Equity in Health – Kabalagala

Kabs

Growing up in a suburb next to a red light district gave me the opportunity to witness prostitution in practice. To the extent that I knew what was happening behind closed doors (through my friends confiding in me). Equally, I had a sense then and now of how difficult it would be to challenge the status quo and change attitudes.

“Harriet, I felt so sorry and guilty watching my mother fade away because we could not access healthcare…death was her only option.” These are the heartbreaking words spoken by my friend, Resty. It was just after her mother’s funeral and she spoke these words in tears, conscious that her family would never be the same because they had lost their breadwinner.

Resty is a childhood friend. Her mother was a well-known sex worker in the area who had been in the business for many years. When she contracted HIV/AIDS, the whole community felt that she was responsible for her predicament because of her line of work. In fact, the local health centres often would deny her care and medication because of how strongly they felt she deserved to be in this situation.

This is unacceptable.

The meaning of equity in health includes the concepts of fairness and justice. It implies that everyone should have a fair opportunity to lead a healthy life and the primary determinant in access to healthcare should be health needs rather than status, gender, ethnicity, race, employment and insurance. Access to healthcare is equitable if there are no financial, information and supply barriers. Based on the Regional Network on Equity in Health in Southern Africa (EQUINET) and the Discussion paper 63 on public health law in Kenya, Uganda and Tanzania, equity in health means to lessen the differences in health status that are unnecessary, avoidable and unfair. Pursuant of this goal is to ensure the redistribution of societal resources and to promote the power and means people have to influence this redistribution.

Uganda has endorsed a number of international and national initiatives in relation to public health, but not all of the provisions included in these initiatives have been endorsed / implemented in full. Technically, international and regional bodies can be a great platform to unite and think through solutions for common human rights and socioeconomic problems, which are beyond the scope of individual countries. Nevertheless, the poor and vulnerable are unable to fully benefit from these supranational initiatives because they lack the information and the means to challenge their states in an international court.

The International Covenant on Economic, Social and Cultural Rights (1966) was ratified by Uganda in January 1987. According to the constitution, it is the state’s duty to ensure all Ugandans have access to healthcare services. If all Ugandans are entitled to healthcare services, what about sex workers? Can a claim be made that sex workers, born and living in Uganda, are not Ugandans? Of course not. This kind of thinking simply does not work. Sex workers are Ugandans who happen to be involved in sex work. Therefore, the current system based on exclusion and marginalisation should not be tolerated.

Unfortunately, the situation with Resty’s mother is the norm rather than the exception. Countless women are being sentenced to death because of lack of access to healthcare. They are being held responsible for the spread of HIV / Aids, which is seen as grounds for their exclusion from and non-priority status within the healthcare system. A catch-22 style situation emerges. Access to sexual health information and medication to treat sexual health-related conditions would mean that the women are less likely to be at risk of becoming infected and pose less risk to others if they are already infected. Denying them access actually perpetuates the spread of infection, which creates a dangerous cycle.

Most initiatives on HIV / Aids in Uganda have focused on prevention rather than treatment. It is wrong to prioritise one over the other as they are both equally important. In fact, treatment of HIV / Aids should be front and centre of any prevention strategy. For example, HIV-positive sex workers who are on the fringes of society – impoverished, marginalised and demoralised – are more likely to take risks and put themselves and others in danger. A sex worker in Kabalagala once told me: “If we are not safe, then no one is safe.” It did not make sense to me at the time but, upon reflection, I realised she was absolutely right. Attitudes towards sex work may be conservative but the reality is that sex workers have customers. Remove the customers from the equation and there will be no sex work – and the link between sex work and the spread of HIV would not exist.

Another important issue to consider is that sex workers have families. They are mothers, daughters and sisters. It is tough to be the daughter of a sex worker not least because you witness and experience the same struggles as your mother. A daughter of a sex worker once told me: “I will do anything to take care of my mother because I have seen how she is abused, mistreated and looked down upon both in the hospitals and entire community.” Moreover, the cycle of mother-to-daughter prostitution is very real. Daughters of sex workers are more likely to become involved in sex work.

To summarise, attitudes in Uganda are very conservative to the extent that prostitution is considered one of the worst sins. Yet, to put things into perspective, approximately 90% of all sex workers are forced into this line of work. Irrespective of the reasons why these women became involved in sex work, what is most important is that they are human beings and should have the same rights as everyone else: they have a right to healthcare which SHOULD be observed and respected.

By Harriet Kamashanyu

Founder of Rhythm of Life