar Bano was horrific and heinous. She was nine months pregnant. They cut open her belly, took out her fetus with a sword and threw it into a blazing fire. Then they burnt her as welL" Survivors Speak emphasises the repeated nature of this story. "The Citizens' Initiative fact-finding team submit that Kausar represents a 'collective experience', that 'photographic evidence of the burnt bodies' of pregnant women and the fetuses torn from their wombs document--metaphorically--'a thousand Kausars'." (6)

The People's Union of Civil Liberties Report from Vadodara ** mentions numerous other cases, including the following: (8)

"I was putting my child to sleep at 9 pm on March 23rd. Suddenly, l found lots of policemen in my house. Thev didn't find our men at home and started giving us gaalis (abuses). Hit me with Dandas (sticks). They hit me on my hand, on my stomach and when they saw I was pregnant, they hit me in my jung (thigh) ... I went into the dargah and hid there. I told them that I was pet-se (pregnant). My mother-inlaw also said that I was pregnant. They said: 'We have to kill it before it happens.'" (Kaushal Bano Mansuri [Kagda Chawl, Bawamanpura] nine months pregnant)

"Bhois came and attacked us on April 28. I was at home with my daughters. Policemen, around ten, came in. They smashed my door, broke it open, and entered inside. They hit me and my daughters on the knees with a stick. One of my daughters, Tahirabano is four months pregnant; they hit her in the stomach with tire rifle." (Ferozabibi Abdul Sattar Mansuri [Chamboosa Baba Dargah Tekra, Raja Rani Talav] 45 years)

"Bilkis Bano, six months pregnant, ran for her life from the village when the mobs attacked on February 28. She had with her her three-year-old daughter, her mother and other relatives. After hiding in the fields overnight, they were confronted by a mob of 20 to 30 men carrying swords and sickles. They gang-raped the four women and killed Bilkis' daughter by smashing her head against the ground. Bilkis pretended she was dead and waited for the mob to leave. After 48 hours, pretending that she was a Hindu woman raped by Muslim men, and helped by a home guard, she trudged to a police station to register a complaint, on the way borrowing some clothes from an Adivasi woman to cover herself

At the police station, there [was] little sympathy. The policeman on duty wrote a distorted First Information Report on which he got the illiterate Bilkis' thumb impression. Two days later, local photographers found eight bodies of the massacred family. This forced the police to act. Post-mortems were conducted, albeit shoddily. Following an order by the Supreme Court, investigations were pursued by the Central Bureau of Investigation in 2004-05. The in camera trial outside the state of Gujarat made it possible for the witnesses to testify without fear. On January 18, 2008 the trial court held 12 of the 20 guilty. Eleven accused were sentenced to life imprisonment and one to a two-year prison term." (9)

Bilkis Bano's was the first case of rape to be registered with a police station. Her exceptional courage and struggle for justice were rewarded. This case has provided hope to human rights activists and the women's movement because justice has been meted out to the perpetrators.

Health consequences of the violence in Gujarat

A report of the Medico Friend Circle has documented the varied and multi-dimensional consequences of the violence in Gujarat. (10) In addition to the obvious physical injuries inflicted by burns, arms and weapons, there was considerable mental trauma and stress, as well as hunger due to curfews, isolation and hiding, and infections and epidemics due to living in inhumanly unsanitary conditions of refugee camps.

With regard to mental health consequences, repeated subjection to sexual violence as well as witnessing family members and other women from the community being violated engendered a psychological threat perception among all women from the Muslim community. Women who were directly violated or whose family members were raped or mutilated were afraid to leave children at home or to walk in the street, yet had to silence their pain. This was either because of fear of lack of acceptance by their community or because that was the price their community agreed to pay to go back to their homes. The lack of public acknowledgement and denial of redress made the trauma acute. The situation was worse for young, unmarried girls who were sexually brutalised, because proclaiming the sexual violence they suffered made it more difficult for them to be married.

