(New York) – The latest revisions to China’s Criminal Law impose up to seven years in prison for “spreading rumors” about disasters, Human Rights Watch said today. The revised law, which took effect November 1, 2015, does not clarify what constitutes a “rumor,” heightening concerns that the provision will be used to curtail freedom of speech, particularly on the Internet.

“The revised Criminal Law adds a potent weapon to the Chinese government’s arsenal of punishments against netizens, including those who simply share information that departs from the official version of events,” said Sophie Richardson, China director at Human Rights Watch. “The authorities are once again criminalizing free speech on the Internet, which has been the Chinese people’s only relatively free avenue for expressing themselves.”

The National People’s Congress Standing Committee approved the addition of a provision to article 291(1) of the Criminal Law (Criminal Law Amendment Act (9)), which states that whoever “fabricates or deliberately spreads on media, including on the Internet, false information regarding dangerous situations, the spread of diseases, disasters and police information, and who seriously disturb social order” would face prison sentences – with a maximum of seven years for those whose rumors result in “serious consequences.” The vagueness of the provision means that individuals doing nothing more than asking questions or reposting information online about reported local disasters could be subject to prosecution.

In the past, the Chinese government has detained netizens who questioned official casualty figures or who had published alternative information about disasters ranging from SARS in 2003 to the Tianjin chemical blast in 2015, under the guise of preventing “rumors.”

The revision was made in the context of a wider effort to rein in online freedom since President Xi Jinping came to power in 2013:

  • In August 2013, the authorities waged a campaign against “online rumors” that included warning Internet users against breaching “seven bottom lines” in their Internet postings, taking into custody the well-known online commentator Charles Xue, and closing popular “public accounts” on the social media platform “WeChat” that report and comment on current affairs;
  • In September 2013, the Supreme People’s Court and the Supreme People’s Procuratorate (the state prosecution) issued a judicial interpretation making the crimes of defamation, creating disturbances, illegal business operations, and extortion applicable to expressions in cyberspace. The first netizen who was criminally prosecuted after this took effect was well-known blogger Qin Huohuo, who was sentenced to three years in prison in April 2014 for allegedly defaming the government and celebrities by questioning whether they were corrupt or engaged in other dishonest behavior;
  • In July and August 2014, authorities suspended popular foreign instant messaging services, including KakaoTalk, claiming the service was being used for “distributing terrorism-related information”;
  • In 2015, government agencies such as the State Internet Information Office issued multiple new directives, including tightening restrictions over the use of usernames and avatars, and requiring writers of online literature in particular to register with their real names;
  • In 2015, the government has also shut down or restricted access to Virtual Private Networks (VPNs), which many users depend on to access content blocked to users inside the country and also help shield user privacy;
  • In March 2015, authorities also deployed a new cyber weapon, the “Great Cannon,” to disrupt the services of GreatFire.org, an organization that works to document China’s censorship and facilitate access to information;
  • In July 2015, the government published a draft cybersecurity law that will requires domestic and foreign Internet companies to increase censorship on the government’s behalf, register users’ real names, localize data, and aid government surveillance; and
  • In August 2015, the government announced that it would station police in major Internet companies to more effectively prevent “spreading rumors” online.
     

Activists in China are regularly prosecuted for speech-related “crimes,” Human Rights Watch said. The best known of these crimes is “inciting subversion,” which carries a maximum of 15 years in prison. But authorities have also used other crimes such as “inciting ethnic hatred,” as in the case of human rights lawyer Pu Zhiqiang, who has been detained since May 2014 for a number of social media posts questioning the government’s policies towards Uighurs and Tibetans.

While providing the public with accurate information during disasters is important, the best way to counter inaccurate information would be to ensure that official information is reliable and transparent, Human Rights Watch said.

Above all, journalists should have unimpeded access to investigate and inform the public about these events, and the wider public should have the freedom to debate and discuss disaster response.

“The casualties of China’s new provision would not be limited to journalists, activists and netizens, but the right of ordinary people and the world to know about crucial developments in China,” Richardson said. “The best way to dispel false rumors would be to allow, not curtail, free expression.”

Posted: January 1, 1970, 12:00 am

Roma children play in the Cesmin Lug Camp outside Trepca mine, on the outskirts of Mitrovica, June 22, 2009.

© 2009 Reuters

The United Nations may be undermining its own efforts to promote human rights, at a time when rights are under threat worldwide.

That’s the view of a UN panel of experts, which investigated complaints of human rights violations by the UN mission in Kosovo after the 1998-1999 war – including widespread lead poisoning at UN-run camps. Displaced members of the Roma, Ashkali, and Egyptian minorities lived there for more than a decade, and hundreds of them got sick, with many still suffering health consequences today.

The UN Human Rights Advisory Panel (HRAP), which conducted the investigation, recommended last year that the UN apologize and pay lead poisoning victims individual compensation.

However, last month UN Secretary-General Antonio Guterres’ press office suggested a different – and watered-down – plan. It announced that the UN was creating a voluntary trust fund for community assistance projects to help “more broadly the Roma, Ashkali and Egyptian communities.” In other words, UN member states would choose whether to donate to the fund, which could be used to provide services that do not specifically target those affected by lead poisoning.

Victims’ lawyers, Roma rights organizations and UN accountability advocates criticized the UN’s decision. Human Rights Watch urged Guterres to follow the HRAP’s recommendations.

Now the former HRAP members have called on the UN to change course. In a June 8 letter to Guterres, they argued that the trust fund fails to provide compensation for violations of the right to life and the right to health. They also warned Guterres that “at a time of backlash against human rights it is vital that the UN be seen to live up to the promise of the [UN] Charter and the obligations it has promoted.” If the UN does not hold itself accountable, “the human rights system as a whole is weakened,” they wrote.

It is high time for the UN to make amends for the suffering inflicted on hundreds of families from Kosovo who were exposed to toxic lead in camps – and who the UN failed to relocate until well after the health effects became clear.

Guterres, who inherited this problem, has promised to build a culture of accountability. But the UN’s refusal to take responsibility here undermines its ability to press governments to remedy their own human rights abuses. 

Author: Human Rights Watch, Human Rights Watch
Posted: January 1, 1970, 12:00 am

Summary

The president of Equatorial Guinea, Teodoro Obiang Nguema Mbasogo, once described the discovery of oil in the 1990s off the coast of the small Central African nation as “manna from heaven,” the Biblical life-saving bread that God sent Israelites as they wandered in the desert. Ravaged by almost six centuries of colonialism followed by an eleven-year brutal dictatorship, the country was one of the world’s poorest and most poorly governed in 1979 when Obiang deposed his uncle and took power.

The discovery of oil in 1991 had the potential to change the fortunes of Equatorial Guinea, and it did, in many ways. Before the discovery of oil the country’s total income was US$132 million, or $330 per capita. Within the next decade per capita gross domestic product (GDP) rose significantly, comparable to that of many industrialized nations—peaking in 2012 at $19 billion ($24,304 per capita). However, oil production has been in decline since 2012, and oil is expected to run dry by 2035 unless new reserves are found.

Equatorial Guinea’s mismanagement of its oil wealth has contributed to chronic underfunding of its public health and education systems in violation of its human rights obligations.

Suddenly the small country of about one million people occupying 28,050 square kilometers had a great but fleeting opportunity to deliver exemplary social services to its citizens in line with its human rights obligations. Obiang raised expectations, repeatedly saying he would prioritize health services and education, but budgetary allocations to health and education have in fact been dismal: in 2011, the most recent year for which there is data, the government spent three percent of its budget on education and less than two percent on health, according to the International Monetary Fund (IMF). Forty-five other countries in Equatorial Guinea’s per capita GDP range spent at least four times as much on health and education during the same period. Instead the country invested heavily in large-scale infrastructure projects, which comprised 82 percent of its total budget in 2011, an approach the IMF and World Bank have repeatedly criticized.

Expand

Share

Equatorial Guinea is one the smallest countries in Africa, with a population of around 1 million and a total landmass of just over 28,000 square kilometers.

Obiang, the world’s longest-serving president, justifies the huge investment in infrastructure as part of a strategy to lay the groundwork for a modern economy. Undoubtedly this investment has improved the country’s transportation infrastructure, which includes a network of more than 2,000 kilometers of roads, five airports, and eight ports, as well as several modern hospitals and a national university campus. But, according to the IMF, such an approach “contribut[es] to low provisions for health and education service delivery.” It also found that “costs and wastage have been high” for infrastructure projects, “because of limitations in oversight and pressure for prestige projects.”

This report shows how the government of Equatorial Guinea has for two decades paved the way for this reality, squandering the promise afforded by its discovery of oil by grossly underspending on social welfare and overspending on wasteful and corruption-riddled infrastructure projects. In the process, it has not fulfilled its human rights obligations to progressively realize the right to affordable and decent health care and education for its people. The report describes how, though upper middle-income on paper, Equatorial Guinea faces severe challenges that commonly affect low-income countries, especially in health and education. It documents how companies, fully or partially owned by the president, members of his family, or senior government officials, have been awarded large public contracts. In some cases, businesspeople allege that they were encouraged by government officials to submit inflated contracts so that the officials could collect considerable kickbacks.

In addition, this research adds to a significant body of work on corruption in Equatorial Guinea, including numerous international investigations that have uncovered evidence of high-level corruption. A 2004 United States Senate investigation into Riggs Bank, a Washington, DC-based commercial bank, for example, revealed direct transfers of millions of dollars from accounts holding the country’s oil wealth into accounts believed to be controlled by the president. Money-laundering investigations into the president’s eldest son, who was appointed vice president in June 2016, allege how within a period of about five years, he spent $110 million in the United States and €175 million (US$189 million at current exchange rate) in France. The French prosecutor alleged that €110 million was transferred from Equatorial Guinea’s public treasury to Teodorin’s personal accounts, part of which funded his French spending spree.

There is an ongoing trial in Spain based on evidence that senior government officials purchased mansions in the country with funds transferred from the Riggs Bank oil account. In Italy, the financial police, when investigating one of the largest construction companies operating in the country, found millions of dollars linked to a network of international bank accounts owned by the president and his son.

All of this contributes to the government’s woeful underinvestment in health and education, at great human cost.

Neglecting the Right to Health

With the discovery of oil, Equatorial Guinea had a great opportunity to improve healthcare by investing in the provision of potable water, adequate sanitation, infection control, and other key determinants of health, as well as in the strengthening of its public healthcare system.

For two decades it has largely failed to seize this chance due to underinvestment in the social sector, when compared to other countries in its income bracket, and misspending on capital projects, such as the sophisticated new La Paz hospitals in Malabo and Bata that appear to be almost exclusively for the benefit of elites—rather than on primary healthcare that benefits most citizens.

While a lack of data makes it hard to fully assess Equatorial Guinea’s performance on key health indicators, available data suggest that despite having far superior resources compared to other countries in the region, there has been little progress. For example:

  • Equatorial Guinea ranks 138 out of 188 countries in the United Nations Development Programme’s (UNDP) Human Development Index, a measure of social and economic development. Its score is similar to those of Ghana and Zambia, despite boasting a per capita income that is more than five times as high.
  • More than half of Equatorial Guinea’s population lacks access to safe drinking water in the vicinity, a rate that has not changed since 1995.
  • Vaccination rates for children have fallen dramatically since the late 1990s and are among the worst in the world. For example, the reported rate for tuberculosis vaccination for newborns and infants was 99 percent in 1997; 64 percent in 2014; and 35 percent in 2015, the last year for which data is available.

Additionally, a 2011 household survey studies found that one in four children are physically stunted due to poor nutrition, and two-thirds are anemic, as are half of women. The World Bank estimates that 60 percent of deaths are the result of communicable diseases or preventable maternal, prenatal, or malnutrition-related illnesses. Maternal mortality is one health indicator on which Equatorial Guinea has apparently made progress at a greater rate than most other countries in the region, with such deaths down from 1,050 per 100,000 live births in 1995 to 342 in 2015, according to the United Nations.

Despite being considered an upper middle-income country, Equatorial Guinea’s healthcare system continues to suffer from many of the ailments that typically afflict healthcare systems in low-income countries: inadequate staffing, long waiting times, stock-outs of basic medications and medical supplies, and frequent misdiagnoses. Doctors, nurses and patients told Human Rights Watch that Malabo General Hospital required out-of-pocket payment up front for any service, and that those who are unable to pay upfront are regularly turned away. “If people [in critical condition] don’t have money, they die,” a doctor who worked in the General Hospital in Bata said.

With the limited funds allocated to the health sector, the government has heavily invested La Paz, the two modern hospitals in Malabo and Bata staffed largely by foreigners. Both hospitals are well-equipped and charge fees that are well beyond what ordinary Equatoguineans can afford to pay.

Neglecting the Right to Education

Government neglect of education is reflected in the poor condition of facilities and quality of services, as well as outcomes that frequently lag behind regional averages and, in some cases, are even worse than the situation prior to the oil boom. For example:

  • In 2012 42 percent of primary school-aged children—46,000 children—were not in school, the seventh worst enrollment rate in the world, mostly topped by war-torn countries.
  • Half of children who begin primary school never complete it, and less than one-quarter who do go on to middle school.
  • Late starts and high repetition rates mean that the ages in any given class can vary widely. In 2012 only 57 percent of students were in the correct grade for their age, a ten percentage point decline from 2000, according to the United Nations Educational, Scientific and Cultural Organization (UNESCO), a specialized UN agency.

Equatoguinean law provides for free primary school, in line with international human rights law, which also requires Equatorial Guinea to work toward eliminating fees for secondary school as available resources allow. Yet local partners and education specialists said that public primary schools charge at least some fees to enroll.

Many teachers are poorly trained or have no training at all, leading to poor quality in public schools. Since 2006 many teachers have received training through a 10-year program jointly funded by the government and Hess Oil, which operates in the country. According to UNESCO’s data, just under half of primary school teachers had some kind of training in 2011.

Equatorial Guinea has invested only a tiny fraction of its budget in its education system, and the bulk of the money spent on education has gone to the university level. A confidential 2016 government report allocated 64 percent of the budget for a multiyear “Education for All” program to higher education, even though it only represents only 2 percent of students, according to the World Bank.

Overspending and Self-Dealing on Infrastructure

Government underfunding of health and education stands in marked contrast to lavish spending on large-scale infrastructure projects, many of which are of questionable social utility and risk being a key conduit for corruption and mismanagement. Human Rights Watch found evidence that senior government officials have stakes in companies that receive public construction contracts, including the president and his family.

After spending huge sums of money on buildings in both the island capital of Malabo and the largest city, Bata, which is located on the mainland and functions as an alternate capital, the government is now constructing a new administrative capital, Oyala, in the middle of the jungle. Although the total cost of Oyala is not known, it is expected to account for half of all public investment in 2016, according to an unpublished report by the IMF. Local content rules that require all companies operating in the country to have at least 35 percent local ownership appear to have been misused to steer business to companies that serve primarily to fill the pockets of politically connected people. The IMF notes the high spending on Oyala in the context of “limited movement on structural reforms, and weak governance and corruption [that] remain a serious impediment.”

After having spent hundreds of millions of dollars on government buildings in the capital of Malabo and economic center of the mainland, Bata, Equatorial Guinea is pouring billions of dollars into building a new administrative capital, Oyala, in the middle of the jungle. The IMF estimated that spending on Oyala would consume half the national budget in 2016. Above is a satellite image of the city under construction on January 12,2015. 

Satellite imagery © 2017 NASA

A US State Department cable made public by WikiLeaks alleged that the country’s sole cement importer, Abayak, is “partially owned by the president and first lady.” An Italian businessman, Roberto Berardi, founded a construction company with the president’s eldest son and putative successor, Teodoro Nguema Obiang Mangue (“Teodorin”), who was then the minister of forestry but was appointed vice president in 2016. Berardi wrote in a formal statement that Teodorin did not contribute any capital or time to the company, and his sole function was to secure subcontracts from lucrative public projects awarded to ABC Construction, at least partly owned by the first lady.

A US Department of Justice investigation, which ultimately settled in 2014, into alleged money laundering by Teodorin revealed allegations that he directed one of the largest construction companies operating in Equatorial Guinea to submit grossly inflated bills to the government, many of the funds from which were then transferred to his personal account.

The US investigation settled in October 2014 when Teodorin agreed to forfeit $30 million approximately the value of his mansion in Malibu, Californiato be given to a charitable organization and used for the benefit of the Equatoguinean people. A French court investigated Teodorin’s spending more than 175 million euro on a Paris mansion, fleet of luxury cars, designer goods, and other extravagances. Teodorin maintains that the money came from legitimate businesses, but on May 25, 2016, the three judges presiding over the case found sufficient evidence of suspected money laundering and diversion of public resources to order Teodorin to stand trial, expected to take place on June 19, 2017.

By squandering enormous wealth the government has already missed opportunities to invest in health and education. The long-term decline and inevitable demise of the oil sector now leaves the government very little time to correct course and invest significantly and sustainably in these sectors. The fall in oil production and historically low oil prices have already caused Equatorial Guinea’s GDP to shrink by 29 percent between its high in 2012 and 2016; the IMF expects future contraction.

De nombreuses zones résidentielles en Guinée équatoriale, comme ce quartier de la capitale, Malabo, ne bénéficient que de peu d'investissements gouvernementaux, voire d’aucune assistance financière, alors que des budgets colossaux sont consacrés à des dépenses liées à des bâtiments gouvernementaux et à divers projets prestigieux.

© 2016 Human Rights Watch

To meet its human rights obligation to progressively realize its citizens’ rights to affordable and decent health care and education, the government should immediately shift investment priorities and undertake comprehensive reform to stem corruption, regulate conflicts of interest, and make the public procurement process transparent and competitive.

Given the country’s small size even modest social investment could go a long way. It is not too late to take urgent measures that would put the country’s oil wealth to work for the good of all Equatoguineans, but the window of possibility is closing fast.

Recommendations

To the Equatorial Guinean Government

  • Regularly publish full accounts of projected and actual government revenues and expenditures. Classify expenditures by function, including health and education.
  • Conduct credible and independent investigations into allegations of misuse of public funds.
  • Increase investment in public health, the healthcare system, education services, and infrastructure that will benefit majority of the population. Take urgent steps to ensure that these services are accessible and available to all, and that all are provided timely care by qualified medical staff.
  • Ensure that healthcare services are affordable for all Equatoguineans.
  • Guarantee free primary school for all in line with international human rights standards and take steps to eliminate school fees for secondary school.
  • Institute and enforce laws that clearly define, regulate, and make transparent conflicts of interest between government officials and their private businesses in line with international best practices.
  • Institute and enforce laws to ensure a competitive and transparent public procurement process, including open bidding and names of companies awarded contracts, as well as their beneficial owners and the amount of and purpose of each contract awarded. Such rules should also extend to companies awarded subcontracts for public projects.
  • Ratify the United Nations Convention against Corruption and the African Union Convention on Preventing and Combating Corruption.
  • Ensure independence of the auditing body established in the 2011 constitutional reform and credibly investigate claims of corruption, including against senior government officials.

To the International Monetary Fund

  • Include expenditures on health and education, as well as analysis and recommendations on public financial management, in annual Article IV reports that assess the economic and financial developments of Equatorial Guinea. Include sources for all social indicators and articulate any identified methodological concerns relating to the data. Do not include unreliable social data.
  • Encourage and assist Equatorial Guinea to improve transparency and quality of information in government budgets and to reform its public financial management to bring it in line with international standards.
  • Encourage and assist Equatorial Guinea in establishing mechanisms for financial accountability, including an independent Court of Auditors, a body mandated by the 2011 constitutional reforms.
  • Press Equatorial Guinea to meet all necessary requirements to join the Extractive Industries Transparency Initiative and safeguard the right of media and civil society to speak out against corruption and human rights abuses.

To the World Bank

  • Regularly undertake and publish a Public Expenditure Review on Equatorial Guinea, including detailed information on the health and education sectors.

To Private Investors

  • Conduct due diligence to determine whether any existing or potential business relationships, including through subcontracts, benefit government officials or close members of the president’s family. Where possible, terminate or avoid such relationships. Where no viable alternative exists, ensure that the relationship is transparent and does not benefit from undue influence.
  • Ensure all company procurement is done through an open and transparent bidding process.

To Foreign Governments

  • Investigate potential money laundering or other financial crimes by Equatorial Guinean officials that are under domestic jurisdiction.
  • Institute and/or enforce rules requiring the publication of all beneficial owners of companies registered within your territory to mitigate the risk of money laundering and other financial crimes.
  • Institute and/or enforce rules requiring financial institutions and sellers to conduct due diligence into the source of funds for transfers or purchases over specified amounts to mitigate the risk of money laundering and other financial crimes.

Methodology

This report examines Equatorial Guinea’s spending on health and education and the impact of chronic underfunding. It also looks at large-scale infrastructure projects, the public financial management system governing such projects, and allegations of self-dealing by senior government officials and members of the presidential family.

Equatorial Guinea has by far the world’s largest gap between per capita wealth and score on the United Nations Human Development Programme’s (UNDP) Index that measures social and economic development. The country’s oil wealth puts it in the league of those countries with sufficient resources to invest in social services, including health and education, and to progressively realize economic and social rights in line with its regional and international human rights obligations.

In researching this report Human Rights Watch reviewed publicly available reports of international financial institutions, as well as one unpublished draft document; national budget documents for all years between 2003 and 2016 except 2012 and other government documents; documents related to investigations into alleged money laundering by a senior Equatoguinean official being conducted by the United States Department of Justice; international and domestic data on health and education; and other documents.

Due to the absence of credible, comprehensive, and current government data, Human Rights Watch relied on a range of sources, using the most up-to-date data available while also privileging, where possible, data collected through surveys or studies over projections based on mathematical models. In some cases there are discrepancies in the data reported by different institutions. In the case of discrepancies regarding financial data Human Rights Watch relied on International Monetary Fund (IMF) figures, as it is based on information obtained and analyzed by IMF experts working in the country rather than solely on government submissions.

Where available, we have included health data from a 2011 household survey conducted by ICF International, along with more recent data from international institutions based on projections or government submissions to these institutions. Given the government’s poor record of data collection the household survey should be viewed as more reliable. For education data we used international and government data, noting any differences between the two sources.

Human Rights Watch staff conducted field research for 10 days in Malabo and Bata in 2016, interviewing a total of 35 people. For security reasons we were unable to interview a larger number of people. Interviewees included nurses, employees of international institutions active in the country’s health sector, former patients at the General Hospitals in Malabo and Bata, teachers, and education specialists employed by international institutions active in the country. In addition Human Rights Watch conducted phone or in-person interviews with three IMF experts and an Equatoguinean budget specialist; an Equatoguinean lawyer; a specialist on the Extractives Industry Transparency Initiative; a specialist for the transparency non-governmental organization (NGO) Publish What You Pay; US government officials; lawyers and representatives of organizations involved in corruption-related legal actions against Equatoguinean officials; and others. A Spanish translator facilitated some of the interviews.

Human Rights Watch withheld the identity of some of the interviewees for fear of possible reprisals; the report indicates where pseudonyms were used. All interviewees freely consented to be interviewed, and Human Rights Watch explained to them the purpose of the interview, how the information gathered would be used, and did not offer any remuneration.

Human Rights Watch wrote letters to some of the companies mentioned in the report, but did not contact others because they are defunct, have no publicly available correspondent or email address, or are only mentioned fleetingly in the report. We also wrote letters to La Paz hospitals in Malabo and Bata and shared the preliminary findings of the report with the Equatorial Guinean Embassy in Washington, DC and requested relevant information from the Ministries of Health, Education, Finance and Budget, and Planning and Development. The embassy confirmed receipt and agreed to pass along to the relevant ministries. We have not received any response to these letters.

The findings of this report are based overwhelmingly on the documentary evidence and basic indicators described above, which provide tangible examples of the systemic problems this report describes.

Note of currency conversion: this report used an exchange rate of 622 Central African Franc (CFA francs) per US dollar for current rates, the exchange rate on February 21, 2017. Sums in CFA francs for past years were calculated based on the rate on December 31 of that year.
 

I.Background

Before Oil: Colonialism, the Macías Dictatorship, and Obiang’s Coup

Colonialism & the Macías Dictatorship

Colonized by Spain until 1968, Equatorial Guinea is the only independent Spanish-speaking country in Africa. Portugal ceded the territory to Spain in a land swap treaty in 1777, but Spain’s early activity there was sporadic and it did not exercise full control until the early twentieth century.[1] In the final decades of its rule Spain began to more intensively exploit Equatorial Guinea’s exceptionally rich soil to cultivate cocoa and coffee. The large colonial plantations relied heavily on workers from neighboring countries, primarily Nigeria, who often worked under abysmal conditions.[2]

As a result of this history, when Equatorial Guinea gained independence in 1968, it had significantly less developed administrative institutions and infrastructure than other countries in the region.[3] Its per capita income was one of the highest in sub-Saharan Africa, but its economy depended almost entirely on a couple of cash crops cultivated by a
foreign workforce.[4] The country also lacked a developed legal system or local law, and the constitution at independence designated Spanish law to fill the gap.

Following independence Francisco Macías Nguema became Equatorial Guinea’s first president. The 11 years of Macías’ rule were marked by political violence and fiscal mismanagement that ruined the economy and many state institutions.[5] Following a coup attempt in 1969, Macías suspended all civil liberties and outlawed political parties other than the ruling party. Those suspected of political disloyalty—usually members of the political, intellectual, or cultural elite—were routinely arrested, tortured, or killed, frequently following real or claimed coup attempts.[6] Macías also had little tolerance for education and intellectuals.[7] Describing himself as the “Unique Miracle,” he outlawed private education, shut down all newspapers, banned the collection of statistics—and even went so far as to prohibit the use of the word “intellectual.”[8]

On August 3, 1979, Teodoro Obiang Nguema Mbasogo, the vice-minister of the armed forces at the time and Macías’ nephew, successfully led a coup to overthrow his uncle. By that time, one-third of the population of 300,000 had gone into exile and at least another 20,000 were believed to have been killed.[9] The economy had collapsed and nearly all public administrative activity had ceased.[10] There were virtually no basic services, such as electricity, banking, postal services, transportation, or telephone lines.[11] There were no universities and most secondary and vocational schools had shut down.[12] Macías kept what little revenues the state had in his home in Mongomo, paying himself millions of dollars in salary and squirreling away suitcases full of cash into his foreign accounts.[13]

It is hard to overstate the devastation wrought by centuries of colonialism followed by Macías’ reign of terror, and its long shadow is still evident in the country’s severely limited administrative capacity, abysmal social indicators, and repressive political system. This history, however, in no way excuses present-day human rights abuses, including the neglect of economic and social rights. On the contrary, the government should work to counter the ill effects of colonial rule by actively promoting transparency, accountability, and the rule-of-law, and by investing in health and education.

President Obiang’s Government

President Obiang is the world’s longest-serving non-royal ruler. When he first came to power, he pledged to rule democratically and respect human rights.[14] Following the coup, the state began once again to carry out its basic functions; schools reopened and public utilities were restored. As time passed, some social indicators, including life expectancy and child mortality, began to improve.[15] Nevertheless, in many respects, the coup did not lead to fundamental change in governance and respect for human rights. The United Nations was sufficiently concerned about the human rights situation in the country that it maintained an independent expert for Equatorial Guinea for 20 years.[16]

Until the discovery of oil off the coast of Equatorial Guinea, the economic situation did not markedly improve under Obiang and the country remained one of the poorest in Africa. In 1991, the year that oil production began but had yet to make any significant economic impact, the total GDP was US$132 million—equal to $330 per capita.[17] The country did, however, begin to receive large amounts of foreign aid, thanks to improved relations with foreign countries, including the United States and Spain.[18] But government corruption undermined the efficacy of some of aid-funded projects, such as the World Bank Coffee Cocoa Rehabilitation Project.[19] The $9.3 million project, which was implemented between 1985 and 1990, was intended to provide coffee and cocoa farmers with credit and strengthen their capacity as a means of reviving the country’s once lucrative cocoa production.[20] Robert Klitgaard, an IMF official living in Equatorial Guinea at the time the project was ongoing, wrote in a book about his work that the government abused the program by nationalizing the choicest cocoa farms in anticipation of the loans that would be made available to farmers, and then transferring them to members of the ruling elite, including the president. Many of these new cocoa farmers never repaid the loans they took out, which they used to fund lavish lifestyles rather than invest in cocoa farming.[21]

The Era of Oil: Political Repression, Corruption, and Lack of Transparency

The discovery of oil transformed the country within a few years from one of the world’s poorest to boasting a per capita GDP on par with many industrialized nations. The Texan oil company Walter International first began to produce oil from the Alba field in 1991, but the meteoric rise of Equatorial Guinea’s GDP began with Mobil’s (now ExxonMobil) discovery of the 1.1-billion-barrel Zafiro oilfield in 1995. Production began the following year, propelling the annual growth rate to double—even triple—digits as billions of dollars poured into the state’s coffers.[22] It is difficult to put an exact figure on the value of the oil contracts as they are not made public. As a partial measure the World Bank estimates that the state took in $25 billion in oil revenue between 2000 and 2008.[23] According to a 2015 budget document obtained by Human Rights Watch, the state took in an additional $20 billion in hydrocarbon revenue from 2009 to 2013.[24]

This massive influx of resources has not translated into significant improvement in living conditions for the majority of the population. Despite having the highest per capita gross national income of any African country, Equatorial Guinea ranks 138 out of 188 countries in the United Nations Human Development Programme’s (UNDP) Index that measures social and economic development. This gap between wealth and human development score is by far the world’s largest. Section III of this report details the conditions of the health and education sectors.

Human Rights Watch documented in its 2009 report Well Oiled: Oil and Human Rights in Equatorial Guinea how pervasive corruption, nepotism, mismanagement, and political repression, as well as unaccountable and non-transparent governance, contributed to large amounts of oil revenue being siphoned off by the ruling elite while the population remained mired in poverty. The persistence of these problems despite shrinking government resources due to the decline in oil production and prices threatens to erode the already weak public health and education systems.

Political Repression

Obiang retained Macías’ prohibition on political activity, citing the dire economic situation, until 1991 when he lifted the ban.[25] But the arrest of political opponents continued under Obiang, especially following real or claimed coup attempts.[26] Obiang has also installed close family members, including his sons, in key government positions and holds full control over the country’s bank accounts, blurring the line between the public purse and his family’s personal pockets.

The constitution, enacted in 1982 and last amended in 2012, reserves considerable power for the president.[27] For example, the president is the first magistrate and appoints all Supreme Court judges without parliamentary oversight, compromising the independence of the judiciary.[28] In 2011 Obiang initiated a process of constitutional reform, the results of which were widely criticized as further consolidating presidential power and undermining accountability.[29] However, the reform also included a presidential term limit of two consecutive seven-year terms, the introduction of a bicameral legislature, and the establishment of a Court of Auditors and Ombudsman to foster transparency and accountability in governance.[30] The Court of Auditors has yet to be established, and the Ombudsman’s office was established in 2015.[31] Another amendment eliminates a maximum age limit of 75 years for presidential candidates—setting the stage for the then 69-year-old Obiang to continue to run for president.

The US State Department and others have long documented the harassment and arrest of opposition leaders and members in advance of elections, as well as rampant procedural violations and fraud on election day, including voter intimidation, opening of ballots, and voting on behalf of children and the deceased.[32] Similar problems plagued the most recent presidential elections, held on April 24, 2016. The election date, which was eight months before the official end of Obiang’s term, was announced by presidential decree only six weeks earlier. Obiang declared victory with 93.7 percent of the vote.

Obiang ran in the elections after declaring that the constitutional amendment limiting presidents to two consecutive seven-year terms is not retroactive.[33] The opposition parties maintained that the early election date violated a constitutional provision that says elections should be held no earlier than 45 days before the end of the president’s term.[34] The parties boycotted the elections citing harassment, procedural irregularities, the absence of an independent electoral body, and lack of media access.[35] Human Rights Watch, the United States embassy, and others criticized the restrictive atmosphere prior to elections, including reports that the military surrounded the headquarters of a political opposition party and that the country’s leading independent group promoting good governance was suspended, making it unable to act as a domestic observer.[36] The embassy noted that its election day observers witnessed cases of voter intimidation, violation of voting secrecy, and other irregularities.[37]

Lack of Transparency

Transparent governance that gives the public access to their government’s administrative decisions such as on income, budgets, and public procurement is fundamental to holding governments accountable and fighting corruption. However, as a recent report by the IMF notes, in Equatorial Guinea “even the most basic data are very hard for the public to access.”[38]

Failed Extractive Industries Transparency Initiative Bid

The government publishes scant information on its income or spending.[39] One exception is a report released in 2010 as part of its failed bid to join the Extractive Industry Transparency Initiative (EITI), a voluntary standard requiring government to publish payments they receive from oil and mining companies, as well as other information.[40] Equatorial Guinea was accepted as an EITI candidate in February 2008, in what was supposed to be a hopeful step toward transparency and civil society participation in overseeing the country’s resources. While the EITI does not require governments to publish information on spending, they must work in a national multi-stakeholder group along with industry and civil society to decide on objectives for EITI implementation.

The government published its first report on oil revenues just before its deadline for becoming EITI-compliant on March 9, 2010, leaving no time for an external validator to review it as required.[41] The government requested an extension from the EITI board, but under EITI rules, extensions are only given in the case of “exceptional and unforeseeable” circumstances beyond the control of the candidate country.[42] The board denied the request because it found the delay unjustified. An EITI specialist with the NGO Publish What You Pay who was closely involved in the process told Human Rights Watch that the EITI board was also influenced by restrictions on civil society.[43]

The president has since affirmed that he remains committed to transparency and the EITI. After protracted delays, a national EITI steering committee, which includes representatives from government, oil companies, and civil society, was re-established in 2015 with the goal of re-applying for membership. However, the process stalled in March 2016 when the minister of internal affairs ordered the suspension of one of the civil society groups on the steering committee.[44] The committee finally met again in November 2016 and February 2017, but restrictions on civil society remain a point of contention.[45]

Available Financial Information

The government released some general budget information for the first time in 2015, leading the International Budget Partnership, an independent group that partners with civil society to use budget analysis and advocacy to improve governance and reduce poverty, to raise the country’s score from zero to four out of one hundred on its measure for budget openness.[46] The measure scores countries based on a 140-question survey on public access to key budget documents in line with international best practice.

International financial institutions such as the IMF have also produced some financial information on Equatorial Guinea. The IMF generally holds annual meetings with each of its member countries to provide its assessment of the country’s economic health and recommendations for improvement. As part of this process it produces a report with summaries of its findings and the government’s responses, called Article IV reports, which it makes public unless the government objects. Since 2003 the IMF published such reports for Equatorial Guinea except for the years covering 2004, 2009, 2010, 2011, and 2014.[47] In 2010 the World Bank released a detailed Public Expenditure Review of Equatorial Guinea, which includes invaluable data and analysis on government spending. Human Rights Watch has also been able to obtain government budgets for nearly every year since 2000, but these documents are not publicly available.

