Mental Health as a Target: New Amnesty Report on South Sudan

It is trite to say that conflicts and health (care) are antithetical. In addition to the direct harm to health resulting from the violence, conflicts generally decrease the resources available for public health and often exacerbate discrimination in the enjoyment of the right to health. The relationships betwesudanen conflicts and mental health tend to be less visible than those related to physical health, but no less acute.

Earlier this month, Amnesty International published the report, Our hearts have gone dark’: The mental health impact of South Sudan’s conflict. In AI’s words, the report ‘documents the psychological impact of mass killings, rape, torture, abductions and even a case of forced cannibalism, on the survivors and witnesses of these crimes’. South Sudan is engaged in a non-international armed conflict between the South Sudan People’s Army under the control of the President and an armed opposition group. Based on interviews with 161 victims of and witnesses to human rights violations, as well as mental health professionals, government and UN officials, and representatives of non-governmental organizations, AI reveals a dire lack of mental health services across the country for people in need of support and care.

Despite the vast literature on the right to health in international human rights law (see, e.g. by  Katherine H. A. Footer and Leonard S. Rubenstein, by Amrei Müller or by Pierre Perrin), it is still rare that human rights organisations provide rights-based analyses on health in conflicts in general, and on mental health in particular. As far as Amnesty International is concerned, this is the organisation’s first report specifically addressing mental health. Hence, it is very encouraging that Amnesty International is focusing on these neglected aspects of the conflict in South Sudan.

In this post, I take the opportunity to review two conceptual aspects of the report that I find particularly interesting:

  1. Harm to mental health: more than a consequence of conflict

First, the title of the report suggests (at least at first sight) that harm to mental health is primarily an impact of the conflict but not a violation itself. Harm to mental health is undisputedly – and sadly – a far too widespread consequence of many abuses of the conflict. But in light of the qualitative research documented in the report, many instances of harm to mental health do not seem to constitute ‘just’ a consequence of the conflict, but the primary intention of perpetrators. The report, for instance, documents shocking cases of government soldiers allegedly forcing people to eat human flesh and to disembowel dead bodies in exchange for their life. In such horrific examples, the infliction of mental pain and suffering is the violation itself and not an impact of other abuses. Such abuses constitute international crimes in certain circumstances, such as war crimes, torture or crimes against humanity. In the text of the report itself, Amnesty International qualifies the commission and the failure to address these deliberate acts as a violation of the respect and protect the right of the South Sudanese population to the highest attainable standard of health (chapter 6, p. 49).

As discussed elsewhere in an article with Aoife Nolan, there is a tendency in the literature to analyse economic and social rights such as the right to health not as part and parcel of past violations but from the perspective of consequences of other abuses. In other words, when economic and social abuses are considered, they are sometimes not analysed on their own terms, but rather as a secondary consequence of civil and political rights violations. This underscores the tendency to view civil and political rights abuses as the forefront issues when discussing human rights and conflicts, with economic and social rights abuses constituting their context and consequences. Remnants of such an approach can still be found in Amnesty’s new report, e.g. where the NGO points out that

‘acts such as torture, sexual violence, and unlawful killing will often have a negative impact on the mental health of “victims” (…).  In addition to being serious violations of civil and political rights in and of themselves, such acts can, therefore, also constitute violations of the right to health.’ (Emphasis added).

While entirely correct, the section outlining the relationship between the violence and the right to mental health could have started much more strongly, e.g. by explaining how some of the documented acts deliberately target people’s mental well-being. Soldiers forcing someone to drink the blood of other victims trigger the State’s responsibility for a violation of the right to mental health independent of whether or not there are also violations of civil and political rights involved in such acts.

2. The right to mental health: not just a reparations issue

Second, and here I entirely agree with the legal framing, Amnesty does not exclusively frame the need to provide for mental health services from the angle of the right to reparations. While the link between mental health and reparations features prominently in the report (as this is often the case when economic or social rights are discussed in relation to violent conflicts), Amnesty International convincingly goes beyond this approach. The NGO appropriately frames the right to mental health care services as part of victims’ right to reparations as ‘an additional specific obligation’ – in addition to the primary obligation of refraining from and preventing acts that case psychological harm. This is important because an exclusive focus on mental health services as a form of reparations would seem legally unjustified given what I argued above.4623b1a7-76d3-4f79-9e7b-fc8f38ca7210

On a side note, Amnesty’s approach to emphasise that the state has a basic obligation to refrain from and prevent acts that harm mental health finds support in concluding observations of the UN Committee on Economic, Social and Cultural Rights. Although South Sudan is not (or not yet?) a state party to the UN Covenant on Economic, Social and Cultural Rights, it is interesting that mental health is one of the few substantive issues on which the Committee has made specific statements tailored to conflict situations (for other issues and more analysis, see my article in the Netherlands Quarterly of Human Rights). It did so for the first time in 1997 when examining the report from Iraq, urging the Iraqi authorities to submit ‘concrete and comprehensive information on measures taken or foreseen in order to address the psychological and emotional problems affecting children after years of armed conflict’. More recently, the Committee recommended to Nepal and Cambodia that a higher priority be accorded to mental health care in relation to persons affected by the conflict. In 2010, the Committee also recommended that Afghanistan, if necessary, seek international cooperation to address conflict-related traumatic disorders.