Sexual health consequences of rape among women who survived--unwanted pregnancies, unsafe abortions, sexually transmitted infections--must have occurred but unfortunately were not documented by the fact-finding teams, possibly because the trauma of the rape overshadowed all else. (5) The Medico Friend Circle Report states that several women reported moderate to severe reproductive tract infections to the fact-finding team. Pregnancy outcomes were affected by sexual and other kinds of violence. Women reported premature deliveries, miscarriages and abortions. Deliveries took place in relief camps in overcrowded, unsanitary conditions because Muslim women could not access health services due to insecurity.

In one camp, the team was told that the tent used to house new mothers had become overcrowded because several women delivered at the same time. There was no provision for bathing in the tents. Pregnant women and new mothers had to use the bathrooms used by the rest of the camp. (10)

Apart from these direct health consequences of violence, there were indirect and long-term health consequences. The continuing economic boycott of the Muslims and deaths and injuries among males led to increasing impoverishment and therefore chronic hunger among the poorer Muslims. Because of fear for their safety, gifts were (and continue to be) married off early, therefore facing earlier pregnancy and childbirth, with all the consequences of adverse maternal and child health. Community health projects in Ahmedabad among the urban poor Muslims reported that even 18 months after the onset of violence, women were reporting menstrual irregularities and lactation failure (Dr Hanif Lakdawala, Personal communication, September 2003).

Response of the health care system

Many questions arise concerning the response of the health care system to the atrocities in Gujarat. Did health providers offer first aid and humanitarian services to all those injured without considering their affiliation? Or did conscious and sub-conscious prejudices result in discrimination during service provision? Did the health care system recognise injuries and other consequences of sexual offences? Was the health care system geared to creating an enabling environment in which women could safely seek treatment for injuries due to sexual violation? The Medico Friend Circle report, based on interviews with women in relief camps, found that existing services did not adequately address women's health needs. (10)

The International Initiative for Justice report states that according to international law, even in times of war, all parties involved are bound to provide medical relief to the injured on both sides. In Gujarat, the situation was such that even this basic human right was denied. While there is some evidence of doctors in different hospitals--public and private--trying to help patients who were badly injured or raped, there is a great deal of evidence to the contrary as well.

Hema and Chetan, (5) working with an organisation in Baroda, provided detailed testimony on the complicity of state hospital officials and health professionals in preventing victims from accessing medical care. Speaking about the ways in which doctors assisted, they said:

"Medical examinations and records of injuries were not maintained, and doctors did not help in ways they could have, to record the violence and strengthen the cases of people who sought help. VHP and Bajrang Dal activists were present in many hospitals, at times in police uniforms, thus discouraging dying declarations and statements of injury." (5)

According to the experience of a male lawyer working in a hospital in Ahmedabad:

"Doctors were being instructed in what to say and what not, e.g., doctors in front of a body with bullet wounds were saying, 'can't say the cause of death' while a junior doctor there was saying quietly 'Police firing at Kalupur'." (5)

The polarisation, induced and abetted by the state machinery, resulted in the ghettoisation even of medical facilities, as one testimony illustrates:

"As an aftermath of the violence, many of the hospitals that were in the Muslim areas have shut down and moved elsewhere. One 40-bed hospital that was running in a Muslim area has moved to a Hindu area. Medical facilities have been reorganized along religious lines." (5)

Despite these serious problems, testimonies reviewed for this paper indicate that many individual health workers put themselves at risk to provide services to those who were injured, regardless of which community they belonged to. Nonetheless, as reported by the Medico Friend Circle and the International Initiative for Justice, the Gujarat violence indicates critical lacunae in the response of the health care services, including:

* Post-mortems were not conducted in several cases. Dying declarations were not recorded. Medical records failed to document medical evidence of violence. Where death certificates and post-mortem reports were available, they failed to mention injuries due to police firing or stabbing.