Even beyond government budget information, very little official government business is made public. Brief and vague summaries of meetings and events are sometimes published on the government’s official webpage, but there are no protocols of parliamentary or other official meetings. Nor is there a centralized legal database housing all the country’s laws and executive decrees, making it difficult to find many laws.[48] Human Rights Watch was unable to obtain a copy of the education law, for example, placing some restrictions on our analysis of the education sector.

In many cases, basic financial and social data is not even collected, hampering the government’s ability to implement effective policies. A representative of the IMF who provides technical assistance to Equatorial Guinea on revenue administration told Human Rights Watch the absence of data is the “main weakness” for improving tax and customs collection. “We don’t have any idea how much global revenue is collected and where it goes. This blind spot makes it very hard to work with them on tax collection.”[49]

 Poor Socio-economic Data Collection

The government collects very little reliable socio-economic data, impeding assessments of indicators such as health, education, and poverty. The lack of reliable social and economic data presents a serious obstacle not only to making informed policy decisions, but also to assessing the social impact of these decisions, including budget allocations. The 2015 IMF report notes a “critical shortage of macroeconomic and socio-demographic data” leading to “considerable uncertainties regarding demographic data—and in turn social indicators.”[50]

Equatorial Guinea has no comprehensive online legal database or library, but hard copies of many laws can be purchased at certain government offices. Above are law pamphlets available for sale at the Delegation for Foreign Affairs in Bata.

© 2016 Human Rights Watch

Even the size of the population is uncertain: international figures put the 2015 population at 845,000 but the government claims it was 1.2 million for that year, revised downwards from the government’s estimate of 1.6 million in 2012.[51] The IMF has long pressed the government to improve its transparency and data collection not only to improve governance and accountability, but also because “the lack of published data could impede prospective foreign investors.”[52] Ironically, the president has hidden behind this deficiency to defend his government from criticism, claiming that critics are using outdated information.[53]

The government has taken some positive steps in recent years to address its acute statistical data weakness. It legally established the Equatorial Guinea National Statistics Office (INEGE) in 2001, although it only became active in the last few years and inaugurated its offices in May 2016. However, it is difficult to assess the reliability of the data generated by the office. For example, INEGE reported to the UN and IMF that poverty declined from 77 percent in 2006 to 44 percent in 2011 and that extreme poverty fell from 33 percent to 14 percent in those years.[54] Both institutions published those findings, although an IMF staff member who worked on the publication told Human Rights Watch that he discussed this data “with the resident UN agencies, and we agreed there are significant methodological weaknesses.”[55] These reservations were not included in the 2016 IMF report in which this data appears, which rather positively notes that a “high quality National Statistical Development strategy has been developed.” However, the previous year, the IMF found that the agency had “relatively few experienced staff.”[56] In a positive step, the government subscribed in 2016 to the IMF’s General Data Dissemination System (GDDS), which sets out standards for the quality, scope, and dissemination of national statistical data.[57] Authorities had resisted IMF recommendations to subscribe to the system for years, making it one of only two countries in sub-Saharan Africa not to do so.[58]

II. Under-Investment in Health and Education

Equatorial Guinea’s health care and education systems are plagued by problems common across poor and developing countries, except that technically, Equatorial Guinea has not been a poor nation since its oil boom began two decades ago. The country stands out for the vast gap between its available resources and the amount that it spends on addressing these problems. This is reflected in health and education outcomes far below other countries in its wealth bracket, and in many cases trailing averages even for poor countries. Public spending is examined in this section, while outcomes are addressed in the following section.

Equatorial Guinea has a human rights obligation to use its public resources, largely derived from oil wealth, to progressively improve the country’s woeful health and education systems, as well as to increase access to basic services, such as potable water and sanitary facilities. Yet, despite pledges to prioritize social spending, the government spends a relative pittance on health and education. Instead it pours most of its resources into large-scale construction projects such as government buildings and transportation infrastructure, some of which have minimal social value. The neglect of health and education violates Equatorial Guinea’s human rights obligations toward its citizens.

Equatorial Guinea’s window of opportunity to invest in improving the social conditions of its population and diversifying its economy to prepare for a post-oil era is quickly closing. Production is already in decline, made worse by historically low oil prices. This has precipitated a sharp drop in the state’s income that is expected to continue for the foreseeable future. Having hit its peak in 2012, the GDP shrunk in the past 4 years; it decreased by 7.4 percent in 2015 and the IMF expects it to further contract by 9.9 percent in 2016.[59] According to the World Bank, known oil reserves are expected to be depleted by 2035.[60]

Lack of Budget Transparency

It is impossible to comprehensively analyze Equatorial Guinea’s budgets because of the paucity of available data and the fundamental weaknesses of the budgets themselves. Equatorial Guinea does not publish government budgets, although, as noted in the previous section, in 2015 it made some general information available for the first time. Human Rights Watch was able to obtain numerous documents related to budgets; however, their usefulness for bringing transparency and accountability to government expenditures is limited because they are apparently incomplete and do not disaggregate and classify spending by function.

It appears that government budgets in Equatorial Guinea do not capture all spending and in many cases there is no accounting of how much money is actually spent. As one World Bank report put it: “The public budget does not record all public spending and the amount of extra-budgetary spending is difficult to evaluate.”[61] An IMF advisor who provides technical assistance to Equatorial Guinea’s revenue administration told Human Rights Watch: “We don’t have any idea how much global revenue is collected and where it goes.”[62]

The budgets also do not classify spending by function (e.g., defense, transportation, health, education). Functional classification is standard practice for government budgets, and the IMF considers it essential for supervising budget implementation, analyzing allocation of resources among sectors, and tracking poverty-reducing expenditures.[63] Instead the budget is divided into capital and current expenditures. Capital spending includes investments in assets such as buildings, roads, and airports, whereas current (also known as recurrent) spending includes salaries and other goods and services for a particular year. The budget divides current expenditures into approximately 180 line items, but capital expenditures, which comprise the bulk of the budget, are recorded in one lump sum. The absence of functional classification in Equatorial Guinea’s budgets not only makes analysis difficult, it also points to underlying “weaknesses in monitoring and control mechanisms,” according to the IMF.[64]

While these deficiencies make it challenging to quantify total expenditures in the social sector and compare them with social spending by other countries in the region, it is possible to draw some conclusions based on the available information. Economists sometimes use current expenditures as a measure for assessing a budget’s ability to deliver quality social services.[65] A 2010 World Bank Public Expenditure Review on Equatorial Guinea and regularly published IMF reports provide additional windows into the country’s finances, as do budget documents on the country’s public investment program (PIP).[66] The PIP consists almost entirely of construction projects, and, unlike the general budget, the PIP is classified by function. The four categories of social, public administration, production, and infrastructure are further subdivided, offering the most precise information available on health and education spending. Taken together, these documents offer a compelling, if fragmentary, picture of government spending on health, education, and infrastructure.

Neglecting Health and Education in Favor of Infrastructure Projects

In 1997, shortly after the start of the oil boom, the government convened a development conference where it committed 40 percent of public expenditure to the social sector, with 15 percent dedicated to education and science and 10 percent to health.[67] The government never came even close to realizing this commitment and replaced it a decade later with a new two-phase plan, called Horizon 2020, with a declared aim of turning Equatorial Guinea into an emerging economy by 2020. On paper, the focus of the first phase, which ended in 2013, was to transform the country’s economic base by investing in infrastructure, good governance, social welfare, and human capital, while the ongoing second phase is supposed to build the pillars of a diversified economy by improving the business climate, investing in human capital, and developing alternative industries such as agriculture, fishing, and tourism.[68]

In practice significant investments in the social sector did not materialize; instead the government has poured the majority of its resources into infrastructure projects. Capital expenditures typically makes up around one-quarter to one-third of a country’s budget (the average is 30 percent for sub-Saharan Africa), and the rest of the budget is spent on current expenditures.[69] Equatorial Guinea’s spending on capital investments, which averaged US$4.2 billion, or 81 percent, from 2009 to 2013, is the mirror image of the norm.[70]

Between 2009 and 2013 Equatorial Guinea took in an average of $4 billion per year in resource revenue and $400 million in tax revenue and other income, and spent an average of around $5.2 billion annually.[71] In absolute terms Equatorial Guinea spent more than $20 billion on capital investments in those five yearsand possibly additional spending not recorded in its budgets. In contrast, in 2011 the government spent roughly $140 million (or 3 percent of its total expenditures) on education and $92 million (2 percent) on health, according to the IMF.[72] Similarly, in 2008 it spent $60 million (2 percent) of its budget on education and $90 million (3 percent) on health.[73]

The IMF notes that Equatorial Guinea’s spending on health and education “is substantially below other high-income countries, even those with lower per capita GDP.”[74] On average countries with a per capita GDP on par with Equatorial Guinea spent around 14 percent of their budgets on each education and health; in a comparison of around 45 countries within Equatorial Guinea’s broad per capita GDP bracket, no other country spent less than 5 percent on either category.[75]

According to an unpublished draft of the IMF’s 2016 report, the situation remains the same despite transitioning, in 2014, to the second phase of Horizon 2020:

To date, there has been limited movement on structural reforms, and weak governance and corruption remain a serious impediment. However, large-scale prestige projects are still ongoing, of which the new capital city at Oyala is expected to account for roughly half of public investment during 2016.[76] 

One explanation for the persistently high amount of infrastructure spending may be that Equatorial Guinea established a “golden rule” that dedicates all oil revenue to physical investments and tax income to current expenditure, according to the World Bank.[77] The logic of this principle, as stated by the World Bank, is to ensure that oil revenues are used for the benefit of future generations.[78] It is not clear when Equatorial Guinea established this rule and in any case it is not strictly followed, since capital spending frequently exceeds annual oil revenues, forcing the government to dip into previous years’ oil proceeds, and current expenditure often exceeds tax revenues. However, it does appear to largely shape the government’s budgets.[79]

From a human rights perspective, there is nothing inherently problematic about investing heavily in new construction; many of the projects were needed to modernize an extremely underdeveloped country. Moreover, some of this spending— albeit only a small fraction —paid for vital health and education infrastructure, including a national university campus and modern hospitals.

But, in the case of Equatorial Guinea, overspending on infrastructure is a problem for two reasons. First, as documented in this section, the government’s extreme emphasis on capital investments comes at the expense of the social sector, including health and education. Second, as documented in the following section, these capital investments appear to be plagued by significant levels of corruption and mismanagement due in part to rules and practices governing public contracts that enable self-dealing by government officials.

In 2016, the IMF concluded that high spending on infrastructure led to low social spending:

Expenditure composition is currently 2:1 in favor of capital spending, whereas it is the inverse in other CEMAC [Gabon, Cameroon, the Central African Republic (CAR), Chad, the Republic of the Congo] countries, contributing to low provisions for health and education service delivery. Budget allocations should be better aligned with the national development program’s social priorities.[80]

This echoes repeated World Bank and IMF criticisms of Equatorial Guinea’s massive spending on physical investment as not financially or socially sustainable, a concern that has become more pronounced since the onset of the oil crisis. The World Bank has said Equatorial Guinea’s golden rule “does not provide an adequate macroeconomic framework” and may lead to overinvestment.[81] It has also found that “despite the considerable public outlays, the budget structure does not favor social investment” and “social sector spending is too low to address the needs of the country’s poor population.”[82]

Health and Education Spending

Available data on government spending on health and education is very limited. The World Bank’s 2010 Public Expenditure Review for Equatorial Guinea, mostly based on 2008 data, offers the most recent (and perhaps only) publicly available comprehensive analysis on government spending on these sectors.[83] However, more recent data from IMF reports and confidential government budget documents suggest that trends detailed in the World Bank report persist.

2008

In 2008 the government was projected to take in $4.7 billion in revenue, $4.4 billion of which came from oil, according to the IMF.[84] The same year, its total executed budget was $2.8 billion.[85] It spent $90 million (3.2 percent) on the health sector, although only $17.7 million went to current spending.[86] The World Bank notes that while total health expenditures increased significantly since 2004, the additional funds went mostly to capital investments, “resulting in a very low current per capita public expenditure of €16 (FCFA 10,600) that fails to meet the population’s health care needs.”[87] Indeed it found that current expenditure was so low that user fees were needed to supplement the budget for salaries of health officials.[88] In other words the personnel costs were passed on to the patients using the system.

Another problem the World Bank found was that there was “excessive” spending on administration and “hospital treatments that do not meet the needs of the general population.”[89] Based on its review of health outcomes and government expenditures, the World Bank concluded:

Unlike most countries of Sub-Saharan Africa, Equatorial Guinea has the financial means to improve the health of its population. However, the concentration of expenditure on [capital] investments has yet to produce any visible impacts, either in improved health conditions or in the quality and quantity of health services.

To correct this problem, it recommended that “infrastructure in the health sector must be complemented by a large increase in human capital.”[90]

The government spent even less on education than on health in 2008. Total spending was $60 million (2.14 percent).[91] In the five years between 2004 and 2008, only seven percent of government expenditures went to education, according to the World Bank report. As the World Bank notes, this is significantly below the percentages allocated by other countries in the region such as Uganda and Tanzania (30 percent), Ghana (25 percent), or Cameroon, Congo, and Gabon (16 percent).[92] Put another way, Equatorial Guinea’s public expenditure on education hovered around one percent of its GDP for those five years, which is one of the lowest shares in the world.[93] In contrast middle-income countries spent an average of 4.3 percent of GDP, and the average spending in sub-Saharan Africa was 3.9 percent.[94]

The imbalance between capital and current expenditures was not as extreme in the education sector as it is in health, but it still skewed heavily in favor of infrastructure. Of the US$60 million of public money spent on education in 2008, $25 million went to current expenditures and $35 million to capital.[95] The relatively higher current spending, however, is largely due to the nearly $12 million spent on scholarships for university students to study abroad and on sports federations, rather than on improving teacher salaries or quality of education at the primary and secondary levels.[96] Spending greatly favored higher education despite the fact that it represents only two percent of the student population: the government spends $410 per primary student as opposed to $11,435 per student in higher education, among the most unequal ratios in the region, according to the World Bank.[97]

As in the health sector, allocation decisions in education disfavor personnel salaries. According to the World Bank report, teachers who finished secondary school earned $175 per month, those with a teaching certificate earn $232, and those with a university degree $296. The report also finds that some 40 percent of teachers are considered “volunteers” and are paid directly by parents rather than by the state. The report also points to a “huge disparity” between education sector salaries, with managerial staff earning seven times more than teachers. Based on its analysis the World Bank concluded that “public financing of the [education] sector is insufficient given the dire needs” and that “authorities need to increase recurrent expenditures to the sector (rather than capital spending) to ensure a stable source of financing to train and hire more teachers.”[98]

2010 and 2011

Spending on health and education did not significantly change in 2010, although there was a slight overall decline in capital spending relative to current, going from 81 percent of the budget in 2008 to 75 percent in 2014.[99]

Budget documents for public investment projects in 2010 and 2011 obtained by Human Rights Watch indicate that the portion of capital expenditures devoted to the social sector remained in the same low range as in previous years. In 2011 Equatorial Guinea earned $4.8 billion in revenues, $4.4 billion of which came from the hydrocarbon sector. The government’s total expenditures for the year were $4.6 billion. As already noted only around $140 million (3 percent) of its budget went to education and roughly $92 million (2 percent) to health.[100]

By June 2011 only 1.3 percent ($18.6 million) of the PIP budget went to education and 1.8 percent ($27 million) to health.[101] This is in line with spending between 2005 and 2008 when 1 to 3 percent of capital spending went to health and 0.5 to 4 percent went to education. In comparison, during the same period, a quarter of the PIP budget ($365.7 million) was spent on airports, roads, and urban infrastructure. These numbers, dismal as they are, were better than the previous year: in the first three months of 2010, only 0.4 percent ($3.3 million) of the PIP budget went to education and 2.7 percent ($20 million) to health. In comparison, during the same period, 23.6 percent of the PIP budget ($175 million) was spent on airports, roads, and urban infrastructure.[102]

Moreover, the projected annual spending on health and education both years was significantly less than the amounts approved by law, while it nearly doubled for spending on airports, roads, and urban infrastructure. The 2011 Budget Law approved between $100 million and $125 million each for education, health, and potable water, but by June 30 the government had only spent a combined $60 million on all three categories. At the same time it had already spent over $80 million on sports, overspending its total approved budget for the year, and expenditures on airports, roads, and urban infrastructure were projected to climb from an approved $783 million to nearly $1.5 billion. According to the IMF only 3 percent of capital expenditures ultimately went to health and education in 2011, while 50 percent went to airports, roads, and urban infrastructure.[103]

The differences between approved and actual spending in the social sector were likely even wider in 2010. The law approved $687.8 million, but by the end of March, only 7.4 percent of that had been spent and the revised projected total for the year was decreased by roughly a third to $465 million. Education suffered in particular: $123.7 million was approved for the sector, but by the end of March only 2.6 percent had been spent, and the revised projection for the year was $43.8 million, approximately one-third the approved amount. On the other hand, as in 2011, the 2010 Budget Law approved $756 million for spending on airports, roads, and urban infrastructure, but that number was projected to rise to nearly $1.5 billion by the end of the year. Human Rights Watch was not able to obtain documents reflecting total PIP expenditures for 2010.

2014 to 2016 and the Looming Economic Crisis

Only limited data is available on social spending for years subsequent to 2011. The IMF’s 2016 Article IV report states that 14 percent of the investment budget was allocated to the social sector, a term it does not define, and it does not include data for actual expenditures, which in previous years fell far short of allocations.[104] In the first half of 2014 6.2 percent of the investment budget was allocated to health, education, and sanitationtotaling $827 million out of a total investment budget of $13.3 billion.[105] The IMF also notes that “current spending remains low ... with relatively low provisions for education and health.”[106]

A confidential 2016 government report written in collaboration with the World Bank includes budget information for the government’s flagship multi-year health and education programs“Education for All” and “Health for All”although it is not clear which years or what portion of the total education budget these cover. According to the report, the government spent $37 million on completed “Education for All” projects, with another $1.18 billion worth of projects underway (and approximately the same amount allocated for future projects). The distribution of the spending, however, is in line with priorities of previous years: only 1 percent is dedicated to teaching and the rest to “access and infrastructure”21 percent ($262 million) to building and renovating preschools, primary, and secondary schools, and 64 percent for higher education ($800 million).[107] The total value of “Health for All” projects that have been completed or are underway, according to the report, was similarly $1.23 billion (with another $475 million planned).[108]

The 2015 and 2016 government budgets on file with Human Rights Watch together include actual expenditures for 2009 to 2014, as well as allocations for 2015 and 2016.[109] Given the poor classification system described previously in this report, their usefulness is mostly limited to comparing overall current and capital expenditures. Even though, as noted, current expenditures are broken down into around 180 line items, most descriptions are too vague or broad to categorize social spending. Based on Human Rights Watch’s calculation line items that explicitly relate to education make up 0.8 to 3.1 percent of current spending for 2009 to 2014, while the range for health is 1.8 to 3.6 percent.[110] The amended budget for 2015 and projected budget for 2016 were slightly above this range, with roughly 4 percent of current spending allocated to health and education each for both years, although actual spending on the social sector has often been less than allocated amounts.[111]

Government officials have pledged that the new phase of Horizon 2020 will dedicate more resources to the social sector. In May 2016 President Obiang said his “top priorities right now are health services and education.”[112] But there is a real risk that the impending economic crisis caused by low oil prices and slowing oil production will negatively impact government spending on these sectors. From January 2014 to 2015 the price of oil halved from $100 per barrel to $50, forcing the government to amend its 2015 budget. The cuts were wide-ranging, but the hardest hit item by far was university scholarships, which were slashed by 60 percent in 2015.[113] At the time the US-based Equatoguinean human rights organization EG Justice reported that students in Malabo and Bata peacefully protested the cuts, but the police dispersed them with tear gas. According to EG Justice, around 100 students were arrested, 56 of whom were detained for 10 days without charge. The Ministers of Education and National Security allegedly questioned some students about the political party behind their protests before police officers beat them with batons.[114]

Spending on Unproductive Investments

The IMF has found that the outsized and opaque budgets for infrastructure projects have led not only to low social spending but also to excessive spending and investments with minimal development value. In 2013, for example, it noted that “costs and wastage have been high because of limitations in oversight and pressure for prestige projects.”[115] The following year it similarly concluded that “some of the largest projects have limited economic payoff.”[116] More specifically, it found: “The infrastructure investment program has also included projects with a weak impact on social indicators, including sports facilities and a new administrative capital city at Oyala.”[117]

The staggering amount of money that has poured into Oyala makes it a prime example of investments with dubious benefits. Equatorial Guinea’s official capital is Malabo, located on Bioko island, but the government operates six months a year out of Bata, the country’s largest city located on the mainland. To accommodate what are effectively dual capitals, the government built gleaming new buildings to house the various ministries in each city. Yet around five years ago, the government began to build a new capital city in the middle of the jungle, some 65 kilometers (40 miles) from the president’s hometown of Mongomo, in effect pouring billions of dollars into a third capital for a country with a population of around one million.

In a 2012 media interview Obiang cited security as the justification for building the new capital. He said that Malabo and Bata’s location on the water make him vulnerable to a coup.[118] According to the IMF’s 2015 report planned spending on Oyala was $8 billionmaking up almost a quarter of the total multiyear public infrastructure program budget of $36 billion.[119] An unpublished draft of the IMF’s most recent report concludes that it is expected to account for half of all government expenditures in 2016.

This bias in favor of infrastructure has also led to inefficient health and education spending, according to the IMF and World Bank. Spending in these sectors is not only too low, it also disproportionately favors capital investmentssuch as hospital buildings, administrative offices, and university campusesover current spending on items such as salaries and trainings for doctors and teachers, medicine, and textbooks. Out of a total planned multiyear public investment budget of $36 billion, $2.5 billion (7 percent) was allocated to health, education, and sanitation.[120] While the government has only executed a part of the planned projects, the IMF found that the bias in favor of infrastructure has led to uneven progress in health and education:

While development indicators that depend on infrastructure, e.g. access to water and electricity, have improved markedly, low overall spending on health and education delivery has led to vaccination and primary school completion rates that have fallen well short of the achievement of other SSA [sub-Saharan African] countries with much lower per capita incomes. In the face of significantly reduced oil revenues, the authorities need to shift limited resources to health and education sector [sic].[121]

This finding reflects past IMF and World Bank conclusions. In 2015 the IMF recommended that budget allocations be “overhauled” in line with development priorities, “notably health and education.”[122] The World Bank noted in 2010 that the government’s “current expenditures are insufficient to provide meaningful public social services.”[123]

The huge sums of money spent on infrastructureand the paltry sums used for health and educationmust also be viewed in the context of evidence indicating that government officials have amassed enormous wealth from public contracts.

III. The Human Cost of Underfunding Health and Education

Ordinary Equatoguineans pay a heavy price for their government’s failure to invest in health and education.

Equatorial Guinea was undoubtedly burdened by the legacy of extreme poverty and brutality of the Macías dictatorship, which ended 38 years ago but gutted the country’s institutions and left it with few qualified doctors and teachers. This should have been all the more reason for the government to invest a significant part of its oil revenues in the social sector, particularly in health and education. While the country has improved on some key health indicators, such as maternal mortality rates, available education indicators show no significant improvements. On many health and education indicators Equatorial Guinea has merely kept pace with general improvements across the African continent, despite its massive resource advantage. Incredibly, some indicators, such as vaccinations and net primary school enrollment rates, have worsened since the start of the oil boom.

Health

Health Data

As noted above, Equatorial Guinea does not routinely collect or publish data on health or other indicators, complicating a comprehensive assessment of its performance. Yet a review of available data and estimatesfrom UN reports and a 2011 household surveysuggests that despite a massive increase in resources, progress on most health indicators has been limited and often falls below other, poorer countries in the region, and in some cases health indicators have actually worsened.

Indicator

Equatorial Guinea’s Performance

Context

Life expectancy

57.6 (2014)

In 2014 Equatorial Guinea’s life expectancy trailed the sub-Saharan African average of 58.6 years by 1 year, while it was slightly above the regional average in 1995 when the oil boom started. Average life expectancy in upper middle-income countries was 74.4 in 2014.[124]

Human Development Index

138 (2015)

Equatorial Guinea ranks 138 out of 188 countries, making it the country with the largest gap between its per capita wealth and the state of human development. Its score is almost identical to that of Ghana and Zambia, despite boasting a per capita income that is more than five times as high.[125]

Infant mortality (per 1,000 births)

65 (2011, DHS)[126]; 68.2 (2015, WB)[127]

Equatorial Guinea’s infant mortality rate has consistently been higher than the average for sub-Saharan Africa, decreasing at a similar pace as the rest of the continent. In 2015 the average for sub-Saharan Africa was 56.4 (World Bank) and 15.2 for upper middle-income countries.[128]

Under-5 Mortality (per 1,000 births)

113 (2011, DHS)[129]; 94.1 (2015, WB)[130]

At the start of the oil boom, Equatorial Guinea’s under-5 mortality was slightly lower than the average for sub-Saharan Africa, but since 2003 it has consistently failed to keep pace with regional progress. In 1995 its rate was estimated at 171.2 deaths per 1,000 births, compared to a sub-Saharan Africa average of 173.2; in 2015 World Bank data estimated 94.1 deaths per 1,000 births, compared to a region-wide average of 83.2. The household survey suggests the actual number is higher than World Bank projections.[131]

Maternal Mortality (per 100,000 live births)

308 (2011, DHS)[132]; 342 (2015, WB)[133]

Equatorial Guinea’s progress on this indicator has significantly outpaced that of the sub-Saharan African region. In 1995 Equatorial Guinea’s rate of 1,050 deaths per 100,000 live births was among the worst in the region. By 2015 its rate was well below the average for sub-Saharan Africa (547), although still significantly higher than the average for upper middle-income countries (54).[134]

Access to improved water (% of households)

56% (2011, DHS)[135]; 47.9% (2015, WB)[136]

The rate of access to improved drinking water in Equatorial Guinea has not improved over the last 20 years, hovering around 50% throughout that period. In 1995 Equatorial Guinea’s score on this indicator was similar to the average for the sub-Saharan African region; by 2015 the regional average had increased to 67.6%, according to the World Health Organization (WHO).[137]

% of infants between 12-23 months completely vaccinated

27% (2011, DHS)[138]

Equatorial Guinea’s vaccination rates for children have fallen dramatically since the late 1990s and are among the worst in the world. For example, the reported rate of tuberculosis vaccination for newborns and infants was 99 percent in 1997; 64 percent in 2014; and 35 percent in 2015, the last year for which data is available.[139]

% of children under 2 that received no vaccines at all

25% (2011, DHS)[140]

The percentage of children under two that have received no vaccines is among the highest in the region. For comparison, the rates were 5% in Cameroon (2011, DHS); 4% in Gabon (2012, DHS); 21% in Nigeria (2013, DHS); and 3% in São Tomé and Príncipe (2009, DHS).[141]

The above data and estimates tell a clear story: Equatorial Guinea is an upper middle-income country that performs worse than many low-income countries on numerous key health indicators.

Nearly six in ten people die from communicable diseases or maternal, prenatal, or nutrition conditions.[142] Equatorial Guinea’s performance on vaccinations is illustrative of the failure of the government to invest in its population’s health. A senior employee of a humanitarian agency active in the country told Human Rights Watch that UNICEF supported Equatorial Guinea’s vaccination program in the 1990s, when the vaccination rate for polio and DPT was over 80 percent.[143] When oil money started filling the country’s coffers toward the end of that decade, UNICEF discontinued its financial support since the Equatoguinean government was supposed to step in. It did not, however. Between 1998 and 2000 vaccination rates for, among others, polio and DPT dropped to around 40 percent. Overall the rates have worsened since the start of the oil boom for every vaccine that the World Health Organization (WHO) tracks.[144]

In the last few years, after a slight recovery, vaccination rates declined further and fell dramatically from 2014 to 2015, the most recent year for which data is available. According to a 2011 household health survey, one quarter of children under 2 receive no vaccines at all and only one quarter of children received all recommended vaccinations.[145] The vaccination rate for tuberculosis in 2015 (35 percent) was the second-lowest rate in the world.[146] Measles vaccination similarly dropped from an 82 percent high in 1997 to 43 percent in 2014 to 26 percent in 2015. Even before this last 17-point drop in 2015, Equatorial Guinea had the second-worst rate in the world, besting only Central African Republic. Polio vaccination rates were the worst in the world at 27 percent in 2015, having fallen from a high of 64 percent in 1997; Somalia has the second worst rate at 42 percent. The decline in vaccination rates tracks the overall decline in Equatorial Guinea’s economy, raising concerns about how expected continuing economic contraction may harm public health programs.

The government’s failure to improve access to safe drinking water over the last 20 years is similarly egregious. While the lack of access is especially severe in rural areas, many neighborhoods in Malabo and Batathe capital and economic centeralso rely on contaminated water from wells or the river, creating tough choices for ordinary Equatoguineans. For example, Arturo, a father of two who lives in Malabo and works in an administrative position for an international agency, told Human Rights Watch that he cannot afford to boil the river water before drinking it: “We prefer to save the money to use the gas for cooking rather than [for] boiling water.”[147] The health risks of contaminated water and poor sanitation are particularly high for children. Researchers conducting a health survey in 2011 found that one in five children under five had experienced diarrhea in the two weeks prior to their visit and nearly one in three had had a fever.[148]

Lack of Access to Affordable Health Care

Equatorial Guinea’s government is obliged under international law to ensure access to healthcare services that are affordable to all. In practical terms credible efforts to meet this obligation are also an indispensable part of any successful government effort to progressively realize the right to health over time.[149] International human rights law is not prescriptive on how countries should achieve this, but the Committee on Economic, Social and Cultural Rights (CESCR), the body of independent experts that monitors implementation of the International Covenant on Economic, Social and Cultural Rights by states party to the convention, has clarified that:

Payment for health-care services, as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households.

Since 2005 the World Health Assembly has urged countries to introduce health financing systems that provide for “sharing risk among the population and avoiding catastrophic health-care expenditure and impoverishment of individuals as a result of seeking care.”[150]

The Sustainable Development Goals, a UN-led universal call to action to end poverty, protect the planet, and ensure that all people enjoy peace and prosperity by 2030, call for the introduction of universal health coverage, which would ensure access to quality essential health services and protect patients against catastrophic health expenditure.[151]

Equatorial Guinea’s Health System

The Ministry of Health and Social Welfare oversees the administration of Equatorial Guinea’s public health system. The ministry’s budget is determined by the Ministry of Finance and Budget, although the Ministry of Planning and Development oversees the implementation of capital spending, which comprises most of the budget.

In 2009, the most recent year for which there is data, there were 45 publicly funded health centers, which provide basic medical services, and 18 hospitals (12 district; 4 provincial; and 2 regional). Rural areas are often served by smaller health posts, which are not necessarily staffed by doctors but can administer basic tests. Although public hospitals and health centers are generally the cheapest option for receiving health care, they still charge user fees, and research by Human Rights Watch indicates that the system does not provide for any mechanism to waive or reduce fees for the poor.[152]

The state also subsidizes employer-based social security insurance called INSESO (Instituto Nacional de Seguridad Social), which covers around 60,000 people.[153] INSESO operates its own network of hospitals and health centers and falls outside the purview of the Ministry of Health. The insured and their minor children receive 50 percent discounts to access INSESO’s services, which reportedly provide better quality care than the public system. INSESO is funded through a combination of employer and employee contributions and public funds; its expenses make up a significant amount of the budget’s current expenditures even though it covers a relatively small percentage of the population.[154]

There is no data on the extent of private health care use, but the World Bank in 2010 noted that “given the lack of public sector coverage, private sector involvement is extensive.”[155] Many charge fees that are considerably higher than the public sector, putting them out of reach of most Equatorial Guineans. However, there are also lower-cost clinics that are funded by foreign aid; most are run by the Catholic church.

Many of the doctors, nurses, and patients interviewed by Human Rights Watch said that those for whom the public option is too costly simply have no access to health care. A nurse at the General Hospital in Malabo said that even women in labor who cannot pay in advance will be turned away.[156] She recalled how one patient who had complications during childbirth that required treatment only available at La Paz Hospital, a publicly funded hospital discussed in more detail below, died after being unable to pay for the necessary medical care. Another nurse in the same hospital confirmed that they turn away patients every day because they are unable to pay, adding that some patients’ conditions worsen while waiting for treatment and trying to get the money together.[157] Expressing her exasperation at the system, she said: “I would understand if this were a private hospital but this is public!”

A doctor who worked in the General Hospital in Bata had the same experience: “If people [in critical condition] don’t have money, they die,” she said.[158] One interviewee told Human Rights Watch that when he is sick, he usually stays home because he doesn’t have the money to pay.[159] He said that when he can afford it, he prefers a private clinic because he doesn’t believe the General Hospital provides quality care. But, he added, a consultation at the clinic costs 7,000 CFA francs (US$11.25). “If right now I had to pay that kind of money, I would die,” he said, laughing incredulously.

The government has heavily invested in two modern, well-equipped hospitals that were built with public funds but charge fees that put them out of reach for most Equatoguineans. These two hospitals, the crown jewels of the country’s health system, are in Malabo and Bata, both called La Paz, and are staffed almost entirely by foreigners.[160] Multiple sources told Human Rights Watch that the hospitals are privately owned but are at least partially government funded.[161] “The line between public and private health carelike for everything elseis very thin in Equatorial Guinea,” a senior employee of a humanitarian agency, told Human Rights Watch.[162] Two medical professionals at La Paz also described the hospital as private, although they said that the government pays their salaries.[163]

La Paz charges fees for services including delivery that make it unaffordable to most Equatoguineans, according to several people interviewed.[164] Patients who arrive at the emergency room at La Paz are expected to pay 30,000 CFA francs (US$49) prior to service, a doctor who works in a private clinic in Bata told Human Rights Watch. One member of the medical staff at La Paz Malabo told Human Rights Watch that the hospital would not turn away urgent cases, such as trauma, even if they could not pay upfront, although they would still be billed. Non-emergency patients who cannot pay upfront are denied service at La Paz, they said.[165]

In some cases, the government apparently subsidizes payment for services at La Paz Hospitala system that may help some patients but does not satisfy the requirement of equitable access under the right to health. Human Rights Watch was unable to determine how often and in which cases the government grants such letters. A number of people interviewed said that they were reserved for the politically connected. One medical staff member at La Paz said that he frequently receives patients with such letters, but most are either senior government officials or connected to them. He gave one example of a well-off foreign employee of a member of the presidential family receiving subsidized treatment.