 

Photo credit: Amnesty International, Justin Lynch/AFP/Getty Images

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Documenting Human Rights in South Sudan

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Victoria Akur (left) and Grace John (right), members of South Sudanese CSOs, with Milena Sterio (middle).

On behalf of the Public International Law and Policy Group (PILPG), a Washington, D.C.-based non-governmental organization (NGO), I participated in a four-day workshop in Nairobi, Kenya.  The workshop was entitled “South Sudan Human Rights Documentation Initiative” and it built on existing PILPG Work in South Sudan.  This particular workshop brought together approximately forty participants: several PILPG members, including yours truly as a consultant, members of various South Sudanese civil society organizations (CSOs), a United Nations representative, as well as members of a partner organization, the Centre for the Study of Violence and Reconciliation (CSVR), a South African NGO.

The workshop was structured over four long days of presentations, interactive dialogs, exercises and guided simulations.  The specific topics covered during the workshop included specifics of documentation in general, such as purposes of documentation, preserving documents, various investigation options and tools, and involving women in human rights documentation efforts.  One day of the programming was organized by the CSVR, with a specific focus on the psycho-social effects of trauma, and the effects of violence and trauma on documentation efforts.  The outcome of the workshop will be the drafting of a joint agreement on a human rights documentation roadmap, as well as the beginning of ongoing discussions with representatives of South Sudanese CSOs regarding how international groups and NGOs can assist in future documentation efforts.

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Kenyan coffee (it helped during long days of workshops).

This post will explore the purposes and importance of documentation efforts in South Sudan.  South Sudan is a war-torn country.  It gained its independence from Sudan in 2011, through a public referendum where the majority of South Sudanese voted in favor of separating from Sudan.  The referendum came at the heels of a decades-long independence war during which South Sudanese rebels fought against the Khartoum regime.  South Sudanese independence, although initially celebrated, did little to quell the ongoing conflict.  The independence in many ways exacerbated already existing tribal and ethnic rivalries, resulting in new violence and civil conflict pitting two major South Sudanese groups against each other: the Dinka and the Nuer.  The Dinka-Nuer conflict, deeply rooted in South Sudanese colonial history and reflected in the independence rebellion itself, has by now involved other minority groups who have been forced to align each other with either the Dinka or the Nuer and to thereby take a more active role in the fighting.  The current South Sudanese president, Salva Kiir Mayardit, is Dinka, and the government regime is composed of mostly ethnic Dinkas.  The Nuer feel particularly vulnerable under this regime, and have reported that police and security forces working on behalf of the government have targeted not just Nuer fighters, but civilians as well.

Documenting human rights violations in this type of climate appears as the first step toward peace-building and reconciliation; ultimately, documented human rights violations can lead toward accountability and can serve a particular role in potential prosecutions of perpetrators of human rights abuses.

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Urban safari at the Nairobi National Forest.

Other countries have already implemented various human rights documentation efforts.  Various groups have worked on documenting human rights abuses in places such as Brazil, Guatemala, Argentina, Cambodia, etc. These efforts, which were briefly discussed during the Nairobi workshop, can serve as models for South Sudan and can provide successful examples of documenting and archiving human rights abuses, and using them toward both reconciliation and accountability.  In addition to serving as a first step toward accountability, documenting human rights violations can serve other purposes, such as building a fair and neutral historical narrative about the South Sudanese conflict, memorializing various types of violence, building long-lasting peace and promoting reconciliation. All of these different purposes of human rights documentation were discussed at the workshop. The ultimate conclusion of the workshop was that documenting human rights violations for all its possible purposes was of particular importance in South Sudan, and that the country’s CSOs would take the lead in this project.

Aid Workers Could Secure Better Protection under the Protection of Civilians Mandate

When two aid workers were shot dead in Afghanistan last month, the world’s media focused its attention on the dangers of 21st century humanitarianism and the challenges that assistance agencies face in protecting their personnel. Those challenges were underscored again this week with the tragic news of more fatal attacks on aid workers in South Sudan. International law plays an undeniably important role in the protection of humanitarian personnel, but these events call into question the extent to which international law’s provisions on protection are effective on the ground. Reframing the protection of humanitarians as a protection of civilians issue could go some way to improving protection across-the-board.

Aid worker security is of vital importance to any humanitarian mission. Insecurity in this regard not only compromises the safety of aid workers themselves, but also the safety of the populations they serve and the quality of the aid they deliver. Condemning the attacks on the above mentioned South Sudanese aid workers, Wendy Taeuber, Country Director for the International Rescue Committee (IRC) in South Sudan, commented that the ‘security and safety of … staff is paramount in order to be able to operate.’