* Medical records of dead or injured women failed to mention sexual violence and abuse. Despite women coming to hospitals in conditions that indicated sexual assault, doctors failed to recognise this. This failure was compounded by the fact that women's prior negative experiences at the hands of health care providers, even in "normal" times and for "normal" events (such as childbirth), prevented many vulnerable, sexually assaulted women from approaching health care providers for medical examinations and recording of evidence.

* While most doctors performed their duties neutrally and did not actively discriminate against any community, very few were pro-active in defending the rights of their patients.

* Public hospitals were working under constant threats of violence against Muslim patients. Partly as a consequence of this, hospitals preferred to prematurely discharge Muslim patients rather than provide them protection and ensure their safety.

* Health services failed to acknowledge the seriousness of psychological trauma and did not adequately address post-traumatic stress disorder. (5,l0)

Discussion

Sexual violence in Gujarat was used as a way of subjugating the "other"; Muslim women's bodies were sites where the war of hatred and rejection was fought. In the process, masculinities were played out in multiple ways: the hegemonic masculinity of the Hindu men as saviours of Hindutva, wielding their weapons in a rage of mob violence; the emasculated masculinity of the Muslim men who witnessed the sexual violation of their womenfolk and the arson and looting of their homes and property and who were forced to "compromise" in order to return to their villages or places of work; and the "masculinising" of Hindu women as they joined the slogan-shouting mobs and attacked Muslims. Gujarat in 2002 witnessed "not merely the violence of men but the violence that lies at the heart of masculinity's hierarchizing of difference and the misogyny, homophobia and racism that are embedded in discourses of masculinity": (11)

Attention worldwide has focused more on sexual violence against women than against men, partly due to gender stereotypes. Sexual violence perpetrated on Muslim men was not documented extensively in Gujarat, apart from references to men being ordered to pull down their pants to show circumcised penises before being attacked or killed, and passing references to the genital mutilation and rape of Muslim men by Hindu men. (5) However, there is increasing evidence of sexual torture of men across the world. In Croatia in the early 1990s, men suffered rape and other forced sexual acts, full or partial castration, genital beatings and electroshock. (12) Male rape was reported in Congo. (13) In Abu Ghraib, the sexual degradation and violation of Iraqi male captives shocked the world as the vivid images flashed across television sets and computer screens. As Petchesky says: "We can no longer cast women's bodies as the inherent and exclusive sites either of sexual and reproductive rights or of sexual and reproductive violations," (14)

The response of the health system is often far from adequate in conflict situations, including in the case of Gujarat. In most conflict situations, the state health system is practically nonexistent or ravaged by the conflict. The outreach health care facilities either lie unused, due to lack of personnel (whose safety cannot be assured) or lack of equipment and supplies, or are used as camps for the military and armed forces. The tertiary hospitals in cities, on the other hand, are overcrowded and working beyond their capacity, (15) The intersectoral coordination between the law enforcement machinery, the medical and forensic sciences departments and the criminal justice system, is weak (even in "normal" times). This results in sexual crimes not being properly recorded and the perpetrators not being punished.

Widney Brown of Human Rights Watch mentions several obstacles that women face while accessing forensic medical exams in cases of sexual violence. (16) Women are often traumatised by how the forensic exam is conducted; many report that it felt like another form of sexual violence. There is also a failure of the public health sector to coordinate with the medico-legal sector.

Ideological and attitudinal barriers exist at the level of the police, the health sector and the justice system. Police become gate-keepers (as was also narrated by several women in Gujarat). They refuse to register women's complaints, or as in the case of Bilkis Bano, make distorted reports. Often, the police themselves subject women who report crimes of sexual and gender-based violence to harassment or abuse. The harassment may go as far as to deliberately sabotage any investigation.

The health sector is guilty of routine insensitivity. Women are seldom told what the physical examination will entail. Examiners fail to respect the woman's privacy, asking her to strip naked without providing a gown or a sheet, and allowing others to watch without her permission. There is also an undue focus on whether the woman is a virgin or "habituated to intercourse". Forensic examinations may be incomplete or inaccurate, due to lack of training or carelessness. And due to lack of integrated systems, there may be no follow-up treatment or counseling. (16)

What needs to be done?