A number of people who are not politically connected told Human Rights Watch that La Paz was only for the elite. When asked whether he had tried to request subsidized treatment at La Paz, a father who earns roughly $300 per month and has two children who suffer from a costly blood disorder said: “It’s a hospital that’s here, but we don’t consider it to be here,” he said. An elderly woman who has worked in government services since 2005 said that her family spent two years applying for such assistance for her grandchild, who has cerebral palsy and requires CT scanning only available at La Paz, but has yet to receive any help. “It depends on who you are, on whether you have government connections,” she said. Two peopleincluding the La Paz staff membersaid that in any case the government has stopped issuing or honoring these letters in recent years due to the economic crisis. Moreover, the barrier to accessing La Paz in Malabo is not only financial. Unlike the General Hospital, which is centrally located, La Paz is situated in an enclave of the island called Sipopo, which can be difficult to reach since it is separated from the city by a tollbooth and police checkpoint. The location reinforces the impression that the hospital was built to serve the elite rather than the broader community; besides a few houses belonging to the members of the president’s family, the enclave has no residential space for Equatoguineans.[166]

Inadequate Quality of Care

Despite having vastly greater resources, Equatorial Guinea’s healthcare system continues to be troubled by many challenges that are common in low-income countries. The doctors, nurses, patients, and foreign professionals with whom Human Rights Watch spoke all stressed that poor quality of care is a major problem. Interviewees raised a lack of qualified staff, frequent misdiagnoses, long waits, and stock-outs of medicines and medical supplies as key concerns about the quality of care. According to the WHO, “a large part of ... health clinics [in rural areas] are not functional given the lack of personnel, equipment, and essential medicine required to provide effective services.”[167] The dismal health indicators described above would seem to bear this out.

Several of the people we interviewed said they were reluctant to seek treatment at the General Hospital in Bata or Malabo out of fear of being misdiagnosed, preferring to meet the higher fees being charged by private clinics if they could afford them.[168] One doctor who works in a private clinic said he frequently sees patients who have been misdiagnosed at public hospitals. As an example he recounted a patient who was diagnosed at the General Hospital with liver cancer but turned out to have a liver abscess: “That's the situation: the doctors [in the General Hospital] can't tell the difference between liver cancer and an abscess,” the doctor said. Another doctor who works at La Paz Malabo said that when patients are transferred in critical condition from the General Hospital, he often thinks to himself that they would have been better off had they never been treated.[169]

Low salaries likely contribute to the inability of the public healthcare system to attract qualified staff. Interviewees said that local doctors are paid around 200,000 CFA francs (US$322) monthly and nurses earn 120,000 CFA francs (US$193).[170] In its 2010 Public Expenditure Review on Equatorial Guinea, the World Bank noted: “The low wages earned by public sector workers with medical training prompt young people in these professions to emigrate to other countries.”[171] Salaries for foreign staffand particularly staff in La Paz Hospital Malaboare significantly higher. One medical staff member there said he earns twice what he would earn in his home country, where the average monthly salary for his field is almost $4,500.[172] He said that cleaners at the hospital make 150,000 CFA francs, or more than a nurse in a public hospital.

Several interviewees told Human Rights Watch that extremelyand sometimes dangerouslylong wait times are common at the General Hospital in Malabo.[173] One interviewee who took his son who had typhoid and malaria to the General Hospital in Malabo told Human Rights Watch that he waited four hours for service.[174]

An obstetrician told Human Rights Watch of a tragic incident that had occurred the morning of our interview to illustrate the conditions of the public hospital system. A pregnant woman named Maria had come to his private clinic the previous night, after she had already been in labor for more than a day. She had never been to a prenatal check-up and did not know if she was full term. She began the delivery at home with a mid-wife, but had complications, so the mid-wife sent Maria to the General Hospital in Bata, Equatorial Guinea’s largest city. There, she waited all day but did not see a doctor, he said. When she left after the hospital closed and came to the doctor’s clinic, it was already too late. Her baby died in the morning, hours after delivery.[175]

Education

The physical condition of many schools in Equatorial Guineafrom crumbling buildings overcrowded with student benches to unsanitary facilities and a lack of drinking wateris a visible symptom of the government’s neglect of the sector. But the problems in the sector go far deeper: high rates of children who never started school, dropped out, or had to repeat multiple grades; unaffordability of even primary education; and low rates of teacher certification, etcetera. Some education indicators, such as rate of children not enrolled in primary school, have in fact deteriorated since the start of the oil boom.

Under international human rights law, Equatorial Guinea’s government is obliged to provide free primary education and to progressively realize the right to education more broadlymeaning an improvement over time in the availability and quality of education.[176] Available data suggest that Equatorial Guinea has not met its minimum obligations despite its vast oil wealth. Interviews with teachers, parents, students, and educational specialists reinforce that view and offer insight into the human cost of that reality.

A telling sign about the poor quality of public schools is how assiduously parents try to avoid them. According to a 2015 government report to UNESCO, more than half of students attend private schools.[177] The report does not offer any reasons for this. One parent told Human Rights Watch that he sent his children to private schools even though he could not even afford to use cooking gas to boil drinking water at home.[178]

Equatorial Guinea’s Education System

Equatorial Guinea’s education system is divided into three levels—pre-school, primary, and secondary—each of which lasts six years. Pre-school begins with nursery for one- to three-year-olds and transitions to kindergarten for children aged four to six. Children begin primary school at age 7 and are expected to graduate at 12. Students who achieve a Primary Studies Certificate may go on to secondary school (also called high school), while those who do not successfully complete their primary school exams have the option of pursuing vocational training. After graduating from secondary school students must take preparatory courses before applying to the National University of Equatorial Guinea, the country’s sole university.

The Ministry of Education, Science and Sport is responsible for administering the public education system. A 2007 law makes pre-school and primary school compulsory and free. In reality, high percentages of students are too old for their grade, many drop out or never enroll, and all educators and parents interviewed told Human Rights Watch that schools charged fees. More than half of students attend private schools.

Missing Children and Repetition

In 2012, the most recent year for which UNESCO has data on the country, 42 percent of children age 7 to 12 were not in primary school, the seventh worst rate in the world.[179] This is worse than before 2000, prior to the onset of oil wealth, when 33 percent of primary school age children were out of school.[180] Many children were never enrolled in primary school, and only half of those enrolled complete it. Remarkably the highest dropout rate is after first grade: in 2011, 12 percent of children left school after first grade and never re-enrolled, according to UNESCO.[181] Another 24 percent repeated first grade, so that only about two-thirds of the class moved on to second grade.[182]

While highest for first graders dropouts and repetition remain problems at every level. This, combined with late starts to education, means that the ages in any given class can vary widely. In 2015 only 56 percent of primary school students were in the correct grade for their age—a 10 percent decline from 2000.[183] “In first grade, you can find kids ranging from 6 to 13 or 14. How do we deal with this?” Ignatio, an expatriate who is an education

specialist working in the country, told Human Rights Watch.[184] Secondary school, which begins in the seventh grade, fares even worse, based on the little data available: less than one-quarter of secondary students are in the correct grade for their age.[185]

As Ignacio noted, the sad state of education is particularly unfortunate since the small size of the country’s population means that even a modest investment would go a long way. For example, the total number of out-of-primary-school children in 2012 was 45,885.[186] “You can practically fit them in one school bus,” he joked. Yet the government “has never invested in education in a substantial way, even though they could do it with pocket change.”[187]

Overcrowding and Dilapidated Schools

A bathroom at the high school, where there is no running water. 

© 2016 Human Rights Watch

The physical condition of schools is often a barrier to learning; 332 of 857 schools have no latrines at all, according to a 2015 government report to UNESCO, and 600 lack electricity.[188] The development plan makes investment in educational infrastructure a priority, but, as discussed in the previous section, most funds are diverted to higher education.[189]

A bathroom at the high school, where there is no running water.

© 2016 Human Rights Watch

Seventy or eighty students per class was common in public high schools, a former public high school teacher, Cristian, said. Another teacher, Diego, told Human Rights Watch he once had 105 students in a class.[190]

Human Rights Watch visited both a recently renovated middle school and a high school that was in very poor condition. In the high school classrooms were tightly packed with around 40 to 50 double benches, and the ceiling panels were completely torn. There was no running water in the bathrooms; cobwebs covered the sinks and the latrines and floors were covered in excrement. There was no running water in the bathrooms; cobwebs covered the sinks and the latrines and floors were covered in excrement. The middle school had around 30 double benches per classroom and running water in the bathrooms. Human Rights Watch also visited a private primary school in Malabo. Conditions were somewhat better than at the public high school. Classrooms held around 25 double benches. There was no running water in the bathrooms, but they were clean and water was available in a well just outside the bathroom for washing hands.

Poor Teacher Training and Low Pay

A number of teachers whom Human Rights Watch interviewedall of whom worked in both public and private schools at some pointblamed the high dropout and repetition rates partly on low teacher pay, lack of accountability in schools, and minimal or no training.

A classroom at an urban public high school. Each classroom held around 40 double benches. Teachers told Human Rights Watch that classes commonly had 70 to 80 students; one said he had 105 students in a class he taught the previous year. The teachers said that the physical conditions of the school were typical and that some schools, particularly in rural areas, fare worse. 

© 2016 Human Rights Watch

Teachers interviewed by Human Rights Watch said that salaries were so low and training so poor that teachers lack both the motivation and skills to meet the challenges of overcrowded classrooms, and the absence of any system of accountability exacerbates the problem. “If a student ends up with a teacher who doesn't have training, he's lost,” one public middle school teacher, Alphonso, said.[191]

Hernando, 19, who recently graduated from high school and transferred from a private to a public high school after his family moved out of Bata, described his experience:

First of all, many times the teachers didn’t even show up. There were 70 kids in my class compared to around 30 in private school. There were no textbooks. The teacher had the book, used it to write on the board, and the class would copy it down. If you want to correct your work, you can. If not, not. They don’t care at all.[192]

A low level of teacher training undermines the quality of education. A government report states that 59 percent of teachers have a professional degree, and, according to UNESCO, 49 percent of primary school teachers have training.[193] Alphonso said that he is among 5 of 13 teachers in his middle school who are certified.[194]

Both according to the international data and an education specialist interviewed by Human Rights Watch, there has been an improvement in teacher training since 2008, when a study found that only 30 percent of primary school teachers had the requisite training.[195]

But the extent and quality of training is also a problem. The same study found “that a high ratio [of teachers] had problems with written expression, spelling, and penmanship.”

Improved training is largely due to a program called el Programa de Desarrollo Educativo de Guinea Ecuatorial (PRODEGE), which is jointly funded by the oil company Hess and the government and fully implemented by US-based NGO FHI 360. Hess and the government contributed $50 million toward the program (Hess pays the full amount and deducts it from what it owes to the government).[196] The ten-year program, which began in late 2006, has trained nearly 1,000 of around 3,500 primary school teachers during its first phase; its second phase focuses on secondary education.[197]

While the educators with whom Human Rights Watch spoke about PRODEGE generally had a positive view of the program, some also said they found it troubling that this is the only well-resourced government education program since its model is unsustainable: the programs ends in 2017 and there are no plans to continue it.[198]

Costs

Equatorial Guinea’s National Education Act mandates that public schools be free, in line with the government’s human rights obligations. However, all educators and parents Human Rights Watch interviewed said that students are required to pay fees for enrollment, although the amounts they gave varied widely. The reason for the variation may be that the official cost is lower than what officials actually charge, Clara, an education specialist active across the country, told Human Rights Watch, and the amounts they demand can vary between schools.[199] Although Human Rights Watch was unable to verify fee amounts, a number of teachers Human Rights Watch interviewed believe that high school fees, particularly in secondary schools, contribute to high dropout rates.[200]

IV. Self-dealing in Infrastructure Projects

The paltry resources Equatorial Guinea invests in its health and education systems can be partly explained by its unusually high spending on infrastructure, which consumes nearly all of its oil revenues, as documented in Section II of this report. Human Rights Watch findings suggest that such massive spending on infrastructure has led to corruption and at least some of those public funds have found their way into the pockets of top government officials and their relatives who own businesses that benefit richly from these public contracts.

In the five years between 2009 and 2013 Equatorial Guinea spent around US$20 billion on infrastructure projects, or an average of around $4 billion annually.[201] In contrast, neighboring Gabon, population 1.62 million with a similar overall GDP, earmarked $1 billion for infrastructure in its 2015 budget.[202] Put another way, Equatorial Guinea spent around one-third of its GDP on infrastructure projects between 2008 and 2013, which is three times the regional average.[203]

Equatorial Guinea has inadequate laws regulating conflicts between government officials’ private interests and public duties, and the enforcement of existing conflict of interest laws are at best spotty, as discussed in Section V of this report. In addition the procurement process for government contracts is informal and opaque. Local content laws require that a minimum 35 percent of all companies operating in the country be owned by Equatoguineans; these types of laws seek to ensure that domestic businesses benefit from investments by multinational businesses, but in Equatorial Guinea they seem to have fueled corruption and self-dealing. This section examines how the legal environment and opaque management of public finances provide fertile ground for foreign businesspeople to partner with powerful officials, whose companies may only exist on paper but who use their influence to secure large government contracts from which they profit. In addition, it appears that it frequently leads to inflated contract prices and approval for projects with little social value that are causing the wasteful diversion of resources away from the neglected social sector, which includes health and education.

Equatorial Guinea has invested hundreds of millions of dollars in building highways, but most residential areas, even in the capital, remain unpaved. Rains often leave large pools of water on the unpaved roads, making driving difficult for residents.

© 2016 Human Rights Watch

Equatorial Guinea’s massive investment in public infrastructure has succeeded in transforming the physical landscape of the country to lay the groundwork for a modern economy. Prior to the oil boom the country had just 60 kilometers of paved road; it now has a road network of more than 2,000 kilometers across the country.[204] The government also built three new airports and modernized the two existing ones in Malabo and Bata, and extended eight seaports. Some investment went toward health and education: the government constructed or rehabilitated 62 primary schools and 65 health clinics and hospitals in the last decade.[205]

But this achievement does not mitigate the waste resulting from conflicts of interest and an opaque procurement process documented in this section, nor does it justify the related neglect of health and education. Indeed, the IMF, World Bank, and others have repeatedly found that the impact of the infrastructure investments on improving social indicators and diversifying the economy is impeded by “deep-seated deficiencies in public financial management.”[206]

This section examines the pernicious self-dealing in Equatorial Guinea’s infrastructure sector. Court cases and other official documents reveal an extensive record of mismanagement and corruption in the sector involving enormous sums of public money that directly contribute to the government’s chronic and extreme underfunding of health and education. However, self-dealing is by no means limited to the infrastructure sector and appears to be deeply rooted in Equatorial Guinea’s political and financial systems. A 2009 US State Department cable made public by WikiLeaks explains what it calls Equatorial Guinea’s “peculiar financial management mechanisms” as a legacy of the government not having sufficient resources to pay salaries. Citing the Equatoguinean treasurer who served until 1993, the cable says that the government often compensated officials with “in-kind transfers” in the form of seized land, operating licenses, and import concessions. Officials were also only expected to work three days a week, and to devote the remainder of their time to earning a living. When oil revenues began to flow, this mix of official and private business proved enormously lucrative. According to the cable:

Most ministers continue to moonlight and conduct businesses that often conflate their public and private interests. The custom of simultaneously maintaining both official and private activities that became entrenched in the era of skinny cows has not been altered for the fat ones. [207]

International Corruption Investigations

Equatoguinean officials have been under frequent scrutiny and investigation for money laundering and corruption, including in the US, Spain, France, and Switzerland. The findings of these investigations offer an invaluable window into the government’s financial system and high-level officials’ business dealings.

US Senate Investigation and Spanish Criminal Case

A subcommittee of the US Senate conducted one of the first investigations in 2003, when it scrutinized a Washington, DC bank for compliance with US money-laundering statutes. Equatorial Guinea was the largest client of Riggs Bank, which, between 1995 and 2004, operated 60 accounts belonging to the government, officials, and family members worth as much as $700 million.[208] Withdrawals from an account that held deposits from American oil companies active in Equatorial Guinea (primarily ExxonMobil and Marathon) required the signature of President Obiang and either his son, Minister of Mines Gabriel Obiang Lima, or his nephew, Secretary of State for Treasury and Budget Melchor Esono Edjo.[209] Obiang was the sole signatory on two investment accounts, which were linked to a money market account from which any of these three individuals could authorize withdrawals. Between 2001 and 2004, these three accounts had combined balances of up to $500 million.[210]

In 2004 the US Senate Permanent Subcommittee on Investigations concluded that Riggs Bank approved more than $35 million in wire transfers from the government account into the accounts of two companies, Kalunga Co. and Apexside Trading, and the committee stated it had “reason to believe that at least one of these recipient companies is controlled in whole or in part by the E.G. President.”[211] The report found other suspicious transfers and unexplained large cash deposits into officials’ personal accounts. It also found that US oil companies made payments into a student scholarship fund, but “[m]any and perhaps all of these students were the children or relatives of E.G. officials.”[212] The US government imposed a $25 million fine on Riggs Bank for “willfully violating its legal obligations to implement an adequate anti-money laundering program.”[213] The bank subsequently closed and merged with PNC Financial Services.

An investigation by a Spanish human rights organization, Asociación Pro Derechos Humanos de España (APDHE), found that at least five of the transfers from government accounts at Riggs Bank into the Kalunga account closely coincided with nine real estate purchases in Madrid, Gijón, and Las Palmas de Gran Canaria in the Canary Islands on behalf of Obiang, members of his family, and other close associates.[214] A total of $26.5 million was deposited into the Kalunga account at Banco Santander from 2000 to 2003.[215]

In May 2008 APDHE filed a criminal complaint against 11 senior Equatoguinean government officials and family members in Spanish court for alleged money laundering. As part of the investigation, Spanish authorities arrested Vladimir and Julia Kokorev and their son Igor, who they allege registered Kalunga and opened its accounts as a front company for government officials.[216] Officials allege that the couple transferred large amounts of money from their accounts into those of senior Equatoguinean government officials, for example a $2 million transfer to Fausto Abeso Fuma, Obiang’s son-in-law and the aviation minister.[217]

The government press responded to these allegations as “unfounded” and “part of the usual attitude of many Western media and institutions, of denigrating and humiliating the African continent and leaders.”[218]

Teodorin Corruption Cases

The outrageous spending habits of Obiang’s eldest son, Teodoro Nguema Obiang Mangue (known as Teodorin), have made him a target of several international money-laundering investigations. Teodorin was appointed vice president in June 2016.[219] Many believe he is a favorite to succeed his father as president.

Corruption Allegations in the United States

Between 2004 and 2010, Teodorin, at the time a minister of forestry and agriculture and earning a salary of under $100,000 a year, went on a $110 million US shopping spree, purchasing a mansion in Malibu, California, a Gulf Jetstream airplane, a fleet of luxury cars, and, famously, a $1 million assortment of Michael Jackson memorabilia including the white crystal-covered glove the pop star wore on his “Bad” tour.[220] The purchases set off alarm bells among US anti-money-laundering authorities, and in 2010 the US Senate Permanent Subcommittee on Investigations published a report detailing its reasons for believing they were bought with ill-gotten gains. The following year the US Department of Justice’s (DOJ) Anti-Kleptocracy Initiative filed a complaint to seize $70.8 million worth of these assets, alleging that they were bought with the proceeds of foreign corruption in violation of US law.[221]

Interviews conducted over the course of the DOJ’s investigation offer a revealing window into how Teodorin used his official position to extort millions of dollars in “taxes” and kickbacks. The DOJ ultimately settled the case after Teodorin agreed to forfeit $30 million in assets, which “will be given to a charitable organization to be used for the benefit of the

people of Equatorial Guinea.”[222] Human Rights Watch research indicates that the money has yet to be distributed.

Rather than initiate its own investigation in the face of overwhelming evidence of Teodorin’s corrupt activities, the Equatorial Guinean government issued a statement condemning the US Senate report as “racist, xenophobic, arrogant, and segregationist.” It defended Teodorin by claiming that under Equatorial Guinean law, government ministers “are perfectly authorized to conduct business and other types of work on the margins of their ministerial obligations.”[223] In court, Teodorin argued that anti-corruption laws that prohibit self-dealing by a “funcionario público” (or government official) apply only to civil servants and not to senior government officials.[224]

Corruption Allegations in France and Switzerland

During the same years as his US spending spree Teodorin allegedly spent €175 million (US$189 million at current exchange rate) in France on a mansion on the exclusive Avenue Foch in Paris, a collection of 26 luxury cars and 8 motorcycles, high-end art, luxury designer goods, hotels, and vintage wines.[225] Two French nongovernmental organizations, Transparency International France and Sherpa, filed a criminal case against Teodorin in 2008, alleging he had violated France’s anti-money-laundering laws. The three judges presiding over the case indicted Teodorin in March 2014, and two years later they ruled that there was sufficient evidence for Teodorin to stand trial.[226] The trial, initially scheduled for January 2, 2017, has been set for June 19, 2017.
 

The case documents are sealed, but Human Rights Watch and the media were able to obtain some information related to the charges. The judicial decision ordering Teodorin to stand trial alleges that between 2004 and 2011, nearly €110 million (US$119 million at current exchange rate) was transferred from the public treasury into accounts held by Teodorin. In particular, it alleges he used his forestry and construction companies, SOMAGUI, SOCAGE, and EDUM, to funnel money to France, although funds for many of the larger expenses passed through five Swiss companies established for that purpose.

In response to the French prosecutor’s decision to indict Teodorin the Equatorial Guinean government issued a statement on May 27, 2016, expressing its “repulsion” that the French prosecutor “does not value the institutional figure of our Second Vice-President” or recognize his immunity.[227] The following month, Equatorial Guinea filed a complaint with the International Court of Justice (ICJ) arguing that France was in breach of its obligation to respect Teodorin’s immunity.[228] The complaint also claimed that the Equatorial Guinean government used the Avenue Foch mansion as a diplomatic mission, and as such similarly deserves official immunity. About a week after filing the complaint President Obiang promoted his son to be his vice president. On December 7, 2016, the ICJ dismissed Equatorial Guinea’s claim that the French prosecution breached Teodorin’s immunity, finding it lacked jurisdiction.[229] However, it ordered France to respect the diplomatic protections of the mansion until it reached a final decision to determine its status.[230]

Switzerland opened a separate investigation into Teodorin in October 2016.[231] It seized 11 luxury cars in connection with the investigation, and Dutch authorities seized a $100 million yacht allegedly belonging to Teodorin at the request of Swiss courts.[232]

Self-Dealing in Public Infrastructure Contracts

Investigations by the US Department of Justice, France, and others exposed how government officials allegedly siphoned off millions of dollars in public money, oftentimes through shell companies that did not appear to do any actual work.[233] For instance, sources interviewed by US investigators pointed to Teodorin’s road construction company SOCAGE (Sociedad de Carreteras de Guinea Equatorial) as an example of a minister-owned shell company whose sole purpose was to steal government money.

As part of separate case filed by a South African businessman in Johannesburg, Teodorin acknowledged in 2006 that SOCAGE’s profits came from public contracts, which, he said, were also a source of wealth for other ministers. That South African businessman claimed he was owed money by the Equatoguinean government and sued to legally seize two Cape Town houses owned by Teodorin. The businessman argued that Teodorin, who was minister of forestry and agriculture at the time, bought the houses with money belonging to the government, and they therefore could be used to satisfy a debt the government allegedly owed him. In response Teodorin filed an affidavit defending his ownership over the homes, claiming that he bought them with money transferred from SOCAGE, which, he wrote, sourced the funds legally, even if the money originated from the public treasury:

Cabinet Ministers and public servants in Equatorial Guinea are by law allowed to own companies that, in consortium with a foreign company, can bid for government contracts and should the company be successful, then what percentage of the total cost of the contract the company gets, will depend on the terms negotiated between the parties. But, in any event, it means that a cabinet minister ends up with a sizeable part of the contract price in his bank account.[234]

While sources interviewed by US and French investigators mostly focused on Teodorin’s companies as the subject of the investigations, according to sources these interviews and other documents indicate that self-dealing is widespread among senior government officials, including the president. The president acknowledged his “private interests” to US officials, according to the 2009 State Department cable made public by WikiLeaks.[235] “I have to take care of my family, soI maintain private interests on the side," he told them. The lack of transparency makes it impossible to quantify the value of public contracts to public officials and their family members, but fragments that offer clues have come to light.

Three IMF advisors who worked in Equatorial Guinea told US investigators that the practice of officials inflating public contracts for private gain is widespread. One IMF expert said:

The leaders of the country who are engaged in building roads, schools, airports and hospitals are not concerned for its citizens. All of these companies are performing these projects under control and being operated by a company which is owned by the President of EG. The perception that the President is attempted to transcend [sic] was he was developing the country of EG, but ... the President and his family members are profiting personally because they have an ownership venture in all these companies.[236]

A second IMF economist similarly “believes that projects requiring public investment and expenditures are significant sources of corruption in EG. These projects include airports, harbors, buildings, and roadways.”[237] A third, hired to work on Equatorial Guinea’s fiscal policy, said he or she had seen indications that “substantial government contracts being awarded from the public treasury accounts maintained at the BEAC [Bank of Central African States] to companies owned by government ministers,” noting that the “largest company in EG is owned by President Obiang which is a construction company.”[238] That company was awarded a contract for a three-mile road between Malabo and the airport, according to the expert, but it took three years to complete because “it was in the best financial interest of the construction company to charge inflated prices and stay on the job longer so that both the company and the EG official would earn more money and collect more payments from the EG public treasury.”[239]

Abayak

A billboard in  Malabo, the capital, installed by the construction company Arab Contractors wishing the president and the people of Equatorial Guinea  a happy new year. Arab Contractors has been awarded numerous lucrative public construction contracts in the country. There are credible allegations that the president has a 12 percent stake in the company through his company Abayak, and that his son and the vice president Teodorin has an 8 percent stake through his company Sofona. 

© 2016 Human Rights Watch

It is possible that the IMF fiscal expert was referring to Abayak, a large construction company that imports construction related-material and is involved in real estate. The US Senate investigation alleged that Abayak, “is controlled by the E.G. President who is also identified in Riggs KYC [Know-Your-Customer] documentation as the company’s president.”[240] Human Rights Watch obtained what appears to be Abayak’s certificate of incorporation, which states that the company was established on November 6, 1998, andgrants the president 75 percent of the shares, the First Lady 15 percent, and Teodorin the remaining 10 percent.[241] According to the state department cable Abayak holds the single license to import cement into the country; it similarly described the company as “partially owned by the president and first lady.” Abayak is also involved in other sectors. For example, according to the US Senate investigation, “in 1998, ExxonMobil established an oil distribution business in Equatorial Guinea of which 85 percent is owned by ExxonMobil and 15 percent by Abayak S.A.”[242] The US Senate report also found that Abayak partially owns a telecommunication company and is the 75 percent owner of a company with a stake in gas and methanol facilities.[243]

According to a personal account by a high-level businessperson who owned various companies in Equatorial Guinea for more than a decade following the discovery of oil and enjoyed a close business relationship with the president, Abayak also owns a 12 percent share in Arab Contractors, one of the largest construction companies in the country. Sofona, a company owned by Teodorin, reportedly owns an 8 percent share.[244] The businessperson claims that they worked as a subcontractor on a project awarded to Arab Contractors for 3,000 social housing units, worth a total of $142.5 million. The businessperson’s account also claims that the president and Teodorin have large stakes in Somagec, another large construction firm, although the exact size of their stake is not noted.

General Works and SOCAGE

General Works was at one point in time one of the largest construction companies operating in Equatorial Guinea. It has been awarded dozens of public projects including constructing highways, bridges, public buildings, and military barracks.[245] According to US and Italian investigators, the company was a major conduit through which the president and his family profited from public contracts.[246] An Italian businessman, Igor Celotti, was CEO of General Works and a majority shareholder until a month before he died in an airplane crash on June 21, 2007. Suspecting foul play the Italian financial police launched an investigation into the presidential family’s interests in the company following the crash.[247]

According to a declaration by the lead DOJ investigator in the US case, Roberto Manzanares, the Italian police found that a month before he died, Celotti transferred 45 percent of the company’s shares to his wife and the remainder to members of the president’s family without receiving compensation, giving them a controlling stake in the company.[248] The police believed that 45 percent of General Works’ revenue “was funneled as kickbacks to [Teodorin].” Based on an analysis of Celotti’s financial and banking records, the Italian police also concluded that Teodorin and his father jointly owned a “network of international bank accounts that contained stolen millions of dollars in government monies misappropriated from EG's treasury through General Work's government construction contracts.”[249] Three construction executives who worked in Equatorial Guinea independently confirmed to US investigators that Teodorin “used General Works as a vehicle through which to misappropriate tens of millions of dollars from EG’s public treasury,” one of whom also said that the president’s family “owned and controlled General Work.”[250]

In addition to profits the president and his family allegedly took in through any ownership of General Works, two former senior employees told US investigators that the company would routinely inflate the cost of the contract and then subcontract a part of the work to shell companies owned by Teodorin, including SOCAGE. One showed DOJ investigators a contract between General Works and SOCAGE and told them:

Even though Minister Obiang’s companies, like SOCAGE, would be listed as a purported subcontractor of General Works in performing various government construction projects, these companies did not actually exist (except on paper). These entities were vehicles through which Minister Obiang could steal and receive payment from the EG government (through General Works) pursuant to some kind of inflated and fraudulent public contract. The actual work described in these contracts, and which were supposed to be performed by Minister Obiang’s companies, were in actuality performed by General Works’ construction crews.

The source produced documents that, according to the investigators’ summary of the interview, “corroborate his/her version of what transpired.” The person also showed the investigators hundreds of original check stub banking records from General Works to Teodorin or his middleman, as well as bank records of two of Teodorin’s companies, SOCAGE and SOMAGUI.

The second former General Works employee told investigators virtually the same thing. Teodorin’s companies, the source said,

only existed on paper and had no real personnel or operations, did not have the ability to pave roads and therefore GW had to complete projects for them. These work projects were a means for Minister Obiang to steal money from the E.G. treasury. GW provided kickbacks to Minister Obiang for various contracts, which were highly inflated at Minister Obiang’s direction.... For instance... if the real cost of a construction project was 2 million dollars, Minister Obiang would instruct GW to prepare and submit a project invoice to the E.G. government for 10 million dollars so that he could receive a ‘kick back’ of 8 million dollars.[251]

Human Rights Watch has received reports that General Works was recently dissolved, but we were unable to confirm these reports or obtain more detailed information.

Eloba and ABC

An Italian businessman, Roberto Berardi, described a business arrangement he allegedly had with Teodorin and Equatorial Guinea’s First Lady Constancia Mangue, to gain access to public contracts. Teodorin and Berardi jointly owned a construction company, called Eloba Construcción. In 2013 Equatoguinean police arrested Berardi at Teodorin’s behest, accusing him of embezzling money from Eloba.[252] Berardi was found guilty and sentenced to more than two years in prison. Berardi claims that the arrest was retaliation for confronting Teodorin over allegations in the US DOJ’s money-laundering complaint that Teodorin used Eloba’s account to funnel nearly $1 million to the US. The legal battle led Berardi to shine light on what he claims were the inner workings of an Equatorial Guinea-based construction company that would under normal circumstances be guarded from public view.

On June 19, 2013, soon after Berardi was provisionally charged with embezzlement, he wrote a letter to his lawyer and the Italian embassy in Equatorial Guinea describing his business arrangement with Teodorin. According to the letter Berardi founded Eloba Construcción in 2008 in partnership with Teodorin, who held a 60 percent stake in the company even though he didn’t contribute any capital or otherwise participate in its administration. Teodorin’s role, rather, was to help secure public contracts, from which he and his mother would also profit.

Berardi, who was living in Equatorial Guinea, explained in the letter an example of how this worked: “One day I received an unexpected call from his [Teodorin’s] offices telling me he has a job list for our company ... the work is subcontracted from ‘ABC’ Company, owned by the First Lady (his mother) ... for a total of 8.8 billion francs (13.5 million).”[253] According to Berardi’s statement the initial subcontracts were for two projects, the Bikuy and Ikunde markets in Bata, but Teodorin was quickly able to secure many more for the company, such as the Bata industrial zone, three military barracks, a public slaughterhouse, and a pulp mill.

In an interview with Human Rights Watch after Berardi was released from prison and had returned to Italy, Berardi said that ABC functioned as a shell company and was awarded millions of dollars in public contracts that it would then subcontract to Eloba and other companies for a fraction of the original contract price.[254] He gave one example where he says ABC was paid 30 billion CFA francs (US$50 million) for a project that the First Lady then subcontracted to Eloba for 12 million (US$13 million).[255]

Berardi said the contracts kept coming in, along with personal requests from the First Lady to complete other public works contracted to ABC, but he said he was rarely paid for his work.[256] In his written statement Berardi claimed that when the company did receive small advances on projects, Teodorin would demand half the amount, even though Berardi had yet to recoup his capital investment or receive a salary as director general of Eloba.[257]

Berardi was freed from prison on July 9, 2015. According to his family and other confidential sources, during his detention Berardi was tortured and subjected to long periods of solitary confinement, as well as frequent denial of access to medical attention and legal counsel.[258]

Laws Enabling Corruption

Conflict of Interest

President Obiang and other officials have defended their actions by stating that it is legal in the country for government officials to operate private businesses and to contract with the government. As noted, Teodorin defended himself in South African and US courts by arguing that the activities of his companies are lawful in Equatorial Guinea. His government has similarly invoked domestic law in response to international corruption investigations.[259]

Equatorial Guinea’s weak legal system is a fundamental part of the problem.[260] In order to avoid conflict of interest in public procurement, Transparency International, a leading anti-corruption civil society group, recommends that countries enact guidelines that clearly define conflict of interest and require officials involved in the process to disclose information on their private interests and assets, in addition to being prohibited from making certain decisions or performing certain functions where opportunities for conflict of interest exist.[261] It also recommends transparency, stakeholder participation, and clear review mechanisms to ensure the guidelines are effectively implemented and enforced. Equatorial Guinea, however, appears to have only skeletal rules regulating conflicts of interest between government officials’ public duties and private companies and even these seem not to be enforced.[262]

Project Appraisal and Procurement Policies

While the practical absence of conflict of interest rules plants the seeds of self-dealing, the opaque and informal process for appraising projects, awarding contracts, and overseeing payments provide fertile ground for it to flourish. In its Public Expenditure Review, the World Bank criticized the “extensive informality” of Equatorial Guinea’s public financial management, highlighting the infrastructure sector in particular as a potential source of misappropriation:

The lack of a legal framework for public finance management is especially obvious in the infrastructure sector where there are neither legal rules for executing expenditure and procurement nor guidelines for project appraisal and selection.... [T]he authorities’ determination to implement projects quickly exacerbates already loose budget constraint. However no up-to-date list of ongoing or finished infrastructure projects in the last five years exists, which limits the capacity to identify newly built infrastructure or the cost of ongoing projects.... Ultimate investment allocation is decided by the Presidency, without the need to record the investment project into the Budget being implemented, bypassing any formal screening and budgetary system in place.[263]

Even in cases where regulatory frameworks exist, they are not always publicly availablethe World Bank, for example, was unable to obtain the 2003 law regulating state public finances for its Public Expenditure Review.[264] (Human Rights Watch succeeded in obtaining a copy). This opacity also extends to contracts: “There are no external audit reports and contract awards are not published. The current lack of transparency reduces agency accountability and increases opportunities for misappropriation.”[265] The opacity of the process gives high-level officials inordinate influence over which projects are approved, who gets the contract, and how much they get paid. According to IMF officials who have worked in the country, the president decides which companies are awarded contracts and how much they are paid. An IMF expert told US DOJ investigators in 2011: “There is no formal process whatsoever relating to how contracts are awarded in EG. It is solely based on the President awarding contracts. He decides what company is allowed to business [sic] in EG.”[266]

A related problem is scant oversight of payments. The National Payments Committee is charged with reviewing and approving all payments, but it does not regularly meet, according to the IMF’s 2015 report.[267] Rather, the job of approving payments appears to fall to the president: an IMF economist told US investigators in 2011 that the “President of EG authorizes all the payments for public investments and expenditures.”[268] An IMF expert who currently provides the country with technical assistance on its national accounts recently confirmed to Human Rights Watch that this remains the case, adding, “The way they deal with their budgets is not proper. Without reform, we can’t know very much.”[269]

Taken together, this opaque and informal system incentivizes foreign businesses to partner with senior government officials to meet the local content law’s requirement that at least 35 percent of companies operating in the country are Equatoguinean owned. Interviews conducted by the US DOJ as part of their money-laundering investigation indicate that the case of Berardi partnering with Teodorin for public contracts via ABC Constructiona company at least partly owned by the First Ladyis not exceptional.