It is a desperately sad reality that attacks on aid workers are so common. According to the Aid Worker Security Database (AWSD), in 2013-2014 alone 610 workers across the major international organizations and national agencies were killed, wounded or kidnapped in the field (so-called ‘major incidents’). That figure does represent a slight decrease in the number of victims compared to 2012-2013 statistics, but the trend over the past decade shows a deeply concerning increase all the same.

So what accounts for such an increase? One might chalk these figures up to weapons becoming more powerful and more indiscriminate (unable to be operated in a manner consistent with the legally required distinction between combatants and non-combatants) than ever before but the statistics remain fairly steady with respect to the number of victims of weapons-related incidents. For an answer, it appears we need to look elsewhere.

The general framework for the protection of humanitarian personnel under international law may provide us one explanation, but certainly not the full array of them. There are several major international legal instruments that pertain to the protection of humanitarian aid workers and each legally classifies those aid workers as civilians. The 1949 Convention relative to the Protection of Civilian Persons in Time of War (the fourth Geneva Convention) and the 1977 Protocols additional to the Geneva Conventions (Additional Protocol I and Additional Protocol II) are civilian protection treaties that oblige Parties to protect aid workers in specified armed conflict situations. Article 71(2) of Additional Protocol I, for example, requires that ‘personnel shall be respected and protected’ generally and Article 71(3) stipulates that each Party in receipt of relief consignments is obliged to ‘assist relief personnel … in carrying out their relief mission’. But despite being classified as civilians for the purposes of the conventions, aid workers are rarely treated like civilians in practice. It is in this paradox that many of the humanitarian protection issues faced today are sourced. Reframing the protection of humanitarian personnel as a protection of civilians issue (in line with international law), therefore, may provide an avenue for some improvement.

So how does the protection of humanitarians vs protection of civilians issue play out on the ground? The problems in this regard are too numerous and too complex to list in full but some key issues can be identified here. For one thing, aid workers look like aid workers and not like civilians. They are often dressed in uniforms with internationally-recognized emblems that guarantee their legal protection if nothing else (the International Committee of the Red Cross’ (ICRC) emblem of a red cross on a white background being the most prolific) and they often travel in marked vehicles with a host of resources and privileges that are not available to the general civilian population. These factors create an operational atmosphere in which humanitarians look to be more protected than they actually are. This is so even without considering that certain types of humanitarian are permitted, unlike the civilian population, to carry guns – a consideration that despite having no legal relevance here (as these humanitarians are governed by a separate branch of international law) does accentuate the differences between humanitarians and civilians. In light of these perceived differences, mission planners have ended up splitting protection of humanitarians units away from protection of civilians units, meaning the two rarely work together or share resources which in turn serves only to foster the unhelpful divide. Major advocacy groups like Human Rights Watch and Amnesty International, too, have responded by prioritizing protection of civilians in their campaigns at the cost of minimalizing protection of humanitarians advocacy. In reality, that perceived protection – emblems, resources, organization, etc. – makes humanitarians look like legitimate military and political targets for certain groups and therefore renders them open to attack in the same way as a combatant but with no means of defending themselves.

Those problems are especially acute in the national aid worker context. The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) has indicated in a 2011 report that despite overall improvements in aid agencies’ security risk management, national aid workers perceive continued inequities in security support compared with their international counterparts.

Placing protection of humanitarians more firmly under the umbrella of protection of civilians may go some way to eradicating issues with respect to operational ‘siloing’, resource allocation and international/national worker inequities. The mandate of protection of civilians encompasses a wide range of activities designed to obtain ‘full respect for the rights of all individuals in accordance with international law – international humanitarian, human rights, and refugee law – regardless of their age, gender, social, ethnic, national, religious, or other background’ (an Inter-Agency Standing Committee (IASC) endorsed definition). Since 1999, protection of civilians has received widespread attention and resources from critical institutional and humanitarian actors and has a framework for prevention and response that is far more developed than that which applies to the protection of humanitarians.

There is certainly institutional and cultural support for a more thorough system of humanitarian worker protection. The United Nations Security Council, for instance, has issued several resolutions condemning attacks on aid workers (most prolifically with respect to the treatment of humanitarian personnel in Syria) and has previously emphasized, in Resolution 1502, that attacks on aid workers constitute war crimes. Garnering this influential support and directing it towards addressing the gaps in international law with respect to how protection is framed, therefore, can only be welcomed.

Despite the fact that a review of the role of international law in the protection of humanitarian personnel would be a positive move, international law plays a frustratingly limited role in conflicts where motivations of politics and religion often have the final say. Humanitarian protection is a complex and multifaceted issue and only a coordinated effort across all risk and security areas can foster the levels of change demanded by the tragedies too often witnessed in humanitarian missions the world over.

As part of that coordinated effort, August 19, 2014, marks World Humanitarian Day, a day conceived to increase awareness of humanitarian work around the world and encourage greater dialogue on key challenges. You can show your support and find out more about the Messengers of Humanity campaign by visiting www.worldhumanitarianday.org.