First, the principle of the right to the highest attainable standard of health (17) has to be applied, even in situations of conflict, or even more so. The state has to ensure that health services are available, accessible, acceptable and of a high quality. Where there is greatest need--among vulnerable populations, orphans, widows, unaccompanied girls and women from separated families-all have to be identified and their health needs addressed. Even where ghettoisation has occurred, health care services have to be ensured. Comprehensive services, including for sexual and reproductive health care, have to be made available in relief camps.

Secondly, non-discrimination has to be demonstrated by health personnel. Health care providers need to acknowledge that they have an important role to play in the context of conflict and social unrest. Major social forces-racism, gender inequality, poverty, political violence and war-often determine who falls ill and who has access to care. Health care providers need to be sensitive to those aspects of structural violence and relate social analysis to their practice of medicine and public health. (18) This may mean putting personal biases about certain groups of patients on hold, and reminding themselves of the need to adhere to professional ethics. It may also mean going beyond the mechanical "treatment of symptoms" and being aware of the need to look carefully for signs of violence and take detailed, accurate histories. It may also mean going outside health care facilities into relief camps, communities and ghettos where people are taking shelter. As individuals, health workers can act as role models by demonstrating attitudes of tolerance, non-violence and non-discrimination.

Health services need to respect the dignity of individual patients, especially those who have suffered the ultimate humiliation and degradation of sexual violence. Establishing confidential ways for women and girls to seek treatment and counselling within camps is essential, especially in contexts where admitting to having been raped can result in stigma from spouses, families and communities. Reporting protocols for sexual violence should be adapted to the cultural environment--in the case of Gujarat, low levels of literacy among Muslim women and the need for confidentiality. (19)

Thirdly, quality of sexual and reproductive health care must adhere to the highest ethical standards. Health providers should be able to identify sexual violence-in both women and men-and not just treat the physical lacerations and ruptures, but also refer for or provide counseling and support.

"Rape victims should have access to medico-legal exams performed by women examiners twenty-four hours a day, seven days a week. Medical treatment and counseling should be available at the same location by trained heath professionals. These health professionals may be doctors, but nurses, midwives and physician assistants could also be trained. Police involvement should not be a prerequisite for conducting medico-legal examination. The woman should be informed of her right to file a report with the police. The focus of the exam should be on detecting signs of nonconsensual sexual intercourse rather than attempting to check the purported virginity status of the examinee." (16)

Logistics management has to be effective. The necessary supplies and equipment should be present in sufficient quantities, including evidence collection kits, safe delivery kits, emergency contraceptives, medicines for sexually transmitted diseases and for medical abortions, and so on.

Fourthly, when the state fails to discharge its obligations to respect, protect and fulfill the right to health care of its citizens and is the perpetrator of violence, as in the case of Gujarat, the role of humanitarian agencies becomes all the more important to ensure availability, accessibility, acceptability and quality of health services. Civil society actors-human fights activists, public health personnel, women's groups, lawyers-have to organise and draw attention to the lapses and failures in the state's role in providing essential services.

Certain measures also need to be taken in times when there is no escalated conflict, in order to lessen the negative impact of conflict and displacement on sexual and reproductive health. Training is the most important measure. The training of all health workers should include conflict as a public health problem and what the health worker's roles and responsibilities in prevention, treatment and documentation of this "disease" should be. Community health workers can be trained to work with the communities they serve to develop conflict resolution skills. The training should also cover the sexual and reproductive health needs that can arise as a result of conflict, including the need to deal with mental trauma. Human rights approaches--including principles of non-discrimination, equity of care, guidelines forbidding the involvement of medical personnel in torture--should also he part of the training. (20) In addition, the key elements of an ethical approach--maximising benefit and minimising harm, obtaining informed consent, ensuring confidentiality and treating people with appropriate clinical care and dignity--should be included.