A former senior official at General Works told investigators: “If a person/corporation wanted to do business in EG, that person/corporation would be required to have contacts or friends in key positions within the EG government to be awarded contracts.”[270] The IMF fiscal policy expert said virtually the same thing: “There are no formal or transparent processes of awarding public contracts other than knowing a government official.”[271] Christopher Kernan, former country program director for Conservation International for EG and Gabon, under a contract from US AID similarly told investigators: “It was difficult to have a business in EG if a company did not have an Obiang family connection. Therefore, companies recruited a member of the family to be on their board of directors and companies entered into joint ventures with EG owned companies.”[272]

Anonymous Companies and Bank Secrecy Laws

Foreign countries that allow companies to incorporate within their jurisdictions without revealing the owners’ names make it easier for corrupt officials in countries like Equatorial Guinea to hide the tracks of money laundering and self-dealing. Teodorin used an anonymous company registered in California to purchase a $35 million mansion in Malibu; he also used anonymous companies to open bank accounts in California, enabling him to hide his identity and skirt US special anti-corruption procedures for political figures.[273] US DOJ prosecutors allege that these companies were conduits for the transfer of illicit funds.

Anonymous companies can also provide a screen for deals tainted by conflicts of interest. For example, the Equatorial Guinean government awarded a company named International Medical Services GE a contract worth 45.3 billion CFA francs (US$75 million) to build a hospital in Oyala, according to what appears to be the contract dated July 11, 2011, obtained by Human Rights Watch.[274] The contract lists Ovadia Yardena, an Israeli with close ties to the President, as the company representative, but what appears to be the company’s certificate of incorporation, also obtained by Human Rights Watch, does not include any names of company shareholders.[275] Equatorial Guinean law requires at least 35 percent local ownership, and this lack of transparency can make it very difficult to discern whether local partners include government officials or their family members.

Foreign countries’ bank secrecy laws also can help shield corruption. The 2004 investigation by the US Denate found that Riggs Bank transferred $35 million in public funds to two companies that US investigators believed belonged to the president, but they were unable to confirm ownership due to Spanish bank secrecy laws. The US Senate report on the investigation found: “This bar on disclosure ... presents a significant obstacle to U.S. anti-money laundering efforts.”[276]

V. Equatorial Guinea’s Human Rights Obligations

The Rights to Health and Education

The International Covenant on Economic, Social and Cultural Rights (ICESCR) recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”[277] The Committee on Economic, Social and Cultural Rights (CESCR), an expert body charged with interpreting the ICESCR, has defined the right to health as including health services, goods and facilities that are available, accessible, acceptable, and of good quality.[278] Such services should include “a system of health protection providing equality of opportunity for everyone to enjoy the highest attainable level of health; the right to prevention, treatment and control of diseases; access to essential medicines; maternal, child and reproductive health; equal and timely access to basic health services.”[279] According to the CESCR, the right to health also extends to “underlying determinants of health,” such as safe drinking water, adequate sanitation, and adequate nutrition.[280]

The Convention on the Rights of the Child (CRC), which Equatorial Guinea ratified in 1992, similarly protects a child’s right to health. Under the CRC governments are obliged to take steps to diminish child mortality; ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care; combat disease and malnutrition; and ensure appropriate pre-natal and post-natal health care for mothers.[281]

Equatorial Guinea’s constitution provides that “the State encourages and promotes primary health care as the cornerstone of its development strategy in this sector,”[282] but its laws and budgets do not reflect this prioritization.

The right to education is protected under both the ICESCR and CRC, with both mandating that primary education be compulsory and available free to all, and that secondary education should generally be available, accessible to all, and progressively made free.[283] The CRC also calls on states to “take measures to encourage regular attendance at schools and the reduction of drop-out rates.”

The CESCR maintains that the right to education requires education to be available, accessible, of acceptable quality, and adaptable to the changing needs of society. Availability depends not only on having sufficient facilities but also requires that the facilities meet certain conditions depending on the “developmental context,” but likely requiring at a minimum “buildings or other protection from the elements, sanitation facilities for both sexes, safe drinking water, trained teachers receiving domestically competitive salaries, teaching materials, and so on.”[284] The ICESCR also provides that “the material conditions of teaching staff shall be continuously improved.”[285]

Equatorial Guinea’s constitution calls education a “primary duty of the state” and mandates that “every citizen has the right to primary education, which is compulsory, free and guaranteed.[286] Despite repeated efforts Human Rights Watch was unable to obtain a copy of the Equatorial Guinea education law from government or other sources. The law’s inaccessibility raises obvious concerns about the extent to which it is being seriously implemented.

More generally, Equatorial Guinea’s constitution explicitly commits the country to act in accordance with international law and “reaffirms its adhesion to the rights and obligations that emanate from the charters of the organizations and international organisms to which it has acceded.”[287]

Progressive Realization and Immediate Obligations

The CESCR maintains that certain “core” components of the rights to education should be understood as the immediate obligation of all states, rather than goals to be progressively realized over time. This includes, inter alia, the obligation to provide free primary education to all and minimum levels of essential primary health care.[288] In general, however, international law recognizes that the capacity of states to realize the rights to health and education varies and is heavily dependent on the financial resources at governments’ disposal. With this in mind the ICESCR provides that in general the rights to health and education, as well as others, are to be realized progressively over time. Equatorial Guinea, like other states party, is obliged to “take steps ... to the maximum of its available resources, with a view to achieving progressively the full realization” of the rights to health and education.[289]

Because the concept of progressive realization is a flexible one that acknowledges varying levels of state capacity and the reality of legitimate, competing spending priorities, it is generally not possible to define with precision the minimum resource commitments any one government should be required to make. For the same reasons it is generally difficult to assert that a particular state has manifestly violated its obligation to “progressively realize” the rights to health and education, or other rights over time. But Equatorial Guinea represents an extreme case and in Human Rights Watch’s view, the government has clearly violated its obligation to progressively realize the rights to health and education.

Equatorial Guinea has failed to make progress on key health and education indicators, which in many cases remain among the world’s worst. The dismal status quo has persisted and in some cases even worsened despite a massive and indeed transformative increase in the government’s financial capacity in recent decades. This failure to achieve progress is not merely due to the failure of policy implementation, but to an extremely low level of investment in health and education relative to both Equatorial Guinea’s regional neighbors and to countries in other parts of the world with comparable income levels. What limited investments the government has made have been unduly focused on university education and the maintenance of elite hospitals that serve only a tiny part of the population. The remainder of the government’s budget has been focused to a highly unusual degree on infrastructure projects. Many of those investments are of questionable social utility and more to the point, there is considerable evidence that at least many large infrastructure projects have served as vehicles for self-dealing or corruption.

Prohibition on Corruption

Corruption is not, in and of itself, a human rights violation. However, corruption that impacts on a state’s ability to progressively realize economic and social rights such as health and education can give rise to a violation of its obligations under the ICESCR.[290]

The United Nations Convention against Corruption, which entered into force in December 2005, was established as an instrument for states to more effectively prevent and investigate acts of corruption and hold public officials to account for any violations. The convention calls on states to “maintain and strengthen systems that promote transparency and prevent conflicts of interest.”[291] In particular, states should require public officials to declare “their outside activities, employment, investments, assets and substantial gifts or benefits from which a conflict of interest may result with respect to their functions as public officials.”[292] States are also expected to establish a procurement system “based on transparency, competition and objective criteria” as part of a litany of measures they should take to prevent corruption.[293] Equatorial Guinea is one of about a dozen countries that are not party to the treaty.[294]

The African Union Convention on Preventing and Combating Corruption also requires states to enact legislation to, for example, prohibit enumerated forms of corruption, enhance transparency, and establish independent and adequate measures to ensure accountability.[295] Equatorial Guinea has signed, but not ratified, the Convention.

The country has, however, signed on to the United Nations Convention against Transnational Organized Crime, which calls on member states to criminalize corruption and to “take measures to ensure effective action by its authorities in the prevention, detection and punishment of the corruption of public officials.”[296] The Convention also calls on states to “institute a comprehensive domestic regulatory and supervisory regime” for financial institutions “in order to deter and detect all forms of money-laundering.”[297] Equatorial Guinea is also part of the Central African Economic and Monetary Community (CEMAC) and is subject to their money-laundering regulation, which requires, for example, that financial institutions identify the ultimate beneficial owners of their clients.[298]

A 2004 Equatoguinean law, Ethics and Dignity in the Exercise of Public Duties, places relatively narrow restrictions on public officials. It forbids them from managing or otherwise rendering services to companies with a public concession or contract only if their position has “direct authority” over the concession or contracting.[299] It does not, however, appear to prohibit ownership of such companies.[300] The law does prohibit officials from receiving gifts or donations of any kind “due to or in the course of the performance of their duties,” and includes some financial disclosure requirements. [301] Certain public officialsincluding all members of the executive branchmust submit a financial disclosure statement listing all assets and income of the official, his or her spouse, and minor children, to the National Commission on Public Ethics within 30 days of taking office.[302] Unelected officials most also submit their work history.[303] These statements are kept confidential except for verification purposes.[304] In addition to these reporting requirements, officials “who have had decisional involvement in the planning, development, and realization of concessions to companies or public services are forbidden from having a role in these entities or in the regulatory commissions of such company or services.”[305] It is not clear whether these reporting requirements are followed.

A Spanish regulation governing public contracts dating from 1968, which is applicable as supplementary to Equatorial Guinea’s law, prohibits government officials from bidding on public contracts.[306] It also mandates that, except in certain situations, public contracts may only be awarded through a transparent and competitive bidding process.[307] All contracts above a certain amount must be reviewed by auditors and published in an official bulletin.[308] It is unclear whether the government recognizes the application of this law and it does not appear to follow it.

Acknowledgements

This report was researched and written by Sarah Saadoun, researcher in the Business and Human Rights division of Human Rights Watch.

It was reviewed and edited by Arvind Ganesan, business and human rights director; Leslie Lefkow, Africa deputy director; Diederik Lohman, health and human rights director; Elin Martinez, children’s rights researcher; Chris Albin-Lackey, senior legal advisor; and Babatunde Olugboji, deputy program director. Additional editorial and production assistance and research support were provided by Amelia Neumayer, business and human rights associate. Research support was also provided by intern Michelle Stacey. The report was prepared for publication by Olivia Hunter, publications/photography associate; Jose Martinez, senior coordinator; and Fitzroy Hepkins, administrative manager.

Human Rights Watch offers its gratitude to the individuals and organizations that helped facilitate this research, including those that have generously supported our work on business and human rights. Human Rights Watch would particularly like to thank the staff of EG Justice and all the individuals who agreed to be interviewed for this report.

[1] Spain largely neglected the area for the first 40 years following the treaty, then leased it to Great Britain from 1817 to 1843. At that point Spain started to take a greater interest in economically exploiting the territory but faced tough resistance from the people living there. Many missionaries died of disease. Spanish Guinea, British Foreign Office Handbook (London: HMSO, 1920). See also Ibrahim K. Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability (Oxford: Westview Press, 1990), p. 25. In 1907, only 404 Europeans lived in what was then called Spanish Guinea. Ibid., p. 32.

[2] Cocoa exports rose from a total of 900 tons in 1900 to nearly 40,000 by 1968, the year of the country’s independence. By 1960 there were 35,000 Nigerians working in Spanish Guinea, compared to a total native population of around 213,000, as well as 6,000 Europeans. Randall Fegley, Equatorial Guinea: An African Tragedy (New York: Peter Lang Publishing, 1989), pp. 42, 44.

[3] See, for example, Spanish Guinea, p. 34.

[4] World Bank, “Report and Recommendation of the President of the International Development Association to the Executive Directors on a Proposed Development Credit of SDR 9.1 Million to the Republic of Equatorial Guinea for a Cocoa Rehabilitation Project,” January 18, 1985, p. 1.

[5] See Arturo Artucio, The Trial of Macías in Equatorial Guinea: The Story of a Dictatorship (International Commission of Jurists and the International University Exchange Fund, 1979); Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability, pp. 63-74; Fegley, Equatorial Guinea: An African Tragedy, pp. 37-110.

[6] Ibid.

[7] Fegley, Equatorial Guinea: An African Tragedy, pp. 106-07.

[8] Ibid., pp. 78-80; Artucio, The Trial of Macías in Equatorial Guinea, p. 11.

[9] Artucio, The Trial of Macías in Equatorial Guinea, p. 2; Fegley, Equatorial Guinea: An African Tragedy, p. 266.

[10] Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability, pp. 42, 91; Fegley, Equatorial Guinea: An African Tragedy, p. 92.

[11] Artucio, The Trial of Macías in Equatorial Guinea, p. 14.

[12] Ibid., p. 17.

[13] Ibid., pp. 35-39.

[14] Fegley, Equatorial Guinea: An African Tragedy, p. 175

[15] For example, average life expectancy rose from an abysmal 43 years in 1979 to 50 by 1995 and under-5 mortality dropped from 217 per 1,000 in 1983, the first year for which there is data, to 171 in 1995. World DataBank, “World Development Indicators: Equatorial Guinea,” “Life Expectancy at Birth” and “Mortality Rate, under-5,” http://databank.worldbank.org/data/reports.aspx?source=2&country=GNQ (accessed February 23, 2017).

[16] An independent expert was first appointed in 1982, and the title and mandate of the monitor changed until the post was abolished by an evenly split vote in the UN Human Rights Commission in 2002. See Human Rights Watch, Well Oiled: Oil and Human Rights in Equatorial Guinea, July 2009, https://www.hrw.org/sites/default/files/reports/bhr0709web_0.pdf, p. 15.

[17] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. I, https://openknowledge.worldbank
.org/bitstream/handle/10986/3011/516560ESW0GQ0P00disclosed0120130110.pdf?sequence=1&isAllowed=y (accessed February 24, 2017).

[18] Equatorial Guinea received virtually no foreign aid throughout the 1970s. Aid began to trickle in as soon as Obiang came to power, steadily climbing to $70 million in 1990, when it began to taper off due to the discovery of oil. OECD Statistics, “Aid (ODA) Disbursements to Countries and Regions,” http://stats.oecd.org/index.aspx?datasetcode=TABLE2A# (accessed February 23, 2017). In 1984, for example, the Gross National Product was $67 million and foreign aid and loans were estimated at $30 million. Robert Klitgaard, Tropical Gangsters: One Man’s Experience with Development and Decadence in Deepest Africa (Basic Books, 1990), p. 27.

[19] Ibid., p. 61.

[20] World Bank, “Projects & Operations: Coffee Cocoa Rehabilitation Project—Equatorial Guinea,” http://projects.worldbank.org/P000638/coffee-cocoa-rehabilitation-project?lang=en (accessed February 23, 2017).

[21] Klitgaard, Tropical Gangsters, p. 61.

[22] World Bank DataBank, “World Development Indicators: Equatorial Guinea,” “GDP Per Capital Growth (Annual %), 1995-2005.”

[23] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. i.

[24] Equatorial Guinea, 2015 Budget Law, p. 1. The 2012 International Monetary Fund Article IV report puts oil revenue from 2007-2011 at $5 billion annually, which is higher than what is recorded in the 2015 budget document on file. IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, March 28, 2013, p. 5, http://www.imf.org/external/pubs/ft/scr/2013/cr1383.pdf (accessed February 24, 2017).

[25] See Artucio, The Trial of Macías in Equatorial Guinea, p. 6, for original justification for barring political activities, and Equatorial Guinea’s 1991 Constitution, article 1, for introduction of “multipartism,” https://www.constituteproject.org/constitution/Equatorial_Guinea_1995.pdf (accessed February 23, 2017).

[26] Human Rights Watch, Well Oiled: Oil and Human Rights in Equatorial Guinea, p. 11.

[27] Equatorial Guinea Constitution (2012), http://www.guineaecuatorialpress.com/imgdb/2012/
LEYFUNDAMENTALREFORMADA.pdf (accessed April 24, 2017). See Fegley, Equatorial Guinea: An African Tragedy, p. 210-11; Sundiata, Equatorial Guinea: Colonialism, State Terror, and the Search for Stability, pp. 76-77.

[28] Equatorial Guinea Constitution (2012), arts. 92 and 98.

[29] See, for example, “Equatorial Guinea: A Move to Consolidate Power,” Human Rights Watch news release, November 11, 2011, https://www.hrw.org/news/2011/11/11/equatorial-guinea-move-consolidate-power.

[30] Ibid. and Government Press, “Summary of the Constitutional Reform,” October 31, 2011, http://www.guinea
ecuatorialpress.com/noticia.php?id=2039 (accessed February 23, 2017).

[31] Government Press, “Installation of the Office of Ombudsman,” August 28, 2015, http://www.guineaecuatorialpress.com/noticia.php?id=6863 (accessed February 23, 2017).

[32] See, for example, US Department of State, “Country Reports on Human Rights Practices for 2010: Equatorial Guinea,” https://www.state.gov/documents/organization/160119.pdf, p. 17-18 (accessed February 24, 2017); US Embassy in Malabo, “Equatorial Guinea: Concerns Regarding the Political Environment in Equatorial Guinea Before and After the April 24th Election,” April 27, 2016, https://malabo.usembassy.gov/news-events/latest.html (accessed February 28, 2017); Human Rights Watch, Well Oiled, pp. 11-15; “Joint Statement Urging a Halt of Pre-Election Civil Society Crackdown in Equatorial Guinea,” Human Rights Watch, March 30, 2016, https://www.hrw.org/news/2016/03/30/joint-statement-urging-halt-pre-election-civil-society-crackdown-equatorial-guinea. For a report documenting legal and practical limitations on civil society, see EG Justice, “Disempowered Voices: The Status of Civil Society in Equatorial Guinea,” March 3, 2011, http://www.egjustice.org/es/node/666 (accessed February 23, 2017).

[33] Transcripts: CNN’s Amanpour Interview with President Teodoro Obiang of Equatorial Guinea, October 5, 2012, http://edition.cnn.com/TRANSCRIPTS/1210/05/ampr.01.html (accessed February 23, 2017).

[34] Equatorial Guinea Constitution (2012), art. 36.

[35] EG Justice, “Opposition Party Boycotts Presidential Elections,” April 18, 2016, http://www.egjustice.org/post/opposition-party-boycotts-presidential-elections (accessed February 23, 2017). For a list of incidents of political repression related to the elections, see Human Rights Watch, World Report 2017 (New York: Human Rights Watch, 2016), Equatorial Guinea chapter, https://www.hrw.org/world-report/2017/country-chapters/equatorial-guinea.

[36] “Joint Statement Urging a Halt of Pre-Election Civil Society Crackdown in Equatorial Guinea,” Human Rights Watch, March 30, 2016; US Embassy in Malabo, “Ambassador’s Corner: Thoughts on the Democratic Process in Equatorial Guinea,” May 4, 2016, https://malabo.usembassy.gov/ta-050416.html (accessed February 23, 2017); US State Department Daily Press Briefing, Mark Toner, Deputy Spokesperson, April 27, 2016, https://video.state.gov/detail/videos/category/video/4866119970001/?autoStart=true (accessed February 28, 2017).

[37] US Embassy in Malabo, “Ambassador’s Corner: Thoughts on the Democratic Process in Equatorial Guinea,” May 4, 2016, https://malabo.usembassy.gov/ta-050416.html (accessed February 23, 2017).

[38] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 19.

[39] See Transparency International, Corruption by Country: Equatorial Guinea, http://www.transparency.org/country/GNQ (accessed February 23, 2017). The country ranks in the bottom one percent in the NGO’s transparency ranking.

[40] EITI website, “Who We Are,” https://beta.eiti.org/about/who-we-are (accessed February 23, 2017).

[41] EITI, “Intensive Validation Activity as Deadlines Approach,” December 10, 2009, https://eiti.org/es/node/4002 (accessed February 23, 2017); Human Rights Watch interview with Asmara Klein, EITI Programme Officer, Publish What You Pay, Barcelona, August 17, 2016.

[42] Letter from Dr. Peter Eigen, EITI Chairman, to H. E. Teodoro Obiang, April 29, 2010.

[43] Human Rights Watch interview with Asmara Klein, August 17, 2016.

[44] “Joint Statement Urging a Halt of Pre-Election Civil Society Crackdown in Equatorial Guinea,” Human Rights Watch, March 30, 2016.

[45] Government press, “Third Meeting of the EITI/ITIE-GE National Commission,” November 16, 2016, http://www.guineaecuatorialpress.com/noticia.php?id=8878 (accessed February 23, 2017).

[46] The global average is 45, with nearby São Tomé e Príncipe scoring 29, Nigeria 24, and Sierra Leone 52. See International Budget Project, Open Budget Survey 2015: Equatorial Guinea, http://www.internationalbudget.org/wp-content/uploads/OBS2015-CS-Equatorial-Guinea-English.pdf (accessed February 23, 2017). The budget information released in 2015 is available on the website of the government press and titled, “The Senate studies the Amending Budget for 2015,” April 10, 2015, http://www.guineaecuatorialpress.com/noticia.php?id=6425 (accessed February 23, 2017).

[47] IMF, “Republic of Equatorial Guinea and the IMF: Article IV Staff Reports,” http://www.imf.org/external/country/gnq/
index.htm?type=9998#top
. There is no publicly available information to determine for which of these five years the IMF did not produce a report and for which the government objected to its publication.

[48] There are some unofficial online legal databases, but to the best of Human Rights Watch’s knowledge, none are comprehensive. Some laws are available for purchase at the specific government buildings, but many are not publicly available. For example, Human Rights Watch observed around 40 law pamphlets available for sale during a visit to the Delegation for Foreign Affairs in Bata, Equatorial Guinea’s largest city. We were told that the corruption law was not available because it was under parliamentary review. Laws may also be requested from the president’s office, but requests do not always yield a response. For example, the World Bank notes in one report that it was unable to obtain certain relevant laws essential to its analysis. See World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 38.

[49] Human Rights Watch phone interview, name withheld, July 26, 2016.

[50] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, September 15, 2015, p. 19, http://www.imf.org/external/pubs/ft/scr/2015/cr15260.pdf (accessed February 24, 2017).

[51] World Bank Data: Equatorial Guinea, http://data.worldbank.org/country/equatorial-guinea (accessed February 24, 2017); Government Press, “Preliminary Results of the 2015 Population Census,” September 24, 2015, http://www.guineaecuatorialpress.com/noticia.php?id=6943 (accessed February 24, 2017). For the government’s previous figure, see IMF, 2015 Article IV Staff Report on Equatorial Guinea, p. 4.

[52] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 4. See also IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 17.

[53] See, for example, Transcripts: CNN’s Amanpour Interview with President Teodoro Obiang of Equatorial Guinea, October 5, 2012, http://edition.cnn.com/TRANSCRIPTS/1210/05/ampr.01.html (accessed February 23, 2017).

[54] Equatorial Guinea’s National Report About the Millennium Development Goals (2015), p. 15; IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 36.

[55] Email from IMF staff member, name withheld, to Human Rights Watch, December 2, 2016.

[56] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 21; IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 19.

[57] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 19.

[58] The other country is Eritrea. IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 19; IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 19.

[59] IMF, “IMF Board Concludes 2016 Article IV Consultation with the Republic of Equatorial Guinea,” September 8, 2016, http://www.imf.org/en/News/Articles/2016/09/08/PR16399-Republic-of-Equatorial-Guinea-IMF-Executive-Board-Concludes-2016-Article-IV-Consultation (accessed February 24, 2017); World Bank DataBank, “World Development Indicators: Equatorial Guinea,” “GDP” and “PPP (constant 2011 international dollar).”

[60] IMF, Republic of Equatorial Guinea: 2007 Article IV Consultation Staff Report, May 14, 2008, p. 12 http://www.imf.org/external/pubs/ft/scr/2008/cr08156.pdf (accessed February 24, 2017).

[61] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 38.

[62] Human Rights Watch phone interview, IMF Fiscal Affairs Department, Revenue Administration, July 26, 2016.

[63] IMF, Budget Classification, December 2009, p. 3, https://www.imf.org/external/pubs/ft/tnm/2009/tnm0906.pdf (accessed February 24, 2017).

[64] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 15.

[65] See, for example, World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 24.

[66] The IMF has published three Article IV reports on Equatorial Guinea—in 2013, 2015, and 2016—since the release of the World Bank’s 2010 Public Expenditure Review (PER). Human Rights Watch also obtained a copy of the 2011 and 2012 public investment projects (PIP) budgets, as well as the 2015 and 2016 general budgets, which include some information on expenditures since 2009. (The data covered in the PIP is generally from the year prior to publication, while the IMF reports is from two years prior.)

[67] See state submission to Committee on the Rights of the Child, CRC/C/11/Add. 26, January 28, 2004. In its submission the state admits: “The 10 % of the general State budget allocated to health by the National Economic Conference has not been disbursed to the sector” and that “For various reasons the Government’s efforts are not yet sufficient to meet the education and survival needs of children from poor families” (paragraph 131), http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=6QkG1d%2fPPRiCAqhKb7yhspWF7dyE4I9U8mmAPSFwafAa%2fWWvnzsC03EPefyLMa%2fZCrD9ioW8xFdiOxxzTbIeUvGKiYZyxKA3%2fg%2fZGUWu8vW9Sn1dHLRpGYPp%2bFY%2bZMlC (accessed February 24, 2017).

[68] Equatorial Guinea Ministry of Planning, Economic Development, and Public Investments, “Guinea Ecuatorial 2020: Agenda para la Diversificación de las Fuentes del Crecimiento,” November 2007 [on file with Human Rights Watch].

[69] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, September 2015, p. 38.

[70] Based on government figures in the 2015 Budget Law, p. 4 (some of these figures are also available in the IMF’s 2012 and 2014 Article IV staff reports). Human Rights Watch converted from local currency based on exchange rates on December 31 of each year and calculated the averages of the available information. See Table below.

[71] Ibid. Non-hydrocarbon government revenue consists mostly of taxes raised from rents and utilities; a value-added tax on goods and services; and import and export licenses, as well as property rentals and sales; administrative fees; and concessions, such as for telecommunications and airports. See, for example, Republic of Equatorial Guinea, Presentation of the General Budgets of the State, 2016 [on file with Human Rights Watch].

[72] The raw numbers are calculated by Human Rights Watch based on percentages appearing in graphs in IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, March 2013, p. 8. Note that a UNICEF worldwide survey of health expenditures has a higher number, but this is likely based on data provided by the government data and may refer to budget allocation rather than actual expenditures. The IMF data is based on the institution’s expert analysis and more reliable.

[73] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, pp. 91-92.

[74] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, March 2013, p. 8.

[75] Ibid. UNESCO recommends that 20 percent of a government’s budget go toward education. UNESCO, “Education for All Global Monitoring Report: Policy Paper 12,” March 2014, http://unesdoc.unesco.org/images/0022/002270/227092E.pdf (accessed February 24, 2017).

[76] Unpublished draft of IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 12 [on file with Human Rights Watch]. The published version retains the first sentence, but removes the reference to Oyala comprising half the 2016 budget in the second sentence.

[77] World Bank, Equatorial Guinea Public Expenditure Review (PER), January 2010, p. 12.

[78] Ibid.

[79] Ibid.

[80] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 11.

[81] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 12.

[82] Ibid., i, 29.

[83] The World Bank plans to release an update to this report in mid-2017.

[84] Calculated based on IMF, Republic of Equatorial Guinea: 2007 Article IV Consultation Staff Report, p. 35.

[85] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 137

[86] Ibid., pp. 91-2.

[87] Ibid., p. 92.

[88] Ibid., p. 93.

[89] Ibid.

[90] Ibid., p. x.

[91] Ibid., p. 137.

[92] Ibid., p. 71.

[93] UNESCO’s data is incomplete and does not include Equatorial Guinea, but the lowest percentage recorded for 2008 for the approximately 80 countries for which data available is 1.29 percent (Central African Republic), and the next lowest is 2.04 percent (Lebanon), http://data.uis.unesco.org/?queryid=181 (accessed February 24, 2017).

[94] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 71.

[95] Ibid., p. 137.

[96] Ibid., p. 72.

[97] Ibid. Between 2004 and 2008, Equatorial Guinea spent an average of nearly 40 percent of its budget on higher education, whereas the average of 10 neighboring countries was 22 percent. Based on Human Rights Watch’s calculations of World Bank data. Ibid.

[98] Ibid., p. x.

[99] Equatorial Guinea, 2014 and 2015 Budget Laws.

[100] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 8; see footnote 72 above.

[101] Conversions based on value of CFA franc on June 30, 2011.

[102] Conversions based on value of CFA franc on June 30, 2010.

[103] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 12.

[104] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, pp. 35-36. The social sector classification in the government’s PIP budget includes health, education, housing, potable water, electricity, sports, and culture; it is unclear whether the IMF’s use of the term reflects this classification.

[105] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 12. Note that the execution rate for projects was only 39 percent and in previous year, social projects had lower execution rates than other sectors.

[106] Ibid.

[107] Ministry of Economy, Planning, and Public Investment, Asistencia Técnica para el Fortalecimiento de los Sistemas de Inversión Pública y Monitoreo al PNDES Horizonte 2020, Informe Annual 2016, p. 18 [on file with Human Rights Watch].

[108] Ibid., p. 22.

[109] The amended 2015 budget is on file with Human Rights Watch.

[110] The percentages for health spending are only slightly below what the World Bank reported in previous years: 3.1 percent of current expenditures in 2008 and 5.1 in 2004. World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 92.

[111] According to the Equatoguinean organization Centro de Estudios Guineaoecuatorianos’ analysis of the 2015 amended budget, only 2.67% of current expenditures were allocated to health and 2.09% to education, http://cesge.org/index.php?option=com_content&view=article&id=92:presupuesto-guinea-ecuatorial-2015&catid=41:economia&Itemid=56 (accessed February 24, 2017).

[112] Talk Africa, Interview with Equatorial Guinea president Teodoro Obiang Nguema Mbasogo, May 29, 2016, https://www.youtube.com/watch?v=qMfu-6RrVao (accessed February 24, 2017).

[113] Equatorial Guinea, 2015 Amended Budget Law [on file with Human Rights Watch].

[114] EG Justice, “Crackdown of Peaceful Student Protestors,” April 7, 2015, http://www.egjustice.org/post/crackdown-peaceful-student-protesters (accessed February 24, 2017).

[115] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 19.

[116] IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 4.

[117] Ibid., p. 13.

[118] BBC, “Hardtalk,” December 19, 2012.

[119] IMF, Republic of Equatorial Guinea: 2015 Article IV Consultation Staff Report, p. 12.

[120] Ibid., p. 12.

[121] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 5. While access to water has improved in urban areas, it has declined in rural areas; as a result, national figures remain virtually unchanged since 2000. See notes 136 and 137.

[122] IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 12.

[123] World Bank, Equatorial Guinea Public Expenditure Review (PER), January 2010, p. 24.

[124] Life expectancy statistics and regional averages estimated by World Bank, data available at World Bank DataBank, “Health Nutrition and Population Statistics,” http://databank.worldbank.org/data/reports.aspx?source=health-nutrition-and-population-statistics (accessed December 1, 2016).

[125] United National Development Programme, “Human Development Report 2015,” 2015, http://hdr.undp.org/sites/default/files/2015_human_development_report_1.pdf, (accessed December 6, 2016), p. 49.

[126] Ministerio de Sanidad y Bienestar Social (Républica de Guinea Ecuatorial), Ministerio de Economía, Planificación e Inversiones Públicas (Républica de Guinea Ecuatorial) and ICF International, “Equatorial Guinea Demographic and Health Survey 2011,” 2012, p. 97, http://dhsprogram.com/pubs/pdf/FR271/FR271.pdf (accessed February 27, 2017).

[127] World Bank DataBank, “Health Nutrition and Population Statistics.”

[128] United National Development Programme, “Human Development Report 2015,” http://hdr.undp.org/sites/default/files/2015_human_development_report_1.pdf, (accessed December 6, 2016), p. 49.

[129] “Equatorial Guinea Demographic and Health Survey 2011,” p. 97.

[130] World Bank DataBank, “Health Nutrition and Population Statistics.”

[131] Under-5 mortality rate estimates developed by the UN Inter-agency Group for Child Mortality Estimation, data available at World Bank DataBank, “Health Nutrition and Population Statistics.”

[132] “Equatorial Guinea Demographic and Health Survey 2011,” p. 229.

[133] World Bank DataBank, “Health Nutrition and Population Statistics.”

[134] Estimates developed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, http://www.wssinfo.org/. Data available at World Bank DataBank, “Health Nutrition and Population Statistics.”

[135] “Equatorial Guinea Demographic and Health Survey 2011,” p. 11.

[136] World Bank DataBank, “Health Nutrition and Population Statistics.”

[137] Estimates developed by the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, http://www.wssinfo.org/. Data available at World Bank DataBank, “Health Nutrition and Population Statistics.”

[138] “Equatorial Guinea Demographic and Health Survey 2011,” p. 125.

[139] World Health Organization, “WHO vaccine-preventable diseases: monitoring system. 2016 global summary: Equatorial Guinea,” last updated December 1, 2016, http://apps.who.int/immunization_monitoring/globalsummary/coverages?c=GNQ (accessed February 27, 2017).

[140] “Equatorial Guinea Demographic and Health Survey 2011,” p. 128.

[141] Institut National de la Statistique (INS), Ministère de l’Économie de la Planification et de l’Aménagement du Territoire (République du Cameroun), Ministère de la Santée Publique (Yaoundé, Cameroun) and ICF International, “Cameroon Demographic and Health Survey 2011,” 2012, http://dhsprogram.com/pubs/pdf/FR260/FR260.pdf, (accessed December 1, 2016), p. 140; Ministère de l’Économie, de l’Emploi et du Développement Durable (République Gabonaise), Ministère de la Santé (République Gabonaise), Direction Générale de la Statistique (Libreville, Gabon) and ICF International, “Gabon Demographic and Health Survey 2012,” 2013, http://dhsprogram.com/pubs/pdf/FR276/FR276.pdf, (accessed December 1, 2016), p. 139; National Population Commissions (Federal Republic of Nigeria) and ICF International, “Nigeria Demographic and Health Survey 2013,” 2014, http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf, (accessed December 1, 2016); Instituto Nacional de Estatística (INE) (São Tomé e Príncipe), Ministério de Saúde (São Tomé e Príncipe) and ICF Macro, “ São Tomé and Príncipe Demographic and Health Survey 2008-2009,” 2010, http://dhsprogram.com/pubs/pdf/FR233/FR233.pdf, (accessed December 1, 2106), p. 133.

[142] World Bank DataBank, ““Health Nutrition and Population Statistics,” 2012.

[143] Human Rights Watch interview, senior employee of humanitarian agency, 2016.

[144] For Equatorial Guinea’s immunization coverage, see “WHO vaccine-preventable diseases: monitoring system. 2016 global summary: Equatorial Guinea.” For a comparison with all the countries the WHO tracks, see http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tscoveragebcg.html (accessed February 27, 2017).

[145] “Equatorial Guinea Demographic and Health Survey 2011,” p. 128.

[146] “WHO vaccine-preventable diseases: monitoring system. 2016 global summary: Equatorial Guinea.” Sweden made a policy decision to only vaccinate certain groups of babies for tuberculosis resulting in the lowest rate.

[147] Human Rights Watch interview with Arturo (not real name), Malabo, 2016.

[148] “Equatorial Guinea Demographic and Health Survey 2011,” p. 135.

[149] See Section V. V. Equatorial Guinea’s Human Rights Obligations.

[150] World Health Assembly (WHA) resolution 58.33, http://apps.who.int/medicinedocs/documents/s21475en/s21475en.pdf (accessed February 27, 2017).

[151] UN, “Sustainable Development Goals: Goal 3,” http://www.un.org/sustainabledevelopment/health/ (accessed February 27, 2017).

[152] Human Rights Watch interviews with Mariana (not real name), doctor in General Hospital in Bata until 2015, Madrid, 22016; Alonso (not real name), doctor in private clinic formerly employed in General Hospital in Bata, Bata, 2016; Jimena and Sofia (not real names; joint interview), nurses in General Hospital in Malabo, Malabo, 2016; research director, EG Justice, 2016.

[153] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 91. There is no more recent available data.

[154] “There is a clear inequality in the health care coverage for INSESO’s subscribers in comparison to the rest of the population since INSESO finances 43 percent of total recurrent health expenditure, which only benefits 60,000 members (or approximately 10 percent of the population) who therefore receive a higher per capita health expenditure than the rest of the population.” Ibid.

[155] Ibid., p. 89.

[156] Human Rights Watch interview with Jimena, nurse, Malabo, 2016.

[157] Human Rights Watch interview with Isabella (not real name), nurse, Malabo, 2016.

[158] Human Rights Watch interview with Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016.

[159] Human Rights Watch interview with Jose (not real name), private primary school teacher, Malabo, 2016.

[160] Human Rights Watch was unable to find official documentation regarding the full amount and extent of public funding, but government communications make clear that the hospitals were built with public money, and two medical staff there said they are paid by the government. Government Press, “The delegations attending the APU sessions visit Malabo and its surrounding areas,” December 3, 2010, http://www.guineaecuatorialpress.com/noticia.php?id=1133 (accessed February 27, 2017) and “The President of the Republic Visits the Infrastructure Works in the City of Malabo,” October 5, 2010, http://www.guineaecuatorialpress.com/noticia.php?id=939 (accessed February 27, 2017). Two medical staff at La Paz Malabo and a senior official at a humanitarian agency also said it was at least partially funded by the government. Human Rights Watch interviews, Malabo, 2016.

[161] Human Rights Watch interviews with Geraldo (not real name), senior employee of a humanitarian agency, Malabo, 2016; Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016; Rafael and Daniel (not real names; separate interviews), medical staff at La Paz Malabo, Malabo, 2016; Jimena and Sofia (joint interview), nurses, Malabo, 2016.

[162] Geraldo also said that the health clinics Guadalupe in Malabo and Bata are publicly funded but privately owned by the First Lady.

[163] Human Rights Watch interviews with Rafael and Daniel (separate), medical staff at La Paz Malabo, Malabo, 2016.

[164] Fee amounts are based on interviews with doctors and patients because Human Rights Watch did not receive a response to letters requesting this information from La Paz Bata and Malabo. Human Rights Watch interviews with Geraldo, senior employee of a humanitarian agency, Malabo, 2016; Alonso, doctor in private clinic, Bata, 2016; Andres (not real name), school director, Bata, 2016; Cristian (not real name), Malabo, 2016; Diego (not real name), Malabo, 2016; Alphonso (not real name), Bata, 2016.

[165] Human Rights Watch Interview with Rafael, medical staff at La Paz Malabo, Malabo, 2016.

[166] For example, Sipopo is home to 52 luxury villas that the government built, along with a conference center and golf course, to house the heads of state when it hosted a week-long African Union summit in 2011. Government Press, “Inauguration of the City of Sipopo,” June 10, 2011, http://www.guineaecuatorialpress.com/noticia.php?id=1643 (accessed February 27, 2017).

[167] WHO African Health Observatory, “Health System Outcomes: Equatorial Guinea,” http://www.aho.afro.who.int/profiles_information/index.php/Equatorial_Guinea:Health_system_outcomes (accessed February 27, 2017).

[168] Human Rights Watch interviews with Jose (not real name), teacher, Malabo, 2016; Cristian (not real name), teacher, Malabo, 2016; Alphonso (not real name), teacher, Bata, 2016.

[169] Human Rights Watch Interview with Daniel, medical staff at La Paz Malabo, Malabo, 2016.

[170] Human Rights Watch interview with Isabella, nurse, Malabo, 2016; Interview with Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016.

[171] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 88.

[172] Human Rights Watch interview with Daniel, medical staff at La Paz Malabo, Malabo, 2016.

[173] Human Rights Watch interviews with Mariana, doctor in General Hospital in Bata until 2015, Madrid, 2016; Isabella, nurse in General Hospital, Malabo, 2016; Andres, school director, Malabo, 2016; Diego (not real name), Malabo, 2016.

[174] Human Rights Watch interview with Diego, teacher, Malabo, 2016.

[175] Human Rights Watch Interview with Alonso, doctor in private clinic, Bata, 2016.

[176] See Section V. V. Equatorial Guinea’s Human Rights Obligations.

[177] República de Guinea Ecuatorial, Ministerio de Educación y Ciencia, “Guinea Ecuatorial, Revisión Nacional 2015 de la Educación para Todos,” p. 9, http://unesdoc.unesco.org/images/0023/002317/231718s.pdf (accessed February 27, 2017).

[178] Human Rights Watch interview with Arturo (not real name), Malabo, 2016.

[179] Reuters, “Liberia Tops UNICEF Ranking of 10 Worst Countries for Access to Primary School,” September 1, 2016, http://www.reuters.com/article/us-africa-education-idUSKCN1173PE (accessed February 27, 2017).

[180] UNESCO data accessed via FHI360, Education Policy and Data Center (EPDC), http://epdc.org/country/equatorialguinea (accessed March 6, 2017).

[181] UNESCO data via FHI360, EPDC, http://epdc.org/country/equatorialguinea (accessed March 6, 2017).

[182] Ibid.

[183] Ibid.

[184] Human Rights Watch phone interview with Ignacio (not real name), education specialist, September 16, 2016.

[185] UNESCO data via FHI360, EPDC, http://epdc.org/country/equatorialguinea (accessed March 6, 2017).

[186] UNESCO Institute for Statistics, Equatorial Guinea: Education and Literacy, http://uis.unesco.org/country/gq (accessed April 12, 2017).

[187] Human Rights Watch phone interview with Ignacio (not real name), education specialist, September 16, 2016.

[188] República de Guinea Ecuatorial, Ministerio de Educación y Ciencia, “Guinea Ecuatorial, Revisión Nacional 2015 de la Educación para Todos,” p. 9.

[189] See footnote 107.

[190] Human Rights Watch interview with Diego, teacher, Malabo, 2016.

[191] Human Rights Watch interview with Alphonso (not real name), Bata, 2016.

[192] Human Rights Watch interview with Hernando, Bata, 2016.

[193] República de Guinea Ecuatorial, Ministerio de Educación y Ciencia, “Guinea Ecuatorial, Revisión Nacional 2015 de la Educación para Todos.”

[194] Human Rights Watch interview with Alphonso, Bata, 2016.

[195] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 63.

[196] Human Rights Watch phone interview with John Gillies, Director of Global Learning, FHI360, September 16, 2016.

[198] Human Rights Watch interview with Clara, Bata, 2016. John Gilies, Director of Global Learning, FHI 360, confirmed in an email to Human Rights Watch, November 28, 2016, that there were no plans to continue the program passed 2017.

[199] Human Rights Watch interview with Clara, Bata, 2016.

[200] Human Rights Watch interviews with Cristian, Malabo, 2016 and Diego, Malabo, 2016.

[201] Based on Human Rights Watch calculations of general budget documents on file.

[202] Stevie Mounombou, “Loi de finances rectificative 2015 : Un budget de 2 651,2 milliards de francs,” Gabon Review, April 13, 2015. http://gabonreview.com/blog/loi-de-finances-rectificative-2015-un-budget-de-2-6512-milliards-de-francs/ (accessed February 27, 2017).

[203] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. viii.

[204] Republic of Equatorial Guinea, Ministry of Economy, Planning and Public Investment, “EG’s Strategic Plan: Horizon 2020,” http://www.egindc.com/presentations/8-8-14/6.pdf (accessed March 1, 2017).

[205] IMF, Republic of Equatorial Guinea: 2016 Article IV Consultation Staff Report, p. 35.

[206] IMF, Republic of Equatorial Guinea: 2012 Article IV Consultation Staff Report, p. 15.

[207] US State Department Cable from US Embassy in Malabo, “Equatorial Guinea Raw, Paper 4: The Business of Corruption,” March 12, 2009.

[208] US Senate Permanent Subcommittee on Investigations, Committee on Governmental Affairs, Money Laundering and Foreign Corruption: Enforcement and Effectiveness of the Patriot Act – Case Study Involving Riggs Bank [US Senate Riggs Bank report], July 15, 2004, p. 38.     

[209] Ibid., p. 41.

[210] Ibid., p. 43. See also Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012), p. 10.

[211] US Senate Riggs Bank report, 2004, p. 3.

[212] Note that the US Senate report did not accuse any of the oil companies providing the scholarships of wrongdoing, nor did US law enforcement authorities. Ibid., p. 104.

[213] Ibid., p.17.

[214] Criminal Complaint filed by Asociación Pro Derechos Humanos de España (APDHE), October 22, 2008, available at https://www.opensocietyfoundations.org/litigation/apdhe-v-obiang-family (accessed February 27, 2017).

[215] Ibid., p. 9; see also US Senate Riggs Bank report, 2004, p. 54-55.

[216] José María Irujo, “The long hunt for the Kokorevs,” El Pais, September 23, 2015, http://elpais.com/elpais/2015/09/23/inenglish/1443001757_417136.html (accessed February 27, 2017).

[217] Ibid.

[218] Government Press, “Russia Condemns the False Information of Some Spanish Newspapers,” May 9, 2012, http://www.guineaecuatorialpress.com/noticia.php?id=2626 (accessed February 27, 2017).

[219] Government Press, “Presidential Decree Naming Vice-President of the Council of the Republic,” June 22, 2016 http://www.guineaecuatorialpress.com/noticia.php?id=8024 (accessed May 16, 2017).

[220] US Senate Riggs Bank report, 2004, pp. 20, 97. See also Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012), p. 20 and Attachment A-1.

[221] US Department of Justice, “Department of Justice Seeks to Recover More Than $70.8 Million in Proceeds of Corruption from Government Minister of Equatorial Guinea,” October 25, 2011, https://www.justice.gov/opa/pr/department-justice-seeks-recover-more-708-million-proceeds-corruption-government-minister (accessed February 27, 2017).

[222] US Department of Justice, “Second Vice President of Equatorial Guinea Agrees to Relinquish More Than $30 Million of Assets Purchased with Corruption Proceeds,” October 10, 2014, https://www.justice.gov/opa/pr/second-vice-president-equatorial-guinea-agrees-relinquish-more-30-million-assets-purchased (accessed February 27, 2017).

[223] Office of the Government Spokesperson, “The Government of Equatorial Guinea Regarding the Information Featured in the International Press about the Report, ‘Keeping Foreign Corruption Out of the United States: Four Case Histories’,” February 15, 2015.

[224] Claimant Motion to Dismiss Complaint for Forfeiture In Rem, p. 29, US v. One Gulfstream G-V Jet Aircraft (January 23, 2012, Case 1:11-cv-01874-ABJ). The Spanish authors of a leading criminal law treatise and a Spanish-English legal dictionary testified that the correct translation of “funcionario público” is “government official,” and would undoubtedly apply to members of government. Exhibit A, Ibid.

[225] Source document on file with Human Rights Watch. See also Simon Piel and Joan Tilouine, “‘Biens Mal Acquis’ : les dépenses astronomiques de Teodorin Obiang,” Le Monde, May 27, 2016, http://www.lemonde.fr/afrique/article/2016/05/27/bien-mal-acquis-les-depenses-astronomiques-de-teodorin-obiang_4927959_3212.html (accessed February 27, 2017).

[226] For a timeline of the case see Transparency International France, “Biens mal acquis : les dates clefs pour comprendre,” March 2007, https://transparency-france.org/project/biens-mal-acquis-dates-clefs-comprendre-2/ (accessed February 27, 2017). See also William Bourdon, Transparency International, “The legal right to fight corruption in France,” September 9, 2016, https://www.transparency.org/news/feature/the_legal_right_to_fight_corruption_in_france (accessed February 27, 2017).

[227] Government Press, “Communique in answer to the French National Financial Prosecutor,” May 27, 2016, http://www.guineaecuatorialpress.com/noticia.php?id=7862 (accessed February 27, 2017).

[228] International Court of Justice Press Release No. 2016/18, June 14, 2016, http://www.icj-cij.org/docket/files/163/19028.pdf (accessed February 27, 2017).

[229] ICJ jurisdiction over contentious cases requires the consent of both state parties, either in the individual case or in a treaty governing the disputed issue. Equatorial Guinea argued that France consented by ratifying the UN Convention against Transnational Crime, but the ICJ concluded that the dispute does not arise out of the Convention. International Court of Justice, Immunities and Criminal Proceedings (Equatorial Guinea v. France), December 7, 2016, para. 50.

[230] Ibid., para. 92.

[231] “Swiss open probe into son of Equatorial Guinea’s president,” Associated Press, October 18, 2016, http://bigstory.ap.org/article/d85c61812b7f4ddbb6c33ec8c8347e6d/swiss-open-probe-son-equatorial-guineas-president (accessed February 27, 2017).

[232] “Geneva Investigates Son of Equatorial Guinea’s leader,” TheLocal.ch, November 4, 2016, http://www.thelocal.ch/20161104/geneva-opens-probe-against-son-of-equatorial-guineas-leader (accessed February 27, 2017); Mfonobong Nsehe, “Dutch Authorities Seize $100 Million Yacht Allegedly Owned by African Dictator’s Son,” Forbes, December 8, 2016, http://www.forbes.com/sites/mfonobongnsehe/2016/12/08/dutch-authorities-seize-100-million-yacht-allegedly-owned-by-african-dictators-son/#570d7eb34c4a (accessed February 27, 2017).

[233] The IMF defines “shell companies” as “legal structures that have little or no employment, operations, or physical presence in the jurisdiction in which they are created. They are typically used as devices to hold assets and liabilities, and do not undertake production.” IMF Statistics Department, “Special Purpose Entities (SPEs) and Holding Companies,” December 2004, http://unstats.un.org/unsd/nationalaccount/AEG/papers/m2holdingcompanies.pdf (accessed February 27, 2017).

[234] Affidavit, Maseve Investments 7 v. Equatorial Guinea and Teodoro Nguema Obiang (High Court of South Africa, No. 1407/2006, paras 11.2 and 11.2.1.

[235] US State Department Cable from US Embassy in Malabo, “Equatorial Guinea Raw, Paper 4: The Business of Corruption,” March 12, 2009.

[236] Exhibit 31 at 4, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012). The interview was conducted on May 2, 2012 with a macroeconomics professor who was hired by the IMF to prepare a macro fiscal model for Equatorial Guinea. The interview was based on notes the interviewee took during a visit to the country and which formed the basis for the IMF’s Article IV report, which investigators viewed.

[237] Exhibit 49 at 3, Ibid. Interview conducted on April 25, 2012, with economist who worked in Equatorial Guinea for the IMF as an economic advisor.

[238] Exhibit 30 at 6-7, Ibid. Interviews were conducted on October 18, 21, and 26, 2011, with an IMF fiscal policy expert for Equatorial Guinea

[239] Ibid., p. 7.

[240] US Senate Riggs Bank report, 2004, p. 49.

[241] Republic of Equatorial Guinea, Ministry of Justice and Culture, “Authorized Copy of Certificate of Incorporation for Abayak,” Malabo, November 6, 1998 [on file with Human Rights Watch].

[242] Ibid.

[243] Ibid. p 50.

[244] Confidential report on file with Human Rights Watch. For Teodorin’s ownership of Sofona, see, for example, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012), p. 38.

[245] See Manzanares Declaration, Exhibit 6 at 57, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012). For a partial list of its projects, see http://www.ge-proyectos.com/es/taxonomy/term/176 (accessed February 27, 2017).

[246] See Manzanares Declaration, p. 57.

[247] The Italian financial police told US investigators that they believed that the “circumstances surrounding this crash were suspicious.” Manzanares Declaration, p. 57. Cellotti’s Cessna went down while flying from Mongomo, Obiang’s native city, to Bata, and only he and a Spanish pilot were on board. According to media accounts the pilot was virtually unscathed and disappeared immediately after the crash, and the Equatoguinean government failed to conduct a credible investigation into the incident. “Il giallo dell’italianoin affari con il dittatore,” La Stampa, August 20, 2008, http://www.lastampa.it/2008/08/20/italia/cronache/il-giallo-dellitaliano-in-affari-con-il-dittatore-nAqV8Pi1juIWIZw9cj35hP/pagina.html (accessed March 2, 2017).

[248] Manzanares Declaration, p. 57.

[249] Ibid.

[250] Ibid. The company is sometimes called General Work.

[251] Exhibit 8 at 5, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[252] “Equatorial Guinea: Halt Prisoner Torture,” Human Rights Watch news release, July 30, 2014, https://www.hrw.org/news/2014/07/30/equatorial-guinea-halt-prisoner-torture#1.

[253] A confidential report by a high-level businessperson active in Equatorial Guinea obtained by Human Rights Watch corroborates Berardi’s claim that the First Lady at least partially owns ABC Construction.

[254] Human Rights Watch phone interview, October 21, 2016.

[255] Ibid. Current exchange rate.

[256] Written statement by Roberto Berardi, June 19, 2013.

[257] Ibid. In an interview with Human Rights Watch, Berardi accused Teodorin of opening bank accounts in the company’s name of which he was not aware and that Teodorin would simply pocket deposits from ABC. Human Rights Watch phone interview, October 19, 2016.

[258] “Equatorial Guinea: Halt Prisoner Torture,” Human Rights Watch news release.

[259] Claimant Motion to Dismiss Complaint for Forfeiture In Rem, p. 42, US v. One Gulfstream G-V Jet Aircraft (January 23, 2012, Case 1:11-cv-01874-ABJ) and Affidavit, Maseve Investments 7 v. Equatorial Guinea and Teodoro Nguema Obiang (High Court of South Africa, No. 1407/2006, paras 11.2 and 11.2.1.) See also footnotes 224 and 225.

[260] See Section V. V. Equatorial Guinea’s Human Rights Obligations. The Equatoguinean Penal Code from 1963, which is adopted from the Spanish penal law, prohibits much of the business activity documented in this report, including taking advantage of an official position to involve oneself in a business directly related to the scope of one’s official duties. Second Amended Verified Complaint for Forfeiture In Rem, p. 8, US v. One White Crystal-Covered “Bad-Tour” Glove (C.D. Cal. June 11, 2012). Based on the government responses to corruption allegations, it appears that it does not consider these laws to apply.

[261] Transparency International, Anti-Corruption Helpdesk: Conflict of Interest in Public Procurement, 2013, pp. 2-3. http://www.transparency.org/files/content/corruptionqas/Conflict_of_interest_in__public_procurement.pdf (accessed February 27, 2017).

[262] See Section V. V. Equatorial Guinea’s Human Rights Obligations.

[263] World Bank, “Equatorial Guinea: Public Expenditure Review (PER),” January 2010, p. 37.

[264] Ibid.

[265] Ibid. p. 39.

[266] Exhibit 31 at 6, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[267] IMF, Republic of Equatorial Guinea: 2014 Article IV Consultation Staff Report, p. 12.

[268] Exhibit 31, p. 6, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[269] Human Rights Watch phone interview, August 9, 2016.

[270] Exhibit 10, p. 4, Second Amended Complaint, US v. One White Crystal-Covered “Bad Tour” Glove and Other Michael Jackson Memorabilia (C.D. Cal. June 11, 2012).

[271] Exhibit 30, p. 6, Ibid.

[272] Exhibit 7, p. 5, Ibid.

[273] Ibid., pp. 49 and 89.

[274] Contract between GEPROYECTOS and IMS-International Medical Services G.E. S.A., July 11, 2011.

[275] Republic of Panama, Twelfth Circuit Notary, November 18, 2011.

[276] US Senate Riggs Bank report, 2004, p. 57

[277] International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 12. Equatorial Guinea ratified the ICESCR in 1987.

[278] Committee on Economic, Social and Cultural Rights, General Comment No. 14 (2000), para. 12, http://www.refworld.org/pdfid/4538838d0.pdf (accessed February 27, 2017). See also Office of High Commissioner for Human Rights and World Health Organization, “The Right to Health: Fact Sheet No. 31,” June 2008.

[279] Office of High Commissioner for Human Rights and World Health Organization, “The Right to Health: Fact Sheet No. 31,” June 2008, p. 3-4 (based on General Comment No. 14).

[280] Committee on Economic, Social and Cultural Rights, General Comment No. 14 (2000), para. 4.

[281] Convention on the Rights of the Child (CRC), adopted November 20, 1989, G.A. Res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), entered into force September 2, 1990, art 24.

[282] Convention on the Rights of the Child (CRC), art. 23.

[283] International Covenant on Economic, Social and Cultural Rights (ICESCR), art. 13; CRC, Convention on the Rights of the Child (CRC), art. 28.

[284] Committee on Economic, Social and Cultural Rights, General Comment No. 13, E/C.12/1999/10 (December 8, 1999), para 6, http://www.refworld.org/docid/4538838c22.html (accessed February 27, 2017).

[285] International Covenant on Economic, Social and Cultural Rights (ICESCR), art. 13.

[286] Equatorial Guinea Constitution (2012), art. 24.

[287] Equatorial Guinea Constitution (2012), art. 8.

[288] Committee on Economic, Social and Cultural Rights, General Comment No. 13, para 57; Committee on Economic, Social and Cultural Rights, General Comment No. 14, paras 43-45.

[289] International Covenant on Economic, Social and Cultural Rights (ICESCR), arts. 2, 12, 13. Note year of EG ratification (1987).

[290] The Limburg Principles, established in 1986 by a distinguished group of international law experts to guide implementation of the ICESCR, provide that, “In determining whether adequate measures have been taken for the realization of the rights recognized in the Covenant attention shall be paid to equitable and effective use of and access to the available resources.” Limburg Principles on the Implementation of the International Covenant on Economic, Social, and Cultural Rights, UN Doc. E/CN.4/1987/17 (January 8, 1987), Article 27.

[291] Convention against Corruption, adopted October 31, 2003, G.A. res. 58/4, U.N. Doc. A/58/422, entered into force December 14, 2005, art. 7.

[292] Convention against Corruption, art. 8.

[293] Convention against Corruption, art. 9.

[294] There are 180 state parties to the Convention. See https://www.unodc.org/unodc/en/treaties/CAC/signatories.html (accessed February 27, 2017).

[295] African Union, African Union Convention on Preventing and Combating Corruption, adopted July 11 2003, entered into force August 5, 2006, arts. 5-7.

[296] Convention Against Transnational Organized Crime, adopted November 15, 2000, G.A. Res. A/Res/55/25, annex I, U.N. GAOR, 55th Sess., Supp. No. 49, at 44, U.N. Doc. A/45/49 (Vol. I) (2001), entered into force Sept. 29, 2003, arts. 9 and 10.

[297] Convention Against Transnational Organized Crime, art. 7.

[298] CEMAC Regulation No 01/03, Relating to the Prevention and Suppression of Money Laundering and Financing of Terrorism in Central Africa, Article 10.

[299] Decree Law 1/2004 on Ethics and Dignity in the Performance of Public Service, Equatoguinean Penal Code art. 12.

[300] See Claimant Motion to Dismiss Complaint for Forfeiture In Rem, p. 6, US v. One Gulfstream G-V Jet Aircraft (January 23, 2012, Case 1:11-cv-01874-ABJ).

[301] Decree Law 1/2004, art. 17

[302] Decree Law 1/2004, art. 5.

[303] Decree Law 1/2004, art. 11.

[304] Decree Law 1/2004, art. 10.

[305] Decree Law 1/2004, art. 13

[306] "Reglamento General para la Aplicación de la Ley de Contratos del Estado” (Spanish regulation), 1968, art. 20. Presidential decree 4/1980 made Spanish laws and regulations applicable in Equatorial Guinea in the absence of specific domestic laws.

[307] "Reglamento General para la Aplicación de la Ley de Contratos del Estado,” arts. 92-94. For exceptions, see art. 117.

[308] "Reglamento General para la Aplicación de la Ley de Contratos del Estado,” arts. 39 and 119.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Senator Bill Cassidy

520 Hart Senate Office Building

Washington DC 20510

 

​Dear Senator Cassidy,

Human Rights Watch is an independent, non-governmental organization that monitors and advocates for human rights, including the right to health. In the last several years, Human Rights Watch has interviewed hundreds of people in every corner of Louisiana about access to health care and services, and released two major reports focused on access to HIV treatment and care.[1] We have worked closely with people living with HIV and their advocates as well as health care providers, state public health officials, correctional officials, state legislators and many others to promote greater access to care, particularly for the most vulnerable populations. As the Senate considers health care reform, particularly changes to the Medicaid program, we write to highlight the impact that such action would have upon residents of Louisiana.

A man with cerebral palsy, epilepsy, and HIV. A mother of two who was legally blind, and now has limited vision. A school bus driver who got Medicaid through the expansion and now can pay for her HIV medications. The director of a drug treatment center who has seen a “sea-change” in who can afford treatment since Medicaid expansion. These are the stories of Louisianans who would suffer if the Senate adopts the Medicaid provisions of the American Health Care Act (AHCA).

Current GOP proposals threaten to decimate the Medicaid program: the AHCA would strip 880 billion dollars from Medicaid over the next ten years, and the administration’s budget proposal removes another 660 billion dollars on top of that. The AHCA would also phase out the Medicaid expansion by 2020, an action that experts estimate would do severe harm to the Louisiana economy, including the loss of 26 billion dollars in federal funding, an estimated 37,000 jobs, and 639 million dollars in state and local tax revenue.[2]

Overall, some experts estimate that under funding cuts proposed by the AHCA, states would have to increase their Medicaid budgets by an average of 37 percent by 2026 in order to maintain Medicaid benefits at current levels.[3] In a state that a recent study recently ranked 50th in economic strength, such drastic cuts in federal funding could be devastating to Louisiana’s economy.[4]

The health impact of phasing out the Medicaid expansion by 2020 would be enormous; in less than one year, expansion has provided health insurance to more than 425,000 Louisiana residents, provided preventive care to 96,000 people, screened more than 14,000 women for breast cancer, and enabled 8,000 people to access treatment for substance use amid a severe opioid crisis.[5]

Nationwide, more than 40 percent of people living with HIV depend on Medicaid, including people like Roberta, a 47-year-old school bus driver who lives in Campti, Louisiana. (Like other Medicaid recipients referenced in this letter, she preferred to use a pseudonym to protect her privacy.) Maintaining her health has not been easy for Roberta. A single mom, she struggled to pay for her HIV medications until the state expanded Medicaid last July. “I couldn’t always afford my medications. Sometimes I had to buy pills from people I knew had extra, a few pills at a time.” Now with Medicaid coverage, she has gotten glasses, been to the dentist, discovered a thyroid condition through blood tests, and most importantly, not missed a dose of her HIV medicine.

 “Maybe President Trump doesn’t realize that these programs help people,” said Steven, a 49-year-old man from Natchitoches. Steven has cerebral palsy, epilepsy, and HIV. He takes 15 medications, all of which are paid for by Medicaid, as are his home health aides who help him with every aspect of his daily activities. For Steven, Medicaid is more than health insurance—it is nothing less than a lifeline.

It is difficult for Ellen, another Natchitoches resident, to imagine how she and her family would survive with less assistance from Medicaid. Ellen, 44, is a mother of two boys. She worked for many years for the school system as a teaching assistant, but in 2006 she became legally blind. After several cornea transplant operations, she has limited vision. Ellen also is HIV-positive and Medicaid pays for her anti-retroviral medications. When asked what impact reduction of Medicaid benefits might have on her, Ellen replied simply, “It would be overwhelming.”

Medicaid benefits are also critically important to efforts to combat the opioid crisis. Nationwide, more than 1.2 million formerly uninsured people have accessed substance use treatment through Medicaid expansion, including 7,000 in Louisiana.[6] Leigh Ann de Monredon is the director of Odyssey House Louisiana, a health clinic that also provides residential drug treatment in New Orleans. Ms. de Monredon described the difference at Odyssey House since the state expanded Medicaid as a “sea- change” in access to care: more people can afford residential treatment as well as medications that are the standard of care for opioid dependence. “We can now give them medications like Suboxone and Vivitrol, and our relapse rates are much lower,” she said. The clinic also provides preventive care services, so that “our doctors can identify potential drug problems before they become addictions.” These services are vitally important in a city where drug overdose deaths doubled in 2016.[7]

These are just some of the stories gathered by Human Rights Watch that demonstrate the importance of protecting Medicaid—both its financial viability and its expansion—in states like Louisiana.  As a sponsor of the Patient Freedom Act, a bill that would permit states to preserve their Medicaid expansions, we know that you share this concern. For the sake of Roberta, Steven, Ellen and thousands like them, we urge you to take all steps necessary to protect Medicaid and continue the progress that is currently underway in promoting public health and human rights in Louisiana.

Sincerely,

Megan McLemore

Senior Researcher

Health and Human Rights Division

 

[1] Human Rights Watch, In Harm’s Way: State Response to Sex Workers, Drug Users and HIV in New Orleans, December 2013, https://www.hrw.org/report/2013/12/11/harms-way/state-response-sex-worke... Human Rights Watch, Paying the Price: Failure to Deliver HIV Services in Louisiana Parish Jails, March 2016, https://www.hrw.org/report/2016/03/29/paying-price/failure-deliver-hiv-s....

[2] Center for Budget and Policy Priorities, “Impact of ACA Repeal, State Fact Sheets”, http://www.cbpp.org/sites/default/ files/atoms/files/12-7-16health-factsheets-la.pdf (accessed June 8, 2017); The Commonwealth Fund, “Repealing Federal Health Reform: Economic and Employment Consequences for States,” January 5, 2017, http://www.commonwealthfund.org/ publications/issue-briefs/2017/jan/repealing-federal-health-reform (accessed June 12, 2017).

[3] People-to-People Health Foundation, “Can the States Survive the Per Capita Medicaid Caps in the AHCA?” post to “Health Affairs Blog” (blog), May 17, 2017, http://healthaffairs.org/blog/2017/05/17/can-states-survive-the-per-capi... (accessed June 8, 2017).

[4] Richie Bernardo, “2017’s Best and Worst State Economies,” WalletHub, June 5, 2017, https://wallethub.com/edu/states-with-the-best-economies/21697/ (accessed June 8, 2017).

[5] “LDH Medicaid Expansion Dashboard,” Louisiana Department of Health, http://ldh.la.gov/healthyladashboard/ (accessed June 8, 2017).

[6] Christine Vestal, “ACA Repeal Seen Thwarting State Addiction Efforts,” Pew Charitable Trusts, February 6, 2017, http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/0... (accessed June 8, 2017).

[7] Rebecca Santana, “Coroner: New Orleans Drug Overdose Deaths Doubled in 2016,” the Associated Press, March 27, 2017, https://www.usnews.com/news/best-states/louisiana/articles/2017-03-27/co... (accessed June 8, 2017).

Posted: January 1, 1970, 12:00 am

Equatorial Guinea is one the smallest countries in Africa, with a population of around 1 million and a total landmass of just over 28,000 square kilometers.

Posted: January 1, 1970, 12:00 am

Ijaz Paras Masih sits in a hospital bed in Thailand (date unknown). 
 

© 2017 British Pakistani Christian Association

(New York) – The government of Thailand should immediately investigate the death of a Pakistani man in immigration detention, Human Rights Watch said today. The case points to the need for Thailand to urgently end the indefinite detention of refugees and asylum seekers.

On May 27, 2017, Ijaz Masih, a 36-year-old Christian Pakistani, had a heart attack at the Immigration Detention Center in Bangkok, where he had been detained for more than a year on an illegal entry charge. The United Nations High Commissioner for Refugees (UNHCR) had rejected his refugee claim the day before. He died shortly after he was transferred to the Police General Hospital.

“Thai authorities are putting people who seek refugee protection at grave risk by keeping them in awful conditions in immigration detention centers,” said Brad Adams, Asia director. “Ijaz Masih’s death should be a wake-up call to end this abusive policy of incarcerating asylum seekers awaiting application results and refugees.”

Thai authorities are putting people who seek refugee protection at grave risk by keeping them in awful conditions in immigration detention centers.

Brad Adams

Asia Director


Ijaz Masih was one of hundreds of Pakistani Christian asylum seekers who claim to have been persecuted in Pakistan and ended up in squalid immigration detention centers in Thailand, where authorities treat them as illegal immigrants without rights – including asylum seekers, as well as those recognized as refugees by the UNHCR. In Pakistan, members of religious minorities face discrimination, criminal charges of blasphemy, and other forms of persecution – including violent attacks.

Under Thai law, all migrants with irregular immigration status – including children, asylum seekers, and recognized refugees – can be arrested and detained for illegal entry. Many immigration detention centers in Thailand are severely overcrowded, provide inadequate food, have poor ventilation, and lack access to medical service and other basic necessities. Detainees are restricted to small cells resembling cages, where they barely have room to sit, much less sleep. Children are frequently incarcerated with adults.

Thailand’s immigration detention facilities have long been reported to fall far short of international standards, but the Thai government has not acted to address the serious problems. Human Rights Watch documented these shortcomings in a comprehensive report on immigration detention of children in 2014, and a report on the treatment of refugees – including the detention of urban refugees – in 2012.    