Training programmes should be systematically implemented for all health professionals designated to conduct medico-legal exams in cases of sexual violence, both as a requirement before appointment and through in-service training. These programmes should focus on relevant medico-legal methodology and principles, the psychological impact of sexual assault on victims, and the legal significance of medical evidence in these eases. Health professionals should be trained in meticulous documentation and methods to present their findings effectively and professionally in court.

Manuals should be developed for health professionals responsible for examining rape victims that outline the relevant laws for their work, review specialised medico-legal techniques (for example, ways of determining the time of injury), and provide detailed descriptions of injuries specific to sexual assault in both adult and child victims.

Health policymakers and health managers should also receive training on reproductive health and gender issues related to conflict and displacement, as well as the management skills needed to respond to these needs.

Role of civil society and women's organisations

During conflict, women's organisations and health activists have to support survivors of sexual violence to seek medical help and to register police complaints. Pressure groups like the Jan Swaasthya Abhiyaan (People's Health Movement) also have to ensure that they are present as watchdogs to monitor the quality of sexual and reproductive health services being provided.

In "peace time" too, civil society organisations have a very important role to play. For example, SAHAJ--Society for Health Alternatives (an organisation with which the author is associated)-has developed a community-based "social health" programme in 15 poor neighbourhoods in Baroda. The main strategy is to train local women from diverse religious and social backgrounds (Hindus, Muslims, Dalits) not only to address reproductive and sexual health needs of women and girls, but also to promote peace and harmony between different communities. Women's groups that create networks of support for women are being promoted by community health workers. Participatory development programmes also help to empower women and marginalised groups and decrease their vulnerability to the impact of conflict.

Civil society groups will also need to use international treaties, instruments and ratified documents to demand justice for survivors. In 2006 the Gujarat case was submitted to CEDAW by women's groups. (21) Committee members commenting on the Indian Government Status of Women Report stated that justice cannot be done with repentance alone. In cases of mass violence, of which grave sexual assault is part, members stressed, prosecution is an essential part of delivering justice. The delay and non-inclusion of the remedial measures undertaken by the government on the violence in Gujarat found parallels in references by CEDAW to events in Bosnia and Rwanda. In addition, in the concluding comments, it was advised that a follow-up report should include information on the impact of the Gujarat massacres and their aftermath on women, particularly with regard to cases of sexual assault and violence, victim protection measures, arrests and punishments, and gender-specific rehabilitative measures.

Some of the recent favourable judgments and convictions are perhaps the result of the long drawn out, behind the scenes, persistent efforts of seekers of justice and show that such efforts can bear fruit.

Acknowledgements

The author would like to acknowledge the contributions of Trupti Shah, Deeptha Achaar, Nandini Manjrekar, the late Bina Srinivasan and many others of the PUCL Vadodara in the collective relief and rehabilitation and fact-finding work in 2002 and beyond. An earlier version of this paper was presented at the Second Asia Pacific Reproductive and Sexual Health Conference, Bangkok, October 2003.

References

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* The members of fact-finding team were Chinu Srinivasan, Deeptha Achar, Iftikhar Ahmed, Johannes Manjrekar, Maya Valecha, Nandini Manjrekar, Raj Kumar Hans, Renu Khanna, Rohit Prajapati and Trupti Shah.

** The Tribunal consisted of Justice VR Krishna Iyer, Justice PB Sawant, Justice Hosbet Suresh, Adv KG Kannabiran, Aruna Roy, KS Subramanian, Prof Ghanshyam Shah and Prof Tanika Sarkar.

([dagger]) The panel consisted of Sayeda Hameed, Ruth Manorama, Malini Ghose, Sheba George, Farah Naqvi and Mari Thekaekara.

Renu Khanna

Trustee, Society for Health Alternatives (SAHAJ), and Member, People's Union of Civil Liberties, Vadodara, Gujarat, India. E-mail: [e-mail]