Thailand is not a party to the 1951 Refugee Convention and has never enacted a law to recognize refugee status and set out procedures to assess asylum claims. Given its own lack of asylum procedures, the Thai government should respect UNHCR-issued persons-of-concern documents and refrain from detaining people who have pending claims for international protection. Besides ending the detention of asylum seekers, Thailand should also adopt alternatives to detention that are being used effectively in other countries – such as open reception centers and conditional release programs.

“The Thai government should recognize that its punitive detention policy towards asylum seekers is both inhumane and counterproductive,” Adams said. “Punishing people who are fleeing ghastly conditions at home will not keep them away but just add to their misery.”

Posted: January 1, 1970, 12:00 am
Posted: January 1, 1970, 12:00 am

Protesters rally on Capitol Hill in Washington, D.C. during US House voting on the American Health Care Act, which would repeal major parts of the 2000 Affordable Care Act know as Obamacare, May 4, 2017.

© 2017 REUTERS/Yuri Gripas
 
(Washington) – The US Senate should categorically reject the healthcare bill passed by the US House of Representatives on May 4, 2017, Human Rights Watch said today. If enacted into law in anything like its current form, the House version of the bill would tear down the foundations of a more equitable, rights-respecting healthcare system that were only recently put into place.
 
Since the Affordable Care Act (ACA) was enacted in 2010, Human Rights Watch has interviewed hundreds of people across the country about how protections under the law have affected their lives. One man told Human Rights Watch that he was able to get treatment for an opioid addiction that was ruining his life. An older person with Parkinson’s disease was able to get care in a nursing home that his family was unable to provide. A woman with a disability was able to live in the community instead of an institutiton. And one woman said that Planned Parenthood, which would lose funding under the bill, had been critically important to her wellbeing because the staff treated her with respect, when other providers had not.
 
“The American Health Care Act is an assault on the right to health that would do the most harm to those who can least afford it,” said Megan McLemore, senior health researcher at Human Rights Watch, “The Senate can and should abandon this destructive path as it begins its own deliberations.”
 
The American Health Care Act would eliminate insurance coverage and reduce access to quality health care for millions of people, including those with low incomes, women, older adults, and people with disabilities and chronic conditions such as HIV.
 
The final bill passed by the House would eliminate mandated coverage for a range of essential health benefits, cut funding for Medicaid and transfer key decision-making authority for the program to the states, and significantly weaken protection for people with pre-existing conditions.
 
Medicaid reimbursement for Planned Parenthood Services would be prohibited. ACA subsidies based on income and geography would be replaced with tax credits based mainly on age. The ability of many people to buy insurance coverage in the private market would decrease sharply, as the average subsidy for buying insurance would drop an average of 60 percent by the year 2020. Companies would be allowed to charge older adults five times as much as younger adults for coverage, and employers over a certain size would no longer be mandated to provide insurance to their employees.
 
If anything like the House bill becomes law, make no mistake about it - lives will be lost.

Megan McLemore

Senior Health Researcher

The Congressional Budget Office, a nonpartisan federal agency that advises Congress on budgetary issues, estimates that the legislation would result in the loss of insurance coverage for an estimated 23 million people in the next decade. By 2026, an estimated 51 million people under 65 would be uninsured, compared to 28 million who would be uninsured under current law.
 
If the American Health Care Act is passed in the Senate and signed into law, it would have potentially devastating results for millions of Americans who could face the loss of health coverage under both private insurance and Medicaid. Human Rights Watch and its partners have spoken to dozens of people about how proposed changes under the House bill would affect them.
 
“Susan,” 33, who, like some others Human Rights Watch interviewed, preferred using a pseudonum to protect her privacy, has had a heart condition, atrial fibulation, since she was 19. For most of her life, she had no health insurance. She told Human Rights Watch that the plans she was offered cost half of her income as an employee of a small non-profit organization. Under the ACA, she has a plan that is affordable for herself and her husband. “It was very stressful when I did not have health insurance,” Susan said, “and I am very fearful of what is going to happen to me if Congress takes this away.”
 
International human rights law protects the right to health, which is also indispensable to the enjoyment of other rights. Under the Universal Declaration of Human Rights, everyone has the right to a standard of living adequate for their and their family’s health and well-being, including medical care, and the right to security in the case of sickness, disability, old age, or other circumstances beyond their control.
 
In February 2017, the United Nations special rapporteur on the right to health, Dainius Pirus, sent an urgent letter to the Trump administration expressing serious concern about the impact that efforts to repeal core elements of the ACA might have on the right to health of residents of the United States. He urged the US government to protect the right to health, particularly for those “of low or middle income, and in situations of poverty or social exclusion.”
 
“If anything like the House bill becomes law, make no mistake about it,” McLemore said, “Lives will be lost.”

 

Medicaid

One of the most important ways the ACA achieved success in insuring more people was by expanding Medicaid to cover people with incomes up to 137 percent of the federal poverty level, providing health coverage to an additional 14 million people in 31 states. The American Health Care Act  would cut Medicaid by US$880 billion over 10 years, replacing the federal program with block grants to states and, beginning in 2020, setting caps on the amount of federal funding that could be spent per person. Medicaid expansion would be frozen for states that have already pursued it and phased out entirely by 2020.

Many states that expanded Medicaid under the ACA saw dramatic improvements in healthcare coverage for their residents. In Louisiana, for example, more than 400,000 people have gained health insurance coverage since July 2016 – more than 60 percent of them women.

Human Rights Watch spoke to one such woman in Louisana, “Jacquelyn.” She has endometriosis, a condition in which tissue that normally grows in the uterus grows outside it, for which she had to undergo surgery at a time she did not have insurance coverage. She made monthly payments to the hospital, then was able to go on the TV program Wheel of Fortune. She used her winnings to pay off the US$25,000 in medical bills.

It was not until July 2016, when Louisiana Governor John Bel Edwards expanded Medicaid, that she was fully insured and able to afford the health care she needed. She went to Planned Parenthood, where she now works, to have an IUD inserted to stop the daily bleeding that comes with endometriosis. She is also able to go to the dermatologist for preventative care that could be potentially life-saving, since she has a history of melanoma, which can be deadly.

“I am terrified that Congress will take away Medicaid expansion because most people on Medicaid are like me, what I call the poor middle class,” Jacquelyn said. “We are people who have student debt and medical debt and who work 40-50 hours a week to keep our heads above water.”

Insurance Coverage

The American Health Care Act changes the subsidy structure for purchase of private insurance under the ACA. The ACA based tax credits and subsidy amounts on income, age, and the local cost of insurance, while under the American Health Care Act, such assistance would be based only on age. This approach would result in less assistance for low income people, while benefits would increase for people with higher incomes.

“Monica,” 46, and her husband own a small business in Kenner, Louisiana. Prior to the ACA, she could not get insurance – either it was denied because she had a pre-existing condition, or was so expensive that she could not afford it. “Before the ACA, the only plans offered to me were more than US$1,000 a month,” she said. Currently, with the help of subsidies and tax credits provided for plans in the insurance exchange, she pays about US$300 a month for a “good plan” that covers her, her husband, and her daughter. She is very anxious about what would happen if the cost of insurance goes out of reach again. “It would be just devastating to my family,” she said.

Mental Health Care and Drug Dependence Treatment

In the US, approximately one in five adults has a mental health condition. But only half of people with mental health conditions are receiving treatment, and they are less likely to be insured than other people. The ACA attempted to address the situation by including mental heatlh and substance use treatment as a mandated essential health benefit for both private and public insurers. Under the American Health Care Act, states could opt out of this mandate, with potentially severe consequences for millions of people seeking treatment for mental and behavioral health problems.

“Deborah,” 49, who lives in Arizona, told Human Rights Watch what it had meant to her family to be without mental health coverage in their insurance plan prior to the ACA. When Deborah’s oldest son, Andrew, began having problems with addiction, her family’s insurance didn’t cover mental health care. He entered a rehab program in 2013, but Deborah and her husband had to pay US$10,000 up front for 30 days. That money would have gone to their mortgage payments. They didn’t make a payment for a year, and had to sell their house on a short sale in lieu of foreclosure. “We lost our home for medical care to save my son’s life,” she said.

In 2014, the family bought coverage under the ACA, and Andrew went back into rehab for a US$1,000 co-pay. “$1,000 vs $10,000 – that’s a huge difference,” she said.

Andrew died from an overdose in 2016, and Deborah wishes they had better mental health care coverage before the ACA. It would have meant better treatment and counseling for Andrew, she thinks. “How do you tell your child you can’t take them for care because you can’t afford it?”

While President Donald Trump has vowed that his administration will end the opioid epidemic, the American Health Care Act has the potential to worsen it. Rural America – particularly areas of Ohio, Kentucky, New Hampshire, and West Virginia – is already “ground zero” for the nation’s opioid crisis, and the House bill threatens to undermine progress being made on this issue.

By eliminating the requirement under the ACA to cover mental health care, including drug treatment services, both with private insurance and with Medicaid, the American Health Care Act would cause many people struggling with opioid dependence to lose access to treatment. In the 31 states that have expanded Medicaid, 1.2 million people who previously had no insurance have received drug treatment services.

Among them is Freddy, a 27-year-old from Tucson. When he first needed treatment for his heroin use, Arizona had not expanded Medicaid, and he had no health insurance. His parents paid out of pocket for him to enter a residential treatment center and ended up losing their home as they could no longer make the mortgage payments. “My parents had to choose between their house, or saving my life,” he said. He is now in outpatient treatment that is covered by Medicaid. He works at an airplane refurbishing company in the area and is in the process of recording a rock/funk album with his brother. “For once in my life,” he says, “I am actually happy!”

Women’s Health and Planned Parenthood

Medicaid is fundamental for women’s health in the US – covering roughly half of all births and 75 percent of public financing for family planning services, among other key women’s health services. Nearly half of low-income women in the US rely on Medicaid for health insurance, as do roughly one in three Black women, one in four Latina women, and one in five Asian and Pacific Islander women of reproductive age.

The bill’s ban on Medicaid reimbursements for Planned Parenthood services would also have devastating consequences. For more than 40 years, federal law has prevented Planned Parenthood, or any service provider, from receiving federal funding for abortion services, but the American Health Care Act targets the organization because it provides abortion care for women with non-federal money.

Planned Parenthood provides a broad range of services to women and men in some of the country’s most marginalized communities, including safe, non-judgmental services for victims of sexual violence; screening for cancer, diabetes and high blood pressure; vaccines; and other preventive health care.

More than half of Planned Parenthood’s clinics are in rural or urban areas that are designated by the federal government as “medically underserved.” In more than 100 counties throughout the country, Planned Parenthood clinics are the only providers of family planning services. Women like Jacquelyn would not be able to seek services at their preferred provider if the Senate adopted apunitive provision to ban Medicaid reimbursements to Planned Parenthood.

Nicole, a 25-year-old woman in Colorado, told Human Rights Watch that she usually seeks care at Planned Parenthood because she considers it compassionate in a way that other service providers are not. She was sexually assaulted one night after the Planned Parenthood clinic near where she lived closed. She couldn’t afford treatment in a private clinic because the deductible on the health insurance she had at work was too high. So she went to a hospital emergency room instead.

“I went to the hospital and saw a doctor and they made me feel like a slut,” she said. “I didn’t even want to tell them what happened, they were so mean about me just asking for a test. I felt alone and it was really bad.” She has since moved to an area where she has access to a Planned Parenthood clinic.

Older People

Contrary to the perception that only Medicare takes care of older people, Medicaid provides integral support to this growing demographic as well. For many of the 1.2 million older Americans who rely on institutional long-term care, almost two-thirds of them women, the median cost of one year in a nursing facility – US$90,000 – would be prohibitive without Medicaid contributions. Because Medicaid covers costs for a nursing facility stay beyond 100 days and for many community-based services, and provides support for people to remain at home, Medicaid cuts would make critical long-term care more difficult to obtain.

“Ken,” a 68-year-old former employee of a trucking company who has Parkinson’s disease, is in a nursing facility in Illinois. He moved there, far from his family, because he required more support and health care than he could obtain at home with the progression of his illness. Medicaid is “very important because that’s where I get the money to stay here,” he said. “I’m in a wheelchair all the time …  nobody at home to take care of me. If I couldn’t stay here, I don’t know where I would be.” His access to essential health services and a safe living environment would be curtailed without access to Medicaid.

“Mark,” 65, lives in Hayward, California. Mark is diabetic, and in spring of this year, the toes on his right foot had to be amputated due to complications from a staph infection. With an income of US$1,499 a month in Social Security, he relies on Medicaid to pay for necessary institutional care and for the rehabilitation sessions that are teaching him “how to walk again and do things without the use of my right foot.” Mark said that Medicaid “was not important to me until I got sick. I think that’s the way it is with a lot of elders. They won’t know it is a problem until it’s too late.” Cuts to Medicaid would threaten the ability of people like Mark to live safely, with dignity, and as independently as possible.

People with Disabilities

For people with disabilities, who have a right to community-based care, the shrinkage of Medicaid could be devastating and force many into instutional settings. It would phase out federal matching funds that give states incentives to support home- and community-based services. Over the next decade, the American Health Care Act would cut 25 percent of Medicaid’s budget – shrinking a program that serves more than 10 million people with disabilities.

In its current form, Medicaid allows people with disabilities to receive at-home personal care services. Medicaid also allows them to have choices and control over their lives – deciding where, how, and with whom to live, and enabling them to carry out normal daily activities from getting up in the morning, bathing, preparing breakfast, and going to work or school.

For people like Alana Thierault, a 50-year-old woman from California with spinal muscular atrophy, loss of Medicaid coverage and funding support for her home-based assistance may result in the end of her ability to live independently. Her condition is a form of muscular dystrophy, a genetic neurological condition that causes muscles to become weak.

Medicaid covers the services of home care workers, who go to her house in the mornings and help her perform ordinary daily activities like bathing, getting dressed, and going to work. If she were to lose those services, she wouldn’t be able to lead an independent life and she would end up living in an institution.

Stacey Milbern, a 29-year-old woman with a disability living in Oakland, said that if Medicaid supports were cut, “I likely would be living in an acute care facility – it’s very much an institutional setting and not my own home.” Milbern is able to get 24-hour attendant and nursing services, including 40 hours a week of private duty nursing that takes care of the medical side of her disability. Other attendants help her get out of bed and drive her to work.

Jade Theriault, who also has spinal muscular atrophy, said that cutting Medicaid “would be like a slow stripping of my freedom.” She now lives in her own apartment and has a team of five or six assistants who each spend two-hour blocks throughout the day to help her with daily activities, including overnight care. She uses a respiratory equipment and her attendants also help to operate it. If Medicaid were cut she wouldn’t be able to pay for these services.

Pre-Existing Conditions

The American Health Care Act would eliminate much of the ACA’s protection for people with pre-existing conditions, creating instead “high risk pools” that experts say will not be adequately funded in this legislation. These provisions and cuts to Medicaid would harm millions of Americans with chronic illness. Sixty percent of people with HIV depend on Medicaid for their health care.

Before Louisiana expanded Medicaid, “Roberta,” a 47-year-old school bus driver, struggled with her HIV care. She had no health insurance and could not always afford her anti-retroviral medication. “Sometimes I had to buy my pills from people I knew who had extra, one pill at a time,” she said. Now with Medicaid coverage, she was able to get glasses, was diagnosed with a thyroid condition she didn’t know she had, and has not missed a dose of her HIV medication.

Posted: January 1, 1970, 12:00 am
Posted: January 1, 1970, 12:00 am

A Palestinian medic inspects a damaged room at Al-Aqsa Martyrs hospital, in Deir el-Balah, central Gaza Strip, after the building was shelled by the Israeli army on July 21, 2014, killing at least 3 people and wounding about 40 others.

© 2014 Ibraheem Abu Mustafa/Reuters

(New York) – Deadly attacks on hospitals and medical workers in conflicts around the world remain uninvestigated and unpunished a year after the United Nations Security Council called for greater action, Human Rights Watch said today.

On May 25, 2017, UN Secretary-General Antonio Guterres is scheduled to brief the Security Council on the implementation of Resolution 2286, which condemned wartime attacks on health facilities and urged governments to act against those responsible. Guterres should commit to alerting the Security Council of all future attacks on healthcare facilities on an ongoing rather than annual basis.

“Attacks on hospitals challenge the very foundation of the laws of war, and are unlikely to stop as long as those responsible for the attacks can get away with them,” said Bruno Stagno-Ugarte, deputy executive director for advocacy at Human Rights Watch. “Attacks on hospitals are especially insidious, because when you destroy a hospital and kill its health workers, you’re also risking the lives of those who will need their care in the future.”

Workers collect human remains at the yard of a hospital operated by Medecins Sans Frontieres in the Abs district of Hajjah governorate, Yemen, after it was hit by a Saudi-led coalition airstrike, killing 19 and wounding 24 staff and patients, on August 16, 2016.

© 2016 Abduljabbar Zeyad/Reuters

A report by the Safeguarding Health in Conflict Coalition, a coalition of international nongovernmental organizations, published in May, found that attacks on health facilities and medical workers continued to occur at an alarming rate in 2016.

International humanitarian law, also known as the laws of war, prohibits attacks on health facilities and medical workers. To assess accountability measures undertaken for such attacks, Human Rights Watch reviewed 25 major attacks on health facilities between 2013 and 2016 in 10 countries. For 20 of the incidents, no publicly available information indicates that investigations took place. In many cases, authorities did not respond to requests for information about the status of investigations. Investigations into the remaining five were seriously flawed.

Expand

Share

No one appears to have faced criminal charges for their role in any of these attacks, at least 16 of which may have constituted war crimes. The attacks involved military forces or armed groups from Afghanistan, Central African Republic, Iraq, Israel, Libya, Russia, Saudi Arabia, South Sudan, Sudan, Syria, Ukraine, and the United States.

The UN system, under its Human Rights Up Front initiative, should collect information on all health facility attacks, press governments to fully investigate them, and recommend avenues for accountability.

The 25 incidents reviewed resulted in the deaths of more than 200 people, including 41 health workers, and injured 180. The attacks also had significant impact on health services as 16 hospitals were partially or completely closed, at least temporarily.

Rescue workers and others remove rubble while looking for survivors in the ruins of a destroyed hospital supported by Medecins Sans Frontieres that was hit by an airstrike, killing 25 health workers and patients and injuring 11 others, in Marat Numan, Idlib province, Syria, February 16, 2016.

© 2016 Ammar Abdullah/Reuters

In the 20 incidents without apparent investigations, governments ignored credible allegations about the attacks, publicly denied responsibility, or blamed other parties without conducting an inquiry. In several cases, authorities claimed to have initiated investigations, but have either failed to present any findings or have not conducted any investigation whatsoever.

In one example, neither Iraqi nor US-led coalition forces acknowledged an October 2016 airstrike that hit the main health facility in a village near Mosul, Iraq, destroying half the clinic and killing eight people, though the forces carried out airstrikes near Mosul on that day.

In another, in February 2016, airstrikes hit the two largest hospitals serving the city of Ma’aret al-Nu’man, Syria, destroying one of the hospitals and killing 20 people, including 11 health workers. But Russia and Syria, the parties most likely responsible for both attacks, immediately denied responsibility and claimed that US-led coalition forces carried out the strikes. US authorities denied this allegation. None of the parties investigated the incident.

Five of the 25 incidents Human Rights Watch reviewed appear to have been investigated in some form. But Human Rights Watch found that investigating authorities either left critical questions about the circumstances unanswered or failed to draw appropriate conclusions from their findings.

For example, a Saudi Arabia-led coalition task force investigating potential violations by their forces in Yemen concluded that an August 2016 attack on a hospital in the city of Abs, Hajjah governorate, was an “error” but failed to determine whether the attack violated the laws of war.

Hospital beds in the Medecins Sans Frontieres hospital in Kunduz, Afghanistan about six months after US airstrikes killed 42 patients and medical staff and wounded dozens of others, on April 26, 2016.

© 2016 Josh Smith/Reuters

Following the October 2015 attack by the US military on a trauma center in Kunduz, Afghanistan, that killed 42 people and injured dozens of others, a US Defense Department investigation concluded that the attack violated the laws of war, but was not a war crime because the hospital was not targeted intentionally. However, the US investigation’s findings indicated criminal recklessness by US forces, which could amount to a war crime.

The Defense Department disciplined 12 military personnel, including by demoting an officer, publicly apologized for the attack, and made changes to policies to prevent similar incidents in the future.

Some of the incidents were in war-torn countries without functioning justice systems. In countries such as Central Africa Republic, Libya, and South Sudan, almost no domestic investigations have been conducted into any alleged laws-of-war violations.

The council should react promptly to every serious attack on a health facility, including by demanding credible investigations and accountability.

Bruno Stagno-Ugarte

Deputy Executive Director for Advocacy

In some cases, UN-affiliated commissions have investigated incidents in which health facilities have been attacked, but at most they can recommend cases for criminal prosecution.

In many instances, the only possible option for accountability rests with international justice mechanisms, such as the International Criminal Court, or under universal jurisdiction laws in other countries. The ICC has taken up two cases of attacks on health facilities.

“The UN Security Council needs to do much more to deter attacks on hospitals,” Stagno-Ugarte said. “The council should react promptly to every serious attack on a health facility, including by demanding credible investigations and accountability.”

Selected Incidents

The eight incidents below illustrate failures of accountability for attacks on hospitals and health workers. The selected cases reflect the variety of responses to these incidents, including denial of responsibility or simple disregard, stalled and flawed investigations, and situations without functioning justice systems.

For this research, Human Rights Watch collected information on 25 incidents that occurred across all major conflicts in which attacks on health facilities were reported between 2013 and 2016. Information on attacks and government responses to them were gathered through interviews with witnesses, health workers, and representatives from humanitarian organizations. This was supplemented by open-source searches, reviews of relevant UN and other publications, analysis of photographs and videos posted on the internet, and analysis of satellite imagery where relevant. Where possible, we spoke to government officials and sent letters with our findings to appropriate investigative bodies.

Airstrike on Hammam al-Alil Health Clinic in Iraq, October 18, 2016

On October 18, 2016, an airstrike destroyed half a clinic in the ISIS-controlled town of Hammam al-Alil, Iraq, 30 kilometers south of the embattled city of Mosul. Eight people were killed, including a 72-year-old man who had taken his two grandsons to the clinic for a polio vaccination. Health workers reported that about 50 people were at the clinic, the main healthcare facility in the area, with a population of 70,000. The strike destroyed the radiation department, vaccination division, and human resources and administrative departments.

Both the US-led coalition and the Iraqi military were conducting airstrikes near Mosul that day in the fighting against ISIS. Human Rights Watch was unable to identify the source of the attack.

A health worker told Human Rights Watch that after ISIS took control of the town in July 2014, fighters took over an office in one of the treatment wards. Health workers said that three ISIS fighters, including the transportation minister, were killed in the attack.

ISIS military use of the hospital was in violation of international humanitarian law. But while the presence of ISIS fighters in the hospital made it a military objective, and thus a possible legitimate target of attack, international humanitarian law requires that attacks on medical facilities only be carried out after a warning has been given, setting a reasonable time limit to heed the warning, and after that time limit has expired. Health workers said that there was no warning.

Moreover, attacks on military objectives must be proportionate: the expected harm to civilians and civilian property cannot be greater than the anticipated military gain from the attack. This incident raises serious questions about whether it met the proportionality requirement. Yet, neither the Iraqi government nor US-led coalition forces have provided information on the intended target of the attack or made a commitment to investigate it as a possible violation of international humanitarian law.

Airstrike on Abs Hospital in Abs, Hajjah, Yemen, August 15, 2016

On August 15, 2016, Saudi-led coalition forces carried out an airstrike that hit a vehicle parked between the emergency and triage areas of Abs Hospital, a facility supported by MSF. MSF reported that the attack severely damaged the hospital’s emergency department and left 19 dead, including one of the hospital’s staff members, and 24 wounded, including 11 staff members.

According to MSF, the hospital had been the only one functioning in the western part of Hajjah governorate, and had been a lifeline to the 300,000 internally displaced people in the region. In the year before the attack, the facility’s 14-bed emergency room had handled more than 12,000 outpatient visits, and hospital staff had helped 1,631 women deliver babies.

Following the attack, the facility was out of service for more than a week. Ten days later, the emergency room, maternity ward, and lab reopened, though attendance remained low.

After the attack generated headlines, the Joint Incidents Assessment Team (JIAT), a body set up by the coalition to investigate potential violations of international humanitarian law committed by their forces in Yemen, opened an investigation into the incident. On December 6, Saudi state media reported that JIAT had concluded that the coalition had targeted a vehicle it considered to be a “legitimate military target” and that the damage to the hospital building was unintentional.

Key findings of the JIAT investigation, as reported by the media, directly contradict MSF’s account and visual documentation of the attack, and raise concerns about the investigation’s thoroughness. For example:

  • JIAT claimed that the building “had no signs of being a hospital before the bombing,” whereas MSF said that it had repeatedly provided the coalition with GPS coordinates of the facility, including on August 10, five days before the incident. MSF’s internal investigation’s report also included photos that show the MSF logo clearly painted on two roofs, which also appeared in videos posted by local media soon after the attack that Human Rights Watch reviewed; and
  • JIAT concluded that seven people were killed in the attack; MSF put the number at 19 and video footage and photos of the site suggest a higher death toll than seven.

Moreover, the JIAT investigation did not address whether the attack violated international humanitarian law and did not recommend a criminal investigation. It did recommend that the coalition apologize for the error and compensate those affected, and that the incident should be “further investigated” without clarifying by whom.

To Human Rights Watch’s knowledge, the Saudi government has neither provided compensation for those harmed nor offered a public apology.

Raid on Clinic in Tangi Saidan, Wardak Province, Afghanistan, February 17-18, 2016

On the night of February 17 to 18, 2016, soldiers reported to be Afghan Security Forces supported by international troops, raided a medical clinic in Tangi Saidan, Wardak province, west of Kabul. The soldiers reportedly handcuffed staff members and made them lie down on the floor, then searched the 10-bed facility for Taliban fighters.

The soldiers took two patients, one of whom was under 18 years old, and a 15-year-old boy from the clinic and shot them dead outside the clinic’s grounds. The Swedish Committee for Afghanistan, which supports the clinic, reported that local staff had observed at least two soldiers wearing foreign uniforms and speaking a language that sounded like English.

On February 25, NATO told IRIN News that its Joint Casualty Assessment Team had begun “a preliminary probe to determine if the allegations concerning civilian victims are credible.” Since then, NATO has made various statements that its investigation had found “absolutely no evidence to support that allegation,” without specifying which allegation it was referring to, or whether international military forces were present at the raid and claiming not to have access to health workers who witnessed the incident. The Swedish Committee for Afghanistan told IRIN that it had “been in contact with NATO and agreed upon a procedure to take testimony from SCA staff.” NATO has not released any findings or conclusions from its investigation.

Reports published in the week after the raid indicated that the Afghan government opened an investigation into the incident concerning the conduct of its forces, but no findings have been released publicly.

Airstrikes on al-Hamadiya Hospital and the National Hospital in Ma’aret al-Nu’man in Idlib, Syria, February 15, 2016

On February 15, 2016, starting at about 9 a.m., at least four separate airstrikes hit two of the largest hospitals serving the city of Ma’aret al-Nu’man within a period of three hours. The northern city is in an area of Idlib governorate, controlled by Syrian opposition groups.

The humanitarian medical organization Medecins Sans Frontieres (Doctors without Borders, or MSF) reported that two strikes in quick succession hit al-Hamadiya Hospital, destroying the four-story building, killing at least 9 medical personnel and 16 patients and caretakers, and injuring another 11 people. Following the attack, emergency medical personnel began transporting the wounded to the National Hospital, six kilometers north of al-Hamadiya Hospital.

At about 11 a.m., the Syrian American Medical Society (SAMS) and the Idlib Health Directorate reported that the Ma’aret al Nu’man National Hospital had been struck by two munitions. SAMS, which supports the facility, said that the first munition hit about three meters from the hospital. Ten minutes later, another munition fell close to the hospital’s entrance, where the wounded from the al-Hamadiya hospital were being shuttled in. The attack killed at least four people, including two nurses in training, according to SAMS. Hospital administrators told Human Rights Watch that the facility did not receive advance warning of the attacks.

Both facilities were attacked from the air, making it likely that Syrian or Russian air forces were responsible. A detailed analysis by Forensic Architecture suggests that the attack on the first hospital was carried out by the Russian Air Force, and the second by the Syrians. The Russian and Syrian governments immediately denied responsibility. On February 16, President Vladimir Putin’s press secretary, Dmitry Peskov, rejected claims made by MSF, which supported al-Hamadiya Hospital, that either the Russian or Syrian air forces were responsible for the attack on the hospital in Ma’aret al-Nu’man, calling the allegation “unacceptable.”

In a statement to the UN press corps, Bashar Jaafari, the Syrian ambassador to the UN, denied Russian responsibility for the attack and claimed that the Syrian government possessed information that it was the US-led alliance that struck a hospital in Syria on February 15, 2016. The US Air Force spokesperson for Operation Inherent Resolve denied these allegations in a tweet.

The Russian government has not responded to a February 2017 Human Rights Watch letter inquiring whether it had investigated these incidents.

Airstrikes on Trauma Center in Kunduz, Afghanistan, October 3, 2015

On October 3, 2015, the US Air Force carried out an aerial attack on an MSF hospital in Kunduz, Afghanistan. The attack killed 42 people, including 14 MSF staff members, and injured dozens more. MSF’s internal review of the case found that much of the hospital’s vital facilities were destroyed, including the intensive care unit, operating theaters, and emergency room.

The hospital was the province’s most advanced medical facility and was the only one of its kind in northeastern Afghanistan. Before it opened in 2011, severely injured patients had to travel to Kabul or Pakistan for treatment. Since 2011, it had conducted more than 15,000 surgeries and treated patients during more than 68,000 emergency room visits.

The day of the incident, the US government confirmed that its military had carried out the attack and promised to investigate. In November 2015, the US Defense Department released a summary of its investigation, which concluded that the attack was the result of a combination of human errors, equipment failure, and miscommunication. A redacted investigation report was published in April 2016, and found that US forces committed several serious violations, including initiating an attack that was unlawfully disproportionate to the expected military gain, as well as failing to distinguish between combatants and civilians. The report ultimately concluded that the attack did not constitute a war crime because forces had not intentionally targeted the medical facility.

However, the report shows overwhelming evidence of recklessness on the part of US forces, which could amount to the necessary criminal intent for a war crime. For instance, the ground commander had authorized the strikes on the basis of a single source, despite being “9 km from the [facility]” and not having a visual “line of sight.” None of the commanders used “resources available … that would have confirmed” that the attacked location was a medical facility and not the intended target, a grouping of Taliban attackers. Moreover, commanders allowed the air crew to continue shooting at the hospital for an additional eight minutes, even after MSF alerted commanders that they were attacking a hospital.

The US government apologized for the attack and made significant changes to military operating procedures to prevent a similar attack in the future. The investigation identified sixteen servicemembers who were involved in the attack, and twelve were given administrative punishments, according to the Defense Department. One officer was demoted and removed from Afghanistan, the others either received letters of reprimand, were sent to counseling, or went through mandatory retraining. The US government also offered compensation to the families of the victims and approved funds to reconstruct the MSF facility.

None of the servicemembers involved faced criminal charges.

Furthermore, the Afghan government’s investigation into the role of Afghan troops in the incident was never completed. While Afghan forces played a crucial role in supplying the US airship first with GPS coordinates of the original target and later with a physical description of the hospital’s compound, the Afghan government has not reported on whether troops knowingly provided their US allies with a description of the hospital, rather than the intended target. Moreover, Afghan officials have repeatedly claimed the hospital compound was being used by the Taliban for military purposes, stating the day after the attack, for example, that the Taliban had taken control of the compound prior to the airstrike. MSF rejected those claims.

On October 10, 2015, Afghan President Ashraf Ghani said he had appointed investigators to look into the Taliban’s capture of Kunduz and the US airstrike on the hospital. However, the final report did not mention the airstrike.

Attack on Shuhada’ al-Aqsa Hospital in Gaza, July 24, 2014

On July 21, 2014, at about 2:40 p.m., Israeli tanks repeatedly fired on the Shuhada’ al-Aqsa Hospital in Gaza while patients and staff were inside. The attacks reportedly resulted in three or four civilian deaths and injured about 40 people, including medical staff and patients. The surgical and intensive care units, as well as two ambulances, were damaged, Palestinian human rights organization al-Haq said.

In June 2016, the Israeli Military Advocate General responded to complaints submitted by multiple Israeli and Palestinian human rights groups, saying that the incident was still under review.

An investigation by the UN human rights office found the facility was not given advance warning of the attack.

Established in 2001, Shuhada’ al-Aqsa Hospital was the only major hospital in the central district of the Gaza Strip, which had a population of about 260,000. In 2011, the most recent year for which data are available, the hospital’s emergency department had more than 90,000 patient visits, and its surgical department admitted 4,521 patients.

An Israel Defense Forces spokesperson told the media that initial investigations into the incident found “that a cache of antitank missiles was stored in the immediate vicinity of the Shuhada al-Aqsa Hospital.” However, Israel has not published findings of any additional investigation.

The Military Advocate General has not responded to a February 2017 Human Rights Watch letter seeking more information about its investigation into this incident.

Shelling of Railway Hospital in Liman, Ukraine, June 3, 2014

On June 3, 2014, nine mortar shells hit the Liman City Hospital (known as the “Railway Hospital”) in Liman, seriously damaging the facility’s pharmacy and general therapy, surgery, and gynecology wings. Health workers told Human Rights Watch that the hospital’s only surgeon was hit in the head by a shell fragment and died several days later. The hospital’s chief doctor said that he believed that Ukrainian government forces, which at the time were fighting for control over the area against Russia-backed rebel forces, fired the mortars.

The hospital had 90 beds and was used primarily by railway workers. Approximately 80 patients were inside the facility at the time of the attack, though none were injured.

The Human Rights Watch investigation found that the hospital may have been intentionally targeted, as it suffered far greater damage from shelling than the surrounding area. Moreover, medical personnel said that soldiers from the Ukrainian military arrived at the hospital on June 4, the day after the attack, and asked to be shown through its wards, referring to the hospital as an “insurgent hospital.” Another group of soldiers searched the hospital on June 9.

A day after the attack, the Ukrainian National Guard denied any involvement, saying its forces had not been in Liman that day. The hospital’s chief doctor said that he had promptly filed a complaint with the district prosecutor’s office and had submitted all shell fragments to prosecutors. He said that the prosecutor’s office also recorded his testimony and examined the hospital grounds. The district prosecutor, however, has not published any findings of the investigation – it remains unclear whether a formal investigation was ever opened.

The Ukrainian government has not responded to a February 2017 Human Rights Watch request for information about any possible investigation into the incident.

Raid on Amitié Hospital in Bangui, Central African Republic, December 5, 2013

At 6 a.m. on December 5, 2013, a group of anti-balaka fighters brought several injured people to Hôpital de l’Amitié (Amitié Hospital) in Bangui, the capital of Central African Republic, according to a report by the International Commission of Inquiry on Central African Republic. A few hours later, fighters from the opposing Seleka militia arrived at the hospital and searched for anti-balaka fighters. They took between 8 and 20 young men – the exact number remains in dispute – out of the hospital at gunpoint and shot them.

In an interview with Al Jazeera, former President Michel Djotodia, who was the leader of the Seleka militia at the time of the attack, acknowledged the killings but denied responsibility: “I control my men. The men I can’t control are not my men.”

Amitié Hospital is one of four hospitals in Bangui. After the attack, it was closed until January 2014, when Save the Children helped to reopen it.

Since the country descended into political and communal violence in 2013, the government has struggled to maintain control. The domestic justice system no longer functions, with limited capacity to investigate or prosecute the large numbers of serious crimes the various armed groups have committed. The killings of patients at Amitié Hospital have not been investigated.

Since September 2014, the office of the prosecutor of the ICC has been investigating the situation in the Central African Republic, focusing on alleged crimes in the country since August 2012, the second investigation by the court into crimes committed in the country.

In June 2015, the country’s then-transitional president promulgated a law to establish a Special Criminal Court, consisting of national and international staff, to investigate the gravest crimes committed in the country since 2003, including war crimes and crimes against humanity. In February 2017, a prosecutor was named to the court. It remains unclear whether the Special Criminal Court will investigate the raid on Amitié Hospital and other attacks on health facilities in the country.

Posted: January 1, 1970, 12:00 am

The fight against global toxic pollution has reached a critical milestone: the 50th country has ratified the United Nations Minamata Convention on Mercury, triggering its entry into force in August.

A 12-year-old boy shows the mercury he carries in his trousers’ pockets for gold processing in Homase, Amansie Central district, Ashanti Region, Ghana.

© 2014 Juliane Kippenberg/Human Rights Watch

Mercury is a shiny liquid metal whose largest use globally is small-scale gold mining; other areas of use include manufacturing and industrial processes. But mercury is toxic. It attacks the nervous system, can result in life-long disability, and is very harmful to children. In higher doses, it can kill.

I have seen with my own eyes how children in Ghana, the Philippines, Tanzania, and Mali have been exposed to this toxic substance. Twelve-year-old “Kwame” in Ghana showed me a small bottle of mercury he always carried with him. He mixed mercury into the ore to create a gold-mercury amalgam, and then burnt this over a fire at home to retrieve the raw gold, breathing in its toxic fumes.

The Minamata Convention brings hope for people like Kwame. It obliges governments that ratify the convention to promote mercury-free gold processing methods; take special measures to protect children from exposure; improve health care; and put an end to particularly harmful practices in gold processing, including the burning of themercury-gold amalgam in residential areas. It also provides controls in many other areas, such as mercury use in products and manufacturing processes, and unintentional emissions stemming from coal-fired power plants.

Ghana has already ratified the convention, as have other important gold mining countries such as Peru, Ecuador, Mali, and Burkina Faso, as well as donors such as the United States and Japan. On May 18, the European Union and seven member states ratified the convention, bringing the total number of ratifications over 50, the number of ratifications required for the treaty’s entry into force.

The convention is named after the Japanese fishing town of Minamata, where mercury was discharged into the bay by a large chemical company from 1932 until 1968. Japan has recognized that more than 2,955 suffered mercury poisoning as a result, but subsequently compensated about 60,000 people. The real number of victims is thought to be even higher.

It is great news for Kwame and millions of others that the Minamata Convention is about to enter into force. Now comes the hardest part: Governments need to put it into practice. 

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

A family from Afghanistan pushes their older mother in a wheelchair near Roszke, Hungary after crossing the border with Serbia. September 13, 2015.

© 2015 Zalmaï for Human Rights Watch
 

(Athens) – Unnecessary delays and arbitrary barriers are keeping older refugees and asylum seekers stranded in Greece, unable to reunite with family members who have legal status in the European Union, Human Rights Watch said today.

Family reunification often focuses on minors and their parents. But hundreds of older refugees and asylum seekers currently in Greece who have fled war zones and persecution are waiting to learn if they will be allowed to reunite with adult family members who have been granted residency in another EU country. Although EU law provides for family reunification for older people, lack of clarity or explicit provisions governing the process means that they can remain in limbo, far from their family for prolonged periods of time.

“These older people, already victims of conflict and persecution, hoped to find protection in the EU after treacherous journeys to Greece, and to be reunited with their family,” said Bethany Brown, researcher on older people’s rights at Human Rights Watch. “Now they don’t know if they will ever see their relatives again.”

Under international human rights law, everyone has a right to family life. For refugees, asylum seekers, and migrants, the possibility of family reunification is an aspect of that right, but barriers, including lack of information and clarity around eligibility for reunification, is causing anguish amongst older people, Human Rights Watch found.

A refugee squat in an abandoned factory on Lesbos, Greece, where dozens of asylum seekers are living in fear of being forcibly returned to Turkey under the EU-Turkey deal. 

© 2017 Arash Hampay for Human Rights Watch

In December 2016, Human Rights Watch interviewed 13 older refugees and asylum seekers in four camps and one refugee squat around Athens. Nearly all said they were seeking to be reunited with family in other parts of Europe. Human Rights Watch found, however, that these people often face seemingly insurmountable legal and practical barriers to reuniting with their families. Almost all had been waiting in Greece for more than eight months. The barriers included: a narrow interpretation of family under national laws, misinformation, and confusion about the process.

While several barriers are common to all asylum seekers, they can have a more significant impact on older people. Older people have been shown, in some contexts, to have significantly higher rates of psychological distress than the general refugee population, and often suffer from health issues, injuries and violence during displacement, and frailty that can be exacerbated by time and uncertainty. One asylum seeker interviewed in December 2016 passed away before officials reached a decision on whether she could reunite with her children in Germany.

Barriers include lack of information about family reunification procedures for older people. Many of those interviewed said they had no idea about the status of their application or how to obtain information about it. In some cases, Greek Asylum Service officials who met with them had told them not to apply for reunification.

An older woman sits outside caravans in a camp for asylum seekers, near Athens, Greece.

© 2016 Human Rights Watch

“Giselle,” a 63-year-old woman from Syria, told Human Rights Watch in December 2016: “I feel pain everywhere: in my head, in my stomach.... I wish to be established, to have the daughters of my sons around me.” She had been with her husband in a camp outside Athens since March 2016. “My granddaughter [in Germany] says ‘I want to break the phone to get through to you.’”

Greek authorities and other actors providing information to asylum seekers, including the United Nations High Commissioner for Refugees, and the International Organization on Migration, should inform anyone requesting asylum of their rights under the Dublin III regulation, the primary EU legal instrument establishing criteria and mechanisms for determining the member state responsible for examining an application for international protection. The information to be provided should explicitly include information about family reunification. Human Rights Watch and other organizations have documented serious gaps in access to information and legal assistance, particularly on the Greek Aegean islands, the main entry point to Greece for migrants and asylum seekers.

Human Rights Watch found an alarming lack of available data on older refugees. Despite repeated requests to the Greek Asylum Service, it has not provided data it says it has on the number of older refugees in Greece; the number of reunification requests; or the average length of time such procedures are taking.

In the short term, recognition and support for a relatively small caseload of older people stranded in Greece seeking to reunite with adult children and grandchildren would relieve suffering, Human Rights Watch said. In the longer term, better systems to address family reunification are urgently needed.

The Greek Asylum Service should identify and provide accurate and timely information to older refugees and asylum seekers on how they can reunite with family members. EU member states should ensure that procedures for family reunification are accessible and efficient for all eligible family members, as outlined by international law.

World Report 2017: European Union

World Report 2017: European Union

Faced with significant strategic challenges, EU governments and institutions responded in 2016 in ways that often undercut or set aside core values and rights protections rather than working consistently together to defend them. 

A number of organizations working for refugees in Greece, including the UN High Commissioner for Refugees, have called for the protection of the right to family and speedy reunification by EU member states. They have criticized EU and national laws for defining “family” to mean only spouses and minor children (under 18 years old).

In an Action Plan published in December 2016, the European Commission recommended tougher measures aimed at increasing the number of returns of those stranded on the Greek Islands to Turkey, under a deeply flawed EU deal signed with Turkey in March 2016. One of these measures ended exemptions for vulnerable groups – which include older people – and people eligible for family reunification. The exemptions were aimed at protecting them from return to Turkey under this agreement. The measures in this Action Plan could have a serious impact on older people’s rights and well-being, Human Rights Watch said.

“Older refugees and asylum seekers should be able to enjoy family life,” Brown said. “The delays and barriers for older asylum seekers undermine the well-being and integration of communities across Europe.”

Accounts by Older Asylum Seekers

Older refugees and asylum seekers in Greece have been forced to leave their homes, their family lives shattered by war. Many spoke of the desperation they felt to reestablish their family relationships after losing everything else.

“Nesrin” is an older Syrian-Kurdish woman who was living in an outdoor camp with her daughter outside Athens when Human Rights Watch interviewed her in December 2016. She and her daughter are unclear about where Nesrin’s application to be reunited with her sons in Germany stands. Nesrin said she did not know her age but has tattoos on her face that she said her mother gave her when she was a baby “to make me beautiful.” This tradition was common until 50 years ago, according to historians. She told us she has slipped discs in her back, and walked with difficulty.

As she talked about her adult children, scattered around Germany, a Greek island, and Iraq, she started to cry and could not continue to speak. Her daughter said: “She is sick, and has been left here. They [officials] said that she can see her sons [in Germany], and then ‘No.’”

Nesrin added: “All of my bones are in pain. I want to die, I really want to die. [But before I do,] I just want to see my sons.”

“Adnan,” 59, an asylum seeker from Syria, has an adult son, daughter-in-law, and two granddaughters in Germany. He has an adult son and daughter-in-law with him in Greece, where he arrived in March 2016. Adnan has applied to join them in Germany, but is unsure about what process they used. He expressed his anxiety about being separated from his family, highlighting the way his family lived together in Syria and what he stood to lose.

At the time of our interview, in December 2016, he lived in a camp just outside Athens. He said:

We came all this way as a family; we fled Syria as a family. [When my son and I were separated into different households with different files during registration here in Greece,] we said, ‘This is not human....’ I begged. ‘You cannot separate us into two families.’ I went to another interview and told them the same. That guy [Greek official] said that my son should give my case number, and maybe we can be together.... We are one family. Why would they want to separate us? Every one of us must serve the other. We have learned to live together. In Europe, everyone is on his own.

“Gisele,” 63, whose young granddaughters live in Germany, said that when it came time for her interview with the Greek authorities, “I told them my children are in Germany, and that I raised my granddaughters who are now there, and I wish to go to them.” She was living in a camp outside Athens when Human Rights Watch interviewed her in December 2016. She said that the officials told her that they could not promise that she will be reunited with them. She told us that when her granddaughter [in Germany] talks with her on the phone, her granddaughter says: ‘I want to break the phone to get through to you!’ Gisele had not seen her sons, her daughters-in law, or her granddaughters for over a year.

“Mussa,” 60, was born in Afghanistan. At the time of our interview in December 2016, he lived in a tent camp outside Athens. He told Human Rights Watch he has three adult children in Germany. He lives with his wife, a son, 18, and a daughter, 19, who has a disability. Mussa told Human Rights Watch that he fled the Mujahedeen in Afghanistan in the 1980s and went to Iran, only to be later threatened by a government official. He spoke quietly and intensely about his family’s journey and his anxiety over separation from his 18-year-old son:

We left [Iran] because I have a daughter who was engaged to marry.… [H]er fiancé became important in his government ministry. He was coming every day with a cool car from the ministry, asking her for a walk. He stopped her from going to school. She was unhappy. So, I called the father of that man, and sought to cancel the engagement. I paid everything. He broke the legs of my two sons. In the end, he was a politician and I had a normal life, [so we had no choice but to] sell the house and car, and flee.

Here in Greece, I have not told anyone this story. We were on a [Greek] island for six months, and we have been here [in the camp] for three or four months. Our first interview [with the Asylum Service] will be in one month. We applied for family reunification, but we are worried about our son because he is 18. They [officials] told our daughter that she could stay [with us] because of her special needs, but they didn’t say that about our son. We can’t leave behind our 18-year-old boy. [I know of] another family with such a case.

Right to Family Life

The right to family in international law is enshrined in the Universal Declaration of Human Rights (Article 16 (3)), and key human rights treaties including the International Covenant on Economic, Social and Cultural Rights (Article 10 (1)), the International Covenant on Civil and Political Rights (Article 23 (1)), the Charter of Fundamental Rights of the European Union, (Article 33 (1)), and the European Convention on Human Rights (article 8). Under international law the definition of “family” is not restricted only to spouses and minor children. The European Court of Human Rights refers to social, emotional, and biological factors when assessing whether a relationship should be considered part of “family life.”

Older people have the right to have their applications reviewed within a reasonable timeframe that considers their specific needs. They are recognized as a vulnerable group under EU law, and are entitled to appropriate support commensurate with that status, including information about how to apply for family reunification. Greece has incorporated EU minimum standards for the reception of asylum seekers into its domestic law, which include requirements to support vulnerable people, including those who are older.

The EU law that determines asylum processing, known as the Dublin regulation, says that in accordance with EU human rights law, “respect for family life should be a primary consideration for Member States when applying this Regulation.” It also states that “in order to ensure full respect for the principle of family unity and for the best interests of the child, the existence of a relationship of dependency between an applicant and his or her child, sibling or parent on account of the applicant’s pregnancy or maternity, state of health or old age, should become a binding responsibility criterion.”

However, the definition of “family member” in the Dublin regulation is limited to spouses, or partners and minor children, while the definition of “relative” refers explicitly only to aunts, uncles, and grandparents of adults. Parents of adults are not listed in this definition. This omission leaves an important gap in the protection of older people’s rights.

The Dublin regulation explicitly states that older asylum seekers in Europe who depend on the support of a family member in another part of Europe should be kept or brought together.

Dependency is not defined in the regulation, but developed by each member state’s case law, and it provides the main basis on which older parents in Greece seeking refugee status who may have adult children in other parts of Europe can seek reunification. Dependency on an adult child can entitle them to be kept or brought together. The European Commission encourages member states to use this option “in the most humanitarian way.”

Practical Barriers

EU asylum processes are failing to properly respect or protect the right to family life of older refugees in Greece. Many older refugees and asylum seekers find their lives are on hold as they wait to learn if they will be reunified with family, with little information and great uncertainty. This issue has long been ignored. The refugee crisis in Greece is just the latest place around the world where this reality is unfolding.

As reports about the deteriorating mental health of refugees and asylum seekers still waiting in limbo in Greece are becoming common, many organizations, including the UN High Commissioner for Refugees, have been advocating quicker family reunification.

The European Court of Justice has ruled that family reunification procedures should provide guarantees of flexibility and promptness to ensure the right to family life is respected. Multiple EU states, however, use a narrow definition of family in assessing family reunification requests.

The organization Action Aid, in its recent advocacy on family reunification, criticized such narrow definitions for effectively breaking up “key support networks that are not only important to the asylum seekers themselves, but to the societies in which they will eventually be integrated.”

The UN High Commissioner for Refugees too, has been vocal about European countries’ narrow interpretation of family to include only nuclear members. It has advocated that: “[T]he concept of family should be interpreted flexibly by States, which could reflect strong and continuous social, emotional or economic dependency between family members, though which does not require complete dependence (for example, as in the case of spouses or elderly parents).” For older people, the last surviving family relationships may not be nuclear family members.

But the Greek Asylum Service has said to Human Rights Watch via Twitter that: “Member States reject such requests when not obliged to accept fam[ily] members.” And that it “sends relocation request[s] to MS [Member States] where the family is if [reunification] not applicable under Dublin. Both too slow.” This pace may become even slower. On May 19, 2017, it was reported by the media that the German Interior Ministry is planning to accept only 70 asylum-seeker family members per month.

The Greek Asylum Service’s chief of the Dublin Unit, Isa Papiliou, also acknowledged to Human Rights Watch that asylum seekers have experienced misinformation, legal and administrative blockages, problems obtaining and verifying documentation, and difficulty communicating across borders. She also noted that refugees and asylum seekers “may believe that the procedure via the [EU] embassies may [take less time] … the embassies have a legal basis [to provide] family reunification directive separately from [the] Dublin [regulation].”

Recommendations

  • The EU, its member states, and, in particular, Greece should ensure that the right to family life for older beneficiaries of protection already in the EU is respected, including through family reunification, without onerous conditions or waiting periods;
  • Greece should resist EU pressure to weaken protections for vulnerable asylum seekers – including older people eligible for family reunification – under the EU-Turkey agreement of March 2016;
  • The European Commission should request the Greek government and its partner agencies to provide clear information from grantees about how the programs it funds in Greece benefit older people and other at-risk groups;
  • Greece should reform the intake system for asylum seekers in Greece, by providing information on family reunification and access to legal aid for at-risk groups, including older people;
  • The EU and member states, including Greece, should provide for speedier reunification for older people; and
  • EU member states should increase the use of dependency determinations for older refugees in Europe seeking family reunification.

Methodology

The research is based on interviews Human Rights Watch conducted between December 16 and December 23, 2016, with 13 older refugees and asylum seekers in four camps and one refugee squat around Athens. This relatively small number reflects the difficulty in accessing formal data about numbers and locations of older refugees and asylum seekers, and their decreased visibility within each setting. Human Rights Watch identified most of those interviewed by word-of-mouth. Despite small numbers, there was similarity in their stories around the anxiety and uncertainty of family reunification, creating reason to believe that other older people have had similar experiences.

Each interviewee consented voluntarily to be interviewed. None received remuneration, a personal service, or benefit in return for the interview. Names of the interviewees have been withheld to protect their privacy and security.

Human Rights Watch also interviewed officials from the UN High Commissioner for Refugees and representatives of nine aid organizations and the Greek Asylum Service’s Dublin Unit between November 2016 and April 2017.

Posted: January 1, 1970, 12:00 am

Mukuma Hamad, a volunteer health worker (L), and James Atai, a nurse, sit at a table displaying almost the total stock of basic medicines in the only health clinic in Hadara village, rebel-controlled Southern Kordofan. 

© 2016 Skye Wheeler/Human Rights Watch

When 14-year-old Hassina had still not given birth after more than two days of labor, her family started to worry. She was bleeding and had passed out more than once from exhaustion and pain. The nearest hospital was miles away. Ambulances had not been seen for years in the war-torn Nuba Mountains – the area of Sudan she called home – and nobody in her village owned a car.

Fearing for the mother-to-be and her baby’s life, the family opted for the only means of transport available: a motorcycle. Wedged between the driver and a relative seated behind her to hold her upright, Hassina was taken on a two-hour-drive along bumpy dirt roads to a larger village. There, the men and Hassina waited for a car. By the time Hassina reached the hospital, the baby had died.

Hassina, now 19, lives in rebel-held Southern Kordofan, a region in Sudan that, following the separation of South Sudan in 2011, has become the site of conflict between forces of the Sudanese government and the rebel Sudan People’s Liberation Movement-North (SPLM/A-North). Six years of on-and-off fighting and bombings by Sudanese government planes have led to hunger, widespread displacement, and destruction of schools, health clinics, and homes. The situation has also had a devastating effect on women’s and girls’ health.

A new Human Rights Watch report, “No Control, No Choice,” shows how both warring parties have obstructed humanitarian aid from reaching the region, leaving women living in rebel-held areas with virtually no access to contraceptives, trained health workers, or well-equipped clinics that could provide preventive or emergency health care for women of childbearing age.

As a result, young women like Hassina have little control over the number of children they bear or the spacing of their pregnancies. Instead they rely on local birth attendants, who often lack formal training or, like Hassina’s midwife, have lost their equipment in government attacks. As many local clinics do not even have stethoscopes or kits to measure blood pressure, the young mothers-to-be risk dying in childbirth or losing their newborns.

Most women and girls in the rebel-held Nuba Mountains of Sudan lack access to reproductive health care, including emergency obstetric care. Their plight is one of the little known yet far-reaching effects of years of obstruction of aid to the area by the Sudanese government and armed opposition. 

At 19, Hassina had already lost three.

Like many girls in the region, Hassina got married while still a child. With no end to the conflict in sight, her family had found it increasingly hard to feed her and her siblings and saw marriage as a way out. Although marrying that young can cause harm to a girl in many ways, including early childbearing, nobody talked to Hassina about sex or family planning. The lean, soft-spoken young woman had never seen a condom or heard about contraception.

Wrapped in a pink, flower-embroidered cloth called tobe, her voice a mere whisper, Hassina tells her story– a story of pain, loss, and lack of control over her body and life.  

When pregnant with her first child, the only prenatal care she received consisted of a local midwife touching her belly and telling her she would be fine. With only two hospitals left in the region to serve hundreds of thousands of people, the nearest full prenatal care is at least one full day’s walk away from Hassina’s village, Hadara. At the time, Hassina did not make the long journey for regular check-ups. Hence, she only learned that her cervix was too narrow to give birth vaginally after the emergency caesarean section that saved her life.

Mukuma Hamad, a volunteer health worker, holds a container of folic acid, the only assistance she can give pregnant women who visit the lone health clinic in Hadara village, in rebel-controlled Southern Kordofan. 

© 2016 Skye Wheeler/ Human Rights Watch

Without access to contraception or knowledge about family planning, she soon became pregnant again.

Knowing she might risk losing another baby during childbirth, Hassina did what many Nuba women with a history of birth complications do when close to term. When she was around seven months pregnant, she embarked on the long walk to the hospital, where she knew professional help would be available to deliver the child. For weeks, she camped in the shade of trees near the hospital, waiting for the contractions to start. Again, she had to have a caesarean, but this time the baby was born alive and healthy. Six months later, however, her little boy fell sick and died.

Many children in the region, health workers say, succumb to preventable childhood diseases before they learn to walk. Despite its bustling marketplace, Hadara, where all kinds of smuggled goods from cigarettes to tomato paste are traded, was already poor before the war began. Today, food is in short supply, and so are medicines. The village’s poorly equipped clinic has a patchy stock of antibiotics, deworming medication, and anti-malaria pills, which were dropped off by aid organizations that defy the ban on operating in the region. But vaccination campaigns for newborns have never reached the area. Even United Nations attempts have been stymied by the parties to the conflict.

Devastated, Hassina was well advanced in her third pregnancy, when, in 2015, Sudanese airplanes attacked, dropping bombs on Hadara. Then Sudanese ground troops moved in, torching most of the village, and forcing its inhabitants, including Hassina, to flee.

For weeks, Hassina and her family hid in a dried-up riverbed, while planes bombed the area and no cars were available to get to the hospital. She was still holed up in the riverbed when her labor began. After days of contractions and excruciating pain, the baby’s body cleared the birth canal. Its head, however, got stuck.  

Her fingers fiddling uneasily with the seams of the pink tobe wrapped around her head, Hassina casts her eyes to the ground, recalling those painful hours during which her family searched for transport to get her to the hospital and have the head taken out.

Not once does she raise her voice in anger. Yet, if the Sudanese government and SPLM/A-North allowed humanitarian aid to the area, she and other Nuba women would have a much better chance of protecting their own health and that of their children – and Hassina might after all be able to have a baby that is born alive and survives.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Summary

Four years ago, after 14-year-old Hassina Soulyman spent two days in labor at home, weak from loss of blood and falling in and out of consciousness, her family knew something was terribly wrong. They set her on a motorcycle—the only transport in her village—with two men holding her between them for a two-hour ride to a larger village. There they waited hours for a car to take her to one of only two hospitals in the rebel-held areas of Sudan’s Southern Kordofan state. When they finally got her there, a doctor delivered her stillborn baby by cesarean section and told Hassina that her cervix was too narrow to give birth vaginally.

Without adequate health information or access to contraception, Hassina became pregnant two more times. Her second baby was delivered at the hospital but died before reaching six months. During the last weeks of her third pregnancy, when she was 18, Hassina and her family fled her village to escape aerial bombing by the Sudanese government. She went into labor in the riverbed where her family was sheltering and endured three days of obstructed labor, during which the body of the baby cleared the birth canal but the separated head was stuck in her womb before she could get transport to a hospital for medical assistance. She survived another operation, but as of December 2016, when Human Rights Watch met her, Hassina still did not have access to family planning assistance.

Most women and girls in the rebel-held Nuba Mountains of Sudan lack access to reproductive health care, including emergency obstetric care. Their plight is one of the little known yet far-reaching effects of years of obstruction of aid to the area by the Sudanese government and armed opposition. 

***

Women and girls living in rebel-held areas of the Nuba mountains of Southern Kordofan, Sudan have little or no access to contraception, adequate antenatal care, or emergency obstetric care—leaving them unable to control the number and spacing of their children, and exposing them to serious health complications and sometimes death.

Reduced access to health services is one of the many devastating consequences of six years of armed conflict between Sudanese government forces and the armed wing of the rebel Sudan People’s Liberation Movement/Army-North (SPLM/A-North), a spin-off of the former southern Sudanese liberation movement and now ruling party of independent South Sudan.

Healthcare access was low in the four areas currently under the control of rebels– and worse than in other parts of Sudan because of marginalization by Sudan’s government and earlier conflicts— even before the current war began in 2011. The poor humanitarian situation there cannot be entirely blamed on the conflict. However, unlawful government bombardment, destruction of clinics including by bombing, poor distribution of medicines, and hard-to-cross frontlines have all further reduced access.

Expand

Share

A United Nations-led humanitarian aid effort to improve the humanitarian situation has not been put in place. Both parties to the conflict have failed to agree on a joint modality for a sustained humanitarian effort, despite 15 rounds of African Union-moderated talks over six years, and many proposals and other efforts by UN officials and diplomats. Hundreds of thousands of people live in the rebel-controlled areas without the health services, food aid, and other basic assistance that a full UN-coordinated humanitarian response would attempt to provide. Humanitarian aid workers in the area are concerned that civilians in some areas may now be facing the worst food shortages since 2011 and 2012, when food shortages contributed to massive displacement and people reportedly died of hunger.

In December 2016, two Human Rights Watch researchers interviewed 90 people in rebel-held areas of Heiban, Delami and Um Dorein counties, including 25 in-depth interviews with women and girls about their access to reproductive healthcare. Researchers also spoke with witnesses and victims of abuse, local rebel authorities, and humanitarian aid workers. This research builds on findings from five earlier Human Rights Watch investigations in the Nuba Mountains region, hilly areas of Sudan’s Kordofan area where communities from different Nuba tribes live, between 2011 and 2015.

While civilians living in Southern Kordofan, especially in the rebel-held areas, face a myriad of human rights abuses, this report focuses on limited access for women and girls to sexual and reproductive healthcare in the hope that highlighting this will draw the attention of the Sudanese government, SPLM/A-North, and the international community to this particularly neglected aspect of humanitarian needs in the area. The report also describes how many years of negotiations and various efforts by diplomats, the African Union (AU) and the UN have all failed to provide humanitarians with unfettered access to communities in the rebel-held areas.

When the conflict began in June 2011, Sudan’s government banned international aid workers, including from UN agencies and international non-governmental organizations, from traveling to rebel-held areas of Southern Kordofan.  This travel ban remained in place as, year after year, the two parties failed to agree on arrangements for humanitarian access or implement agreements. Restrictive national regulations for humanitarian groups, closures of NGOs, and expulsions of staff from Khartoum, including senior UN staff, created a climate in which humanitarian groups chose not to push hard for access (in rebel-held areas of Southern Kordofan). These restrictions meant that few international aid workers were allowed to work even in government-held areas of Southern Kordofan, and their activities were limited. Sudan’s government has also consistently forbidden aid workers to cross international borders into rebel-held Sudan from neighboring South Sudan or Ethiopia.

The SPLM/A-North have— despite these restrictions—encouraged and allowed aid workers to cross these borders into areas they control to deliver assistance. These programs, unauthorized by the Sudanese government, offer life-saving medical care and humanitarian assistance to civilians, but they only reach part of the population and their supplies are limited. Recently, the SPLM/A-North have asked for further negotiations rather than accepting a late-2016 offer from the United States government to deliver medical assistance from government-controlled areas within Sudan. The rebels have continued to insist that they will only accept a proposal that allows for at least some cross-border aid, both so they can safely transport wounded fighters to medical assistance in neighboring countries, and because they have little trust that Khartoum will not interfere with any flow of assistance originating from within Sudan, as the government has in the past. Human Rights Watch found that civilians living in the rebel areas, many of whom have lived through two wars and faced terrible violations by government forces, also do not trust the Sudanese government not to interfere in delivery of aid.

According to the World Health Organization (WHO), Sudan’s maternal mortality rate has fallen from 744 per 100,000 live births in 1990 to 311 in 2015. However, women and girls in conflict-affected areas like rebel-held Southern Kordofan do not have access to the key government health services, supported by donor money, that have contributed to this decline. No recent data on maternal mortality is available for the region, but a joint research effort by the UN and the Sudanese government in 2006 put Southern Kordofan’s maternal mortality rate at 503 per 100,000 live births, compared to 91 per 100,000 births in Northern state and 213 in Southern Kordofan’s neighboring Northern Kordofan state.

In rebel-held Nuba areas of Heiban, Delami and Um Dorein, antenatal care from skilled and equipped health workers is available at two hospitals and their outreach clinics, both operating without government authorization. However, many women and girls live too far away to access emergency care or live on the other side of frontlines of the conflict, making it too hazardous to travel to the facilities. Most pregnant women must rely on local birth attendants who have no formal training, or trained midwives who have not been able to acquire new or sterile equipment since the conflict began. Women and girls experiencing complications during labor may have to travel for days, often on dangerous routes, including across frontlines, to get emergency obstetric care.

Family planning is not available except in rare instances. The rebel SPLM/A-North administration provides the bulk of health care through a network of some 175 clinics, but these do not distribute contraception, including condoms. One agency provides three-month injectable contraception but restrictions imposed on them by the local rebels require patients’ husbands to give permission before they can provide the contraception to women.

Most of the women we interviewed did not know what a condom was and had not heard about other options for contraception. NGO workers, health workers and authorities told Human Rights Watch that condoms are rarely available in markets despite an increase in gonorrhea and syphilis cases over the past two years and high percentages of pregnant women testing positive for hepatitis B. Women and girls are unable to protect themselves from sexually transmitted infections or control their fertility.

In January 2017, the United States government, through a presidential order, lifted its economic sanctions on Sudan, citing the government’s cooperation on counterterrorism, its role in addressing regional conflicts, reduced fighting in the conflict zones, and an easing of restrictions on humanitarian access. US policy makers are due to report on Sudan’s continued performance in these respects in July 2017, and to decide whether to make the sanctions suspension permanent. Human Rights Watch has urged US policy makers to adopt a clear set of human rights benchmarks in this assessment. These should include respect for international humanitarian law, and in particular an end to indiscriminate bombing; demonstrable and tangible improvements to humanitarian access in conflict zones; releasing individuals arbitrarily detained without charge by the National Intelligence and Security Services; ending use of lethal force to suppress protests; and reforms to key legislation.

Human Rights Watch urges the US to postpone its evaluation of Sudan’s progress from July 2017 to a later date, as meaningful progress will take longer than the six months prescribed in the executive order. Also, more time is needed to assess Sudan’s commitment to making broader human rights improvements.

Since the government declared a unilateral ceasefire in June 2016, large-scale fighting has not been reported in Southern Kordofan, but shelling has been reported in some of Sudan’s conflict zones. In 2017, aerial bombardment, which has marked much of the conflicts in Southern Kordofan, Blue Nile state and the Darfur region, appears to have been paused, or at least greatly reduced. This year Sudan has allowed humanitarian agencies to conduct an assessment and deliver some aid in a previously inaccessible part of government-held Darfur, and allowed more UN staff in the government-held areas of Southern Kordofan and Blue Nile. Humanitarian organizations have welcomed improvements but government travel restrictions remain, especially in conflict-affected areas like Southern Kordofan.

Unimpeded humanitarian aid across all conflict areas is critical. Unless the Sudanese government, the SPLM/A-North, and the international community act to ensure humanitarian aid reaches rebel-held areas, the ability of hundreds of thousands of civilians to secure food and access healthcare—including comprehensive reproductive healthcare—may continue to deteriorate.

Even with limited available resources, all governments have obligations to provide access to essential medicines as defined by WHO, and to make reproductive and maternal healthcare available and accessible.

Obstructing the delivery of desperately-needed healthcare by impartial humanitarian aid groups in rebel-held areas, as the Sudanese government has done in the past, is a violation of Sudan’s obligations under international humanitarian law, a violation of the right to health, and discriminates against the Nuba people who are the population directly impacted. The SPLM/A-North also has violated its obligations as a party to the conflict by arbitrarily refusing to accept international aid to be delivered impartially from within Sudan.

The policies and actions of authorities on both sides— Sudan’s government and the SPLM/A-North – in preventing the delivery of life saving humanitarian assistance to communities in need, should be investigated by the UN's Independent Expert on Sudan and other special rapporteurs, including experts on the right to health and the rights of internally displaced persons, to determine whether they constitute prosecutable offenses of war crimes or crimes against humanity. In conducting such investigation, consideration should be given to the context in which the actions to obstruct humanitarian assistance have taken place, such as the Sudanese government’s aerial bombardment of populated areas, in order to determine the potential scope of crimes that may have been committed.

The UN Security Council should impose individual sanctions against commanders or leaders determined to be responsible for clear obstruction of aid or any serious violations of international humanitarian law and human rights law in Southern Kordofan and Blue Nile, and it should extend the arms embargo that currently exists on Darfur to Southern Kordofan and Blue Nile states. It should authorize a panel of experts to continue to monitor the situation in both areas. Currently, the Security Council maintains a sanctions regime on Sudan, which only covers violations that occur in Darfur.

Sudan should allow the UN and other international agencies to operate unobstructed in conflict areas, including Southern Kordofan and Blue Nile states. The SPLM/A-North should agree to access by impartial aid providers, and not withhold agreement for delivery of humanitarian assistance arbitrarily.

International law protects women’s right to healthcare, including access to family planning services.  Along with provision of food and other essential health services, humanitarian programming in rebel-held Southern Kordofan should include improving women’s access to reproductive health services that allows them to exercise autonomy and control over their bodies and lives.

Recommendations

To the Government of Sudan

  • Immediately stop all indiscriminate attacks on civilians and civilian objects, including the use of unguided fragmentation bombs and cluster bombs.
  • Immediately pledge to cease use of cluster munitions, in line with the international ban on cluster munitions.
  • In accordance with obligations under international law, urgently facilitate unimpeded access by UN agencies and national and international humanitarian aid groups to deliver impartial assistance, including sexual and reproductive healthcare, to civilians in need in all parts of Sudan, including areas under rebel control; expedite entry visas and travel authorization for humanitarian aid organizations and workers, and fully cooperate with such organizations.
  • Cancel arbitrary regulations on the operations of national and international nongovernmental organizations that place unnecessary obstacles and constraints on humanitarian assistance, and stop all bureaucratic and other obstruction of such operations. 
  • Agree on modalities for impartial humanitarian aid to be delivered into rebel-held parts of Southern Kordofan and Blue Nile states, both cross-line and cross-border. Allow international monitoring of the aid delivery. 
  • Investigate, charge and prosecute commanders responsible for unlawful attacks on civilians and civilian objects, including schools, hospitals and places of worship;
  • Invite investigators from the African Union and the United Nations and their respective human rights bodies, and allow them to carry out impartial investigations into human rights abuses in Sudan, including in Southern Kordofan, by both parties to the conflict.
  • Ratify and implement the UN Convention on the Elimination of All Discrimination Against Women and the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (the Maputo protocol).

To the Sudan People’s Liberation Army-North

  • In accordance with obligations under international law, urgently facilitate unimpeded access by UN agencies and national and international humanitarian aid groups to deliver impartial assistance, including sexual and reproductive healthcare, to civilians in need in all parts of areas under SPLA-North control; allow international monitoring, expedite travel authorization for all humanitarian aid organizations and workers, and fully cooperate with such organizations.
  • Working with international humanitarian partners, provide, in all clinics, comprehensive sexual and reproductive healthcare, including information about family planning and sexually transmitted infections, as well as contraception methods that protect against HIV/AIDS and other sexually transmitted infections.
  • Cancel any local regulations, whether formal or informal, requiring women to obtain permission from their husbands to access contraception, make a public announcement of the change, and conduct information campaigns about family planning.
  • Conduct public awareness campaigns about family planning, female genital mutilation, child marriage, and maternal mortality.
  • Promote and ensure participation of women in peace talks and in senior positions in the civilian administration of rebel-held areas.
  • Adopt strategies to end child marriage and female genital mutilation and ensure perpetrators of domestic violence are punished within the law.
  • Publicly commit to respect the Convention on the Elimination of All Discrimination Against Women and the Maputo protocol.

To Humanitarian Organizations and Donors, including the European Union, the United States, the United Kingdom and Norway

  • Advocate with parties of the conflict and the United Nations Security Council to ensure that civilians affected by conflict in Sudan, including those living in rebel-held areas, can access humanitarian aid services that meet international standards and press for access to these areas with both parties.
  • Conduct a full, independent humanitarian needs assessment once access to rebel-held Southern Kordofan and Blue Nile is possible, and address the urgent sexual and reproductive healthcare needs of women and girls.
  • Ensure that all health services provided in the rebel-held areas adequately address the sexual and reproductive health needs of women and girls.

To the United Nations Security Council

  • Demand that the parties to the conflict ensure safe and unhindered access for impartial humanitarian aid to rebel-held areas of Southern Kordofan and Blue Nile states, across both conflict lines and borders.  Follow through with additional measures under Article 41 of the UN Charter, in the case of non-compliance, as outlined in Security Council resolution 2046.
  • Impose targeted sanctions such as asset freezes and travel bans against Sudanese government and SPLM/A-North or SPLA-North officials deemed to be responsible for serious crimes, including indiscriminate bombing and other violations, and for willful obstruction of impartial humanitarian assistance to Southern Kordofan and Blue Nile states in violation of international law;
  • In view of the significant evidence of serious violations of international humanitarian law against civilians by the Sudanese armed forces since 2011, expand the existing arms embargo on Darfur to apply to Southern Kordofan and Blue Nile.
  • Authorize an independent inquiry into serious breaches of the laws of war by both sides in Southern Kordofan and Blue Nile.

To the Independent Expert on Sudan

  • Travel to rebel-held areas of Southern Kordofan and Blue Nile states to monitor limitations on women's right to health. If access is not possible due to obstruction by the government of Sudan or the SPLM/A-N, conduct interviews in refugee camps in South Sudan and Ethiopia to collect this information.
  • Include a review of women's health in next report.

To the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health

  • Travel to rebel-held areas of Southern Kordofan and Blue Nile states to monitor limitations on women's right to health. If access is not possible due to obstruction by the government of Sudan or the SPLM/A-N, conduct interviews in refugee camps in South Sudan to collect this information.

To the United States Government

  • Monitor progress made by the Sudanese government against a concrete set of human rights benchmarks to evaluate its eligibility for continued sanctions relief. Key among these benchmarks is whether Sudan allows unimpeded access by humanitarian aid groups to all conflict affected areas, including rebel-held Southern Kordofan and Blue Nile. Include access to maternal health care and family planning as a key indicator of access to humanitarian assistance;
  • Delay formal evaluation of Sudan regarding the US sanctions to allow sufficient time for real progress to occur. The US should also re-evaluate the sanctions regime with an eye to imposing “smart” sanctions and designate new individuals against whom there is credible evidence, for targeted sanctions.

Methodology

This report is based on an 11-day fact-finding mission to Sudan and South Sudan in December 2016. Two Human Rights Watch researchers visited villages and displaced communities in Heiban, Delami, Buram and Um Dorein counties in Sudan’s SPLM/A-North controlled areas of Southern Kordofan, as well as the Yida refugee camp in Unity state, South Sudan. Through interviews with local communities, humanitarian aid workers, and authorities, as well as site visits, Human Rights Watch assessed the impact of Sudan’s humanitarian blockade on the civilian population, and documented other human rights violations committed during the armed conflict, including the impact of the conflict on women’s reproductive rights.

Human Rights Watch interviewed more than 90 people in Southern Kordofan and South Sudan, including displaced people, refugees, victims, witnesses, local authorities, and humanitarian and health workers. We interviewed 25 women to understand obstacles to reproductive healthcare and the other human rights challenges confronting women. All but one of the women interviewed had children or had given birth, and most had done so recently. We interviewed 25 humanitarian aid workers and civil society members, including ten doctors and other health workers. Human Rights Watch also spoke to five people of authority in SPLM/A-N. Interviews were conducted mainly in English or in Arabic (and in once case in the local Turo Nuba language), through translators. Human Rights Watch researchers conducted most interviews individually, but sometimes, because of the preference of the interviewee or with their permission, in groups. Interviews took place in towns, villages, settlements, and in the Yida refugee camp.

We informed all interviewees of the purpose of the interview, its voluntary nature, and the ways in which data would be collected and used. We have withheld the names and other identifying information of some of those interviewed, and in some cases replaced them with pseudonyms due to their preference for anonymity. Interviewees were also told that they could end the interview at any time, and choose to answer only the questions they wanted to.

Human Rights Watch was unable to access many SPLM/A-North controlled areas that are harder-to-reach or lie across frontlines. Access to healthcare is, by all accounts, far worse in these other areas.

While civilians living in Southern Kordofan, especially in the rebel-held areas, face a myriad of human rights abuses, this report focuses on sexual and reproductive healthcare in the hope that highlighting this will draw attention of the Sudanese government and the international community to this particularly neglected aspect of the humanitarian needs in the area.

Human Rights Watch was unable to verify allegations of human rights and international humanitarian law violations by the SPLM/A-North in areas controlled by the Sudanese government, due to lack of access.

I. Background

The Protracted Conflict in Southern Kordofan

Civilians in rebel-held Southern Kordofan, estimated to be one million people, have spent most of their lives in conflict.[1] Much of Southern Kordofan is the “Nuba Mountains,” areas characterized by rocky hills where dozens of Nuba tribes live. In 1985, Nuba fighters began supporting the mostly southern Sudanese rebel movement, the Sudan People’s Liberation Movement/Army (SPLM/A), in its long war against the government of Sudan. The conflict was characterized by ethnic cleansing of the Nuba; abusive ground attacks; forced relocation from ancestral lands; widespread arrests, detentions and killings of Nuba individuals; and aerial bombardment.[2] A 2002 ceasefire, followed by the 2005 Comprehensive Peace Agreement between the SPLM and the government of Sudan, brought civilians a temporary respite.[3]

On June 5, 2011, Sudanese government forces and Nuba SPLA forces clashed again in Southern Kordofan’s capital, Kadugli.[4] The fighting followed escalating tensions over security arrangements in the state and the narrow re-election of the governor, Ahmed Haroun, wanted by the International Criminal Court (ICC) for serious crimes in Darfur.[5] The Sudanese government resumed aerial bombardment on populated rebel-held areas within days.

South Sudan officially seceded from Sudan in July 2011. The South’s independence did not address the desire for meaningful political change in the Nuba Mountains and neighboring Blue Nile state. The SPLA forces based there renamed themselves SPLM/A-North.[6] Fighting between the SPLM/A-North and Sudanese government forces spread to Blue Nile state in September 2011.  During the first year of the renewed conflict, scores of SPLM/A-North members and perceived sympathizers were arrested and detained.[7] 

The “new” war, now almost six years old, has had a devastating impact on civilians. Those living in rebel-held areas have been subjected to heavy bombing from planes and jets, and shelling, including on populated areas by the Sudanese government. These attacks killed at least 292 civilians and injured 749 between June 2011 and November 2016 in Southern Kordofan and Blue Nile states.[8] Civilians repeatedly described to Human Rights Watch researchers the intense terror and distress they experienced as a result of the bombardment. In December 2016, Diana Angelo, an aunt to six children killed in a bombing incident on May 1, 2016, described what she witnessed that day after the children, on hearing the sound of the planes, jumped into one of the large foxholes or ditches dotted all over villages and towns for people to crouch in during bombings:

One of the bombs fell straight into the foxhole and threw the boys outside and cut them to pieces. We found one of their heads past the fence, and the others were burned beyond recognition. There were pieces of brain, lungs and intestine everywhere. When I got there, the wife of Abdurahman (the mother of the children) kept on shouting: ‘Where are the children? Where are the children?’ She was injured too by the debris and had to be taken to the hospital. Abdurahman wanted to kill himself after the attack.[9]

Nearly 250,000 people have fled both states to refugee camps in South Sudan between June 2011 and November 2016, including about 100,000 from Nuba.[10] While some information about deaths, injuries and displacement is available, there is little detailed information about the effects on education, health, and livelihoods for those who have remained.

The African Union High-level Implementation Panel (AUHIP), a body created to deal with African Union (AU) recommendations on Darfur, as well as implementation of the 2005 Comprehensive Peace Agreement as the South’s secession approached, initiated negotiations between the government of Sudan and the SPLM/A-North a few weeks after the start of the conflict. The AUHIP drafted a framework agreement for political partnership and security arrangements, signed by both sides in August 2011, but later rejected by President Omar Hassan al Bashir. In November 2011, the SPLM/A-North joined two other Sudanese rebel groups and agreed to a unified political and military approach to regime change under the Sudan Revolutionary Front umbrella. This complicated the peace negotiations considerably, as did poor relations between Sudan and South Sudan, especially during and immediately following a short 2012 border war at the Heglig oil fields, and the civil war in South Sudan that began in December 2013.[11]

Fifteen sets of talks between the government and the SPLM/A-North in Addis Ababa, Ethiopia, have failed to produce a permanent, joint cessation of hostilities (both sides have issued temporary unilateral ceasefires), unfettered access for humanitarian agencies, or a hint of lasting peace.[12] UN Security Council resolution 2046 of May 2012, following the border violence, stated that both parties in Southern Kordofan and Blue Nile should allow unhindered humanitarian access or face punitive measures; but both sides have ignored the resolution and the Security Council has not taken any further action.[13] Diplomats from the US, the European Union, Germany, the United Kingdom, and Norway, as well as AU officials, have supported the peace process and urged both sides to end fighting and allow for unhindered delivery of humanitarian assistance.

 The government signed the AUHIP’s ‘roadmap for peace’ on March 16, 2016, promising to urgently resume negotiation on humanitarian access, and a cessation of hostilities, followed by a permanent ceasefire; however, the SPLM/A-North refused to sign until August.[14] Within days of their unilateral signing of the roadmap, the government launched several large-scale land offensives, preceded by aerial bombing and shelling, to capture important SPLM/A-North controlled agricultural areas, Al-Mardes in Delami county, Al-Azraq in Heiban county and Karkaraya in Um Dorein.[15] Two of those areas were successfully captured by government forces, but Karkaraya was later reclaimed by the rebels. When these areas were under their effective control, government forces and allied militias killed civilians and destroyed civilian property.[16] The attacks continued in April and May 2016 and displaced some 50,000 people from fertile areas according to one estimate by a humanitarian agency. President al-Bashir announced an initial four-month unilateral ceasefire in June 2016, which he subsequently extended until the end of June 2017.

There have been very few reports of aerial bombardment since the June 2016 ceasefire and, in comparison to earlier years, the dry season has arrived without government attacks. However, Human Rights Watch has received reports of some indiscriminate shelling on civilian areas by Sudanese armed forces.[17]

US Sanctions Relief in 2017

In January 2017, then-US President Barack Obama issued an executive order lifting longstanding US sanctions on Sudan.[18] According to a statement released by the US Treasury, the decision was “the result of sustained progress by the Government of Sudan on several fronts, including a marked reduction in offensive military activity, a pledge to maintain a cessation of hostilities in conflict areas in Sudan, steps toward improving humanitarian access throughout Sudan, and cooperation with the United States on counterterrorism and addressing regional conflicts.”[19]

Within six months or by July 2017, the Secretary of State, in consultation with the US Agency for International Development (USAID) and government intelligence community members, will issue a report with recommendations to current US president Donald Trump on whether the sanctions revocation should become permanent. The order did not identify clear benchmarks for progress or explicitly require improvements to the human rights situation — a remarkable oversight considering Sudan’s long, violent and extensively documented record of abuses against civilians.

Some progress on the ground, described later in this report, in terms of humanitarian access, has been made since the US and the Sudanese government began new negotiations over the US sanctions in 2016. Sudan’s Humanitarian Aid Commission (HAC) issued new regulations on December 15, 2015, which promised that humanitarian work would be facilitated and expedited.[20] However, it is not yet clear how far this access will extend or for how long. At the time of writing, there has not yet been any new access to rebel-held Southern Kordofan or Blue Nile, although Sudanese officials have told at least one senior UN official that she may travel to Kauda, the main town in the rebel-held areas.[21]     

Human Rights Watch has urged the US to adopt a set of human rights benchmarks to guide its assessment of Sudan, and to delay the final assessment to provide meaningful opportunity to determine if there has been real, lasting progress.[22] Six months is not sufficient time for meaningful progress in the areas mentioned in the executive order, or for improvements in the human rights situation. The benchmarks to measure Sudan’s progress should include an end to indiscriminate bombing and shelling, tangible improvements in humanitarian access, release of arbitrarily-held prisoners by the National Intelligence and Security Services, an end to use of lethal force to suppress protests and various law reforms. Regardless of decisions on broad economic sanctions, US relations should not be normalized without significant progress on human rights. 

US government officials should also carefully review the sanctions policy, with an eye on more effective measures over the long term, continuing to enforce existing individual targeted sanctions against those deemed responsible for serious abuses and consider additional designations, particularly in light of the overwhelming evidence of abuses by the Rapid Support Forces and National Intelligence and Security Service.[23]

Obstruction of Humanitarian Aid

The food situation here is terrible, sometimes we have nothing to eat; if there is, we eat once a day, even the children.

— Khaltouma Bashir, a 20-year-old woman currently nursing a breastfeeding baby, December 2016.[24]

In protracted conflicts all over the region, civilians depend on humanitarian assistance to ensure they can secure sufficient food and access health care, and rely on assistance to provide basic schooling.

All the women interviewed for this report, as well as NGO workers, other humanitarians and authorities in the rebel-held areas were especially concerned about current food shortages, a result of poor rains, conflict in high food-production areas, increasing restrictions on traders from government-held areas and South Sudan’s massive currency inflation, which has led to much-increased prices for basic commodities in markets in South Sudan. There is general agreement that food shortages by mid-2017 may be as bad as those in late 2011 and 2012, when people reportedly died of hunger.[25] A report issued in early 2017 has warned that crop production in 2017 may be even lower than in 2016, when poor rains led to small harvests.[26]

Independent monitors projected 2017’s harvest to only provide enough food in some areas to last through March in South Kordofan and through May in Blue Nile.[27] The USAID-funded Famine Early Warning Systems Network has predicted that areas currently in “crisis” status, including rebel-held Southern Kordofan, will deteriorate to “emergency,” one level above famine, between June and September 2017.[28] Hard-to-reach areas that are controlled by the SPLM/A-North may be particularly impacted. A news release issued by the humanitarian wing of the rebel movement in March 2017 said that people in the Kau-Nyaru area only have roots and leaves to eat.[29]

Some interviewees said that they were already running low on food and unable to afford the little food available in markets. “We had planted and harvested but when we fled attacks [including bombing], we did not bring any of it with us. We used to produce surplus but now we have almost nothing,” Nur Amin, 40 years old and displaced from the high-production area of Mardais, said.[30]

Volunteer teachers have kept schools open but most have few or no supplies.[31] Civilians have continued to flee bombardment and move to escape hunger. For example, in the first half of 2016, 7,500 people left Southern Kordofan for overcrowded refugee camps in South Sudan.[32] Within the area, tens of thousands of people are living in displacement.

The government repeatedly denied access to rebel-held areas to United Nations and international non-governmental organizations (INGOs) requesting permission to assess needs and provide aid from within Sudan (“cross line,” i.e. across front lines, assistance), despite multiple requests by the UN, especially in the first six months of the conflict. In August 2011, after two months of UN requests for better access, President al-Bashir said that no international agencies would be allowed to work in rebel-held areas.[33] The government has also insisted, citing sovereignty, that aid agencies cannot enter rebel-held Sudan bordering South Sudan and Ethiopia in the form of “cross-border” aid.

These restrictions created a de facto blockade of international humanitarian aid to rebel-held areas of both Southern Kordofan and Blue Nile. The government has also made travel to rebel-held areas difficult and stopped flights and cars from traveling to those areas. It bombed two key airstrips in rebel-held towns in the first month of the conflict.[34]

Staff from UN agencies also struggled to get the required permits to travel to government-held areas of the state and only a few UN international staff could work there, and sometimes no international staff from international NGOs were allowed to visit or live there.[35] In May 2016, the government issued a new set of directives putting further onerous restrictions on aid agencies seeking access to government-held areas. These include establishing three layers of permission for travel to government-held areas of Darfur and requiring that humanitarian NGOs “shall commit not to disseminate information, data and statistics relating to humanitarian work reports and surveys without returning to the government Humanitarian Aid Commission (HAC).”[36]

The Sudanese government under President al-Bashir’s National Congress Party has a long history of obstruction and hostility toward independent humanitarian agencies seeking to provide impartial and life-saving humanitarian assistance in Sudan. The government repeatedly used an array of strategies to delay, limit and deny access by humanitarian agencies to civilians in need of assistance during the long civil war from the 1980s to 2005. Flight bans, denials or massive delays in the processing of travel permits, limitations on the numbers of staff and unnecessarily bureaucratic or arbitrary procedures for importing and transporting relief materials have all been common Sudanese government tactics to restrict aid to civilian populations.

These policies contributed to the deaths of hundreds of thousands of people from famine and diseases, and led to international pressure on the Sudanese government to cooperate with Operation Lifeline Sudan (OLS), a cross-border UN-led relief operation that accessed much of southern Sudan in the 1990s.[37] The Nuba Mountains was, however, excluded from the OLS operation; even during the OLS years, agencies were only able to operate clandestinely.  In the 1990s, a famine there killed thousands of people.[38] In May 2006, Human Rights Watch reported on widespread intimidation, arbitrary obstruction and denials of access by the Sudanese government, including its Humanitarian Aid Commission, during the conflict in Darfur.[39] In March 2009, the government of Sudan expelled 13 international agencies and revoked the permits for three national NGOs working in Darfur.[40] In June 2012, the Sudanese government expelled another four agencies from eastern Sudan.[41] The government expelled four senior UN workers between 2014 and 2016, including the head of the Office for the Coordination of Humanitarian Affairs (OCHA).[42] These examples represent only some of a broader pattern of expulsions. International and national NGOs, including humanitarian providers, have also been shut down.

Although this tense environment was a disincentive for individual aid agencies to seek improved access to rebel-held Southern Kordofan, significant efforts were made by international actors collectively. On February 9, 2012, the United Nations, the African Union, and the Arab League jointly proposed a “Tripartite Agreement” for the provision of international humanitarian assistance to the civilian populations in South Kordofan and Blue Nile. Both sides finally agreed to the deal in August 2012 with their own conditions, but no serious progress on implementing the accord was ever made. UN and US government officials blamed the Sudanese government for this failure.[43] In November 2012, the agreement expired without facilitating any assistance. In the same month, a senior Sudan government official stated: “there is no humanitarian crisis in war-torn South Kordofan and Blue Nile.”[44] 

In 2013, OCHA, the UN Fund for Children (UNICEF) and the World Health Organization initiated a new effort to vaccinate children in the rebel-held areas.[45] The agencies estimate that some 162,000 children under five years of age live in the rebel-held areas of Southern Kordofan and Blue Nile and have not had access to routine vaccinations since the conflict began in 2011. The UN Security Council backed the plan.[46] The parties initially agreed in theory to a two-week cessation of hostilities in November 2013, but ultimately failed to agree on modalities for the transport of vaccines. “I think it is fair to say both sides have made a lot of effort, but neither side took the last mile in order for it all to happen”, a senior UN official told Human Rights Watch in 2014.[47] Negotiations have continued, but no further progress has been made.

Sudan has offered some humanitarian aid to the rebel-held areas of Southern Kordofan, but, at least in the first years of negotiations, only via government assistance or NGOs closely affiliated to the government, such as the Sudan Red Crescent.[48] The SPLM/A-North has rejected this form of assistance saying it is not impartial.[49] The government indicated some willingness to allow international agencies into the areas in recent years, on the condition of controlling all service delivery.[50]  However, none of these negotiating positions were ever tested.

The SPLM/A-North has however encouraged international NGOs and Nuba NGOs to operate in the rebel-held areas. These groups have brought critical medical assistance in from across international borders. Although patchy, these services—operating outside of officially sanctioned channels—represent the only services civilians and injured rebel fighters can access without leaving their homes for a refugee camp or becoming displaced in government-controlled Sudan. 

In early to mid-2015, the head of the AUHIP, former South African president Thabo Mbeki, proposed another way to break the deadlock. He suggested that both parties agree that a proportion of aid would enter the rebel-held areas from within Sudan, and a proportion from Ethiopia, cross-border. The SPLM/A-North agreed to as much as 80 percent of humanitarian aid entering the area cross-line, i.e. from within Sudan, and 20 percent from Ethiopia. The SPLM/A-North told Human Rights Watch that they considered this to be a major concession.[51] The Sudan government rejected the deal, and said again that no aid could enter from other countries into rebel-held areas.[52] 

In late 2016, in response to this deadlock, the US government offered to provide humanitarian assistance from within Sudan, consisting of only US government aid, delivered by US government-funded international humanitarian groups.[53] However, the SPLM/A-North did not accept this offer, instead asking for further negotiations and again demanding cross border aid.[54] Rebel leaders say cross border aid is important because, firstly, they want to be able to safely transport wounded fighters to medical assistance in neighboring countries. Rebel leaders said, secondly, that Sudan’s history of aid obstruction and human rights violations against Nuba has meant that both the rebel leadership and civilians have lost trust that aid controlled by Khartoum will be safe—one doctor told Human Rights Watch that he believes many Nuba civilians would, for example, refuse vaccinations from Sudan— or reliable, i.e. not subject to further obstruction and interference. Following the US decision to provide sanctions relief, the Sudanese government also said that it would allow UN staff to travel to rebel-held areas and it appears that at the time of this report’s publication that the major impediment to UN access to rebel-held areas is the SPLM/A-North.

Regarding access to government-held areas, Sudan has made nominal progress. Sudan’s HAC issued new regulations on December 15, 2016. These promised that humanitarian work would be facilitated and expedited.[55] However, government-approved travel permits are still necessary for conflict-affected areas and humanitarians must notify government authorities before traveling to any location outside of the capital.

 International humanitarians have subsequently been able to assess needs and deliver assistance in parts of Darfur’s Jebel Mara area now controlled by the government. At the time of writing, there has been not yet been any change to actual access to rebel-held Southern Kordofan or Blue Nile. 

Women’s Rights in Rebel-Held Areas of Southern Kordofan

You are told to hush, not to talk.

— Zeinab Mohammed displaced and living in Lula village, Heiban County, December 2016.[56]

Women have no voice. We have no voice here. You could get into politics, maybe, but only if you are educated.

— Afaf Saeed, displaced and living in Lula village, Heiban County, December 2016.[57]

As described below, women and girls in rebel-held Southern Kordofan face discrimination and violence, and have limited avenues for redress. All the women interviewed for this report felt that women’s rights were either at a standstill, or were going backward. Often women said they felt undervalued, including in their lack of voice or influence in their family lives, communities or in the SPLM/A-North administration. Women face multiple barriers to full participation in public life, including in the peace processes.

The people we interviewed said that in rebel-held Southern Kordofan child marriage is common and families often value educating their sons over their daughters. In some areas, many families still practice female genital mutilation (FGM). Women experiencing domestic violence lack legal protections, including against rape in marriage.

A 2016 NGO report on women’s rights and gender in the rebel-held areas of Southern Kordofan concluded that “the SPLM/A-N remains a traditional male-dominated and militarized movement with no clear agenda for delivering on their rhetorical commitments to gender equality and the empowerment of women and girls … (they are) to a large extent gender-blind and with strong patriarchal tendencies.”[58]

Political Participation

There are three women represented at the intermittent peace talks.[59] Only one of the women interviewed in the rebel-held areas had information about what was happening with the peace process, and all said they felt there was no way for women’s voices to influence the talks.

Nuba women fight in the rebel army and occupy some positions in local government, including leading two of the secretariats in the civilian administration; however, none of the seven commissioners or top leadership are women, and the SPLM/A-North’s 25 percent quota for administrative positions for women has not been met. Some women said they felt many men now consider 25 percent as a ceiling rather than a floor for female participation. “We are so far behind, there are no women’s rights here. Women have no respect, the [SPLM/A-North] promises are all just talk,” a Nuba female social worker working with an NGO said.[60]

There have not been any elections in the area since the war began and there are unlikely to be any soon. The SPLM/A-North women’s association is large and widespread but there are no independent women’s rights organizations or networks.[61]

Early Marriage

In the rebel-held areas families often marry off their daughters early, especially if the family cannot afford to send some or all of their children to school. Some interviewees said that sometimes, especially when they were displaced from villages, there was no nearby school available. “Early marriage is common. No one is trying to stop it. About 14 or 15 is normal, much worse since the war because there’s no money,” Hanasi Mohsin, who works for the social development secretariat in Heiban town, said.[62] Of the 25 women interviewed, 14 of them had married before they were 18 years of age, most guessed or said they were around 15 years of age, and two of them were married as soon as they had started menstruating. All over the world, child marriage often leads to early childbearing with attendant health risks and disrupts or ends a girl’s formal schooling.[63] Sudan’s law allows marriage at 14 years for both boys and girls.

Access to Education

Interviewees said that when resources are limited, they prioritize education of boys over girls. “I’ve had 11 children, five girls are surviving and three are married, they are 15, 16 and 17 years old. They were not able to go to school because we have no money. The boys are going to school,” 41-year-old Aisha Hussein said.[64] “Boys are treated better, because when he grows up he will provide for the family through a job while the girl will marry into another family,” Afaf Saeed, a mother of two children, said.[65] Khaltouma Bashir, who was uncertain of her age but looked around 15 or 16 years of age, married a soldier in part because there was no money for her to go to school. “My brothers did go, but there was not enough for me. I was just idle so decided to go for marriage,” she said.[66]

Several of the women interviewed identified education as the most important path for women to get authority and influence. “Education is the one thing that has to change for us to get our rights,” Amal Tutu, mother of five children, said.[67] A 30-year-old NGO worker, well-known in the Nuba humanitarian community, and newly-married, said, “I wanted to be able to finish my schooling and then get a job which is why I didn’t get married. No other way.”

Female Genital Mutilation

The civilian administration has done some work to end female genital mutilation (FGM), which is common in some areas closer to government-controlled parts of Southern Kordofan. 

All women and girls interviewed in Hadara village, Delami county, said that they, their sisters, and all the women and girls they knew, had clitorodectomies as young children.[68] (FGM was not reported in any of the other sites of research.) Sudan has a startlingly high national prevalence of FGM, just under 87 percent according to joint UN and government research.[69] Restrictions on access to aid have meant that women and girls in the rebel-held area have been unable to benefit from efforts by the government and the UN Population Fund (UNFPA) and partners to end the practice.

Domestic Violence

The SPLM/A-North Secretariat of Social Development and Women’s Rights, together with the women’s association, has worked to tackle domestic violence in at least Heiban and Delami counties, including through holding meetings with the community and asking senior people from the civilian administration to address the issue in public.[70] “There was a gathering and we were all warned by the chief,” Rabha Yabus, a 30-year-old from the area, said, “I was beaten but now my husband has stopped.”[71]

However, domestic violence cases are still reported to local organization staff and civil servants. One woman who worked for the local civilian administration said that she had to find transport to hospital up to six times a month for women who had been seriously beaten by their husbands.[72] “Recently a woman was cut badly on her skull, another one the skull was dented,” she said. Six of the 25 interviewees, from different counties, said that their husbands beat them. One of them, Amal Tutu, said:

Women’s rights are going backwards. Even when you want to express yourself you are not listened to. Even when you’re very tired your husband can make you get up and do your work. I have been beaten when I resist many times.[73]

Five others said that their neighbors, relatives or women they knew well were also beaten.

Lack of Legal Protections

The SPLM/A-North areas use the “New Sudan” laws and penal code, which punishes rape with up to 14 years of imprisonment and a fine. There are no other provisions in force that specifically protect women against gender-based violence.[74]

The justice system in rebel-held areas is mostly staffed by volunteers with little or no training. There are about 1,500 volunteer police working in the rebel-held Nuba mountains—only a small proportion of whom are women—and they have had no specific training or protocols on handling or investigating gender-based violence.[75] The rebel-held region has 21 volunteer judges who have not had any recent training, but no prosecutors or lawyers.[76] The head of the judiciary, Kodi Abd Rahman Harik, said that as far as he was aware, there had been no trials of perpetrators of domestic violence since 2011 and only one case of rape.[77]

International doctors working in the area said that they had treated a few rape cases over the years. Women’s rights advocates said they believe rape in marriage is fairly common, and six of the 25 women interviewed said that they had no choice but to have sex when their husbands wanted to. “You can say no if you’re menstruating, otherwise you have to do it,” a 35-year-old woman, Amal Ali, said.[78] “You have to have sex when he wants, if you refuse you might be caned. This has happened to my neighbors. For me, whether you like it or not, you do it,” another woman explained.[79]

Under the “New Sudan” laws, non-consensual sex, or sex against a woman’s will, is not rape if the man is married to the woman.[80] Only one health NGO provides post-rape care that includes the provision of emergency contraception if requested as outlined by World Health Organization standards.[81] None of the women interviewed knew that seeking medical attention is important after rape. There is no counselling or long-term psychological support available in rebel-held areas, including for survivors of sexual violence.

II. A Weak Health System

Decades of conflict and marginalization by Sudan’s government left Southern Kordofan state’s health system underdeveloped even before the current war began. Subsequent obstruction of humanitarian aid has meant that there has been no coordinated humanitarian relief effort to ameliorate the negative impact of an abusive conflict on the healthcare services available to the population there. Humanitarian organizations estimate that there are some 900,000 people living in rebel-held areas of Southern Kordofan (and a small area of neighboring Western Kordofan state).[82] Only roughly 650,000 of them are accessible to aid workers.[83] Largely volunteer-run clinics in the rebel-held area often lack supplies, and health workers, including midwives, have little formal training or capacity. Hospitals and clinics, which appear to have been specifically targeted, have also been damaged by aerial bombardment by Sudanese government planes.

Weak Health Infrastructure in Rebel-Held Southern Kordofan

In many clinics, there’s not even Tylenol.

—Hospital Director, Mother of Mercy Hospital, Heiban county, December 2016.[84]

Women, men and children living in rebel-held Nuba mountains have not had access to Sudanese government health services or unhindered humanitarian aid since the conflict began in 2011.

The availability of health care facilities and skilled health care providers in rebel-held South Kordofan falls far short of the need. In 2006, the World Health Organization set the standard for delivery of essential maternal and child health services at a minimum of 23 doctors, nurses and midwives per 10,000 people, while the International Labour Organization (ILO) sets the standard at 34.5 skilled health professionals per 10,000.[85] In 2013, research by WHO and the US Agency for International Development said 59.4 skilled health professionals per 10,000 were needed to end preventable maternal deaths.[86] For an estimated population of about a 900,000 people, the rebel-held areas of Southern Kordofan has only five doctors. There is no gynecologist or obstetrician in the rebel-held area.[87]

There are only two working hospitals, the Mother of Mercy Hospital run by the Diocese of El Obeid, also known as “Gidel,” (435 beds) and the smaller Cap Anamur - German Emergency Doctors’ (GED) hospital in Loweri (70 beds).[88] Both hospitals are in Heiban county, which can be a long journey—several hours or even two days—even by car from other parts of the rebel-held areas. Sometimes, because of active frontlines, the hospitals are entirely inaccessible.[89] These hospitals are the only facilities with the staff and equipment for surgery, treatment of serious wounds, and medical testing. Doctors working in these hospitals told Human Rights Watch that they regularly treat civilians or combatants who had reached the hospital only after lengthy journeys.

There are no ambulances in the rebel-held areas and very few civilian cars. As discussed later in this report, this is a major problem for women trying to access healthcare, including in emergencies such as complications during labor.

The SPLM/A-North secretariat of health runs around 175 clinics across the area that provide basic health care. None of the secretariat staff receive a salary. While this network of clinics means that, in theory, most communities are served by one, the clinics are typically staffed by volunteer nurses or community health workers, who often have no or only basic training.[90] The clinics lack basic equipment like weighing scales or test kits. Rapid tests for malaria are the exception.

Chronic shortages of medicines and difficulties in transporting them mean that basic medicines to treat malaria, worm infections and respiratory diseases are often not available. “In 2015 for a period we ran out of malaria drugs, seven people died, they came to the clinic but we had nothing to give them,” Gadam Ali, who runs the health secretariat in Delami county as a volunteer, said. “We never have any drugs for TB or leprosy.” All the community clinics that Human Rights Watch researchers visited in December 2016 were experiencing shortages of essential medicines or key equipment.[91] “The amoxicillin [an important antibiotic] is finished and we have no more medicines for urinary tract infections, which are very common here,” James Atai, a trained nurse in charge of the Hadara clinic, in Delami county, little more than a room with medicines on a table, said.[92]

The inadequacy of health services extends to key preventive care. Only a few facilities provide vaccinations, and child vaccination coverage is extremely low in part because of a lack of refrigerators.[93] In Hadara village, for example, health workers and local women leaders said almost none of the children have been vaccinated because the village is located far away from clinics with vaccinations. A major outbreak of measles in 2014 and 2015 involved at least two thousand suspected cases, and killed at least 30 children.[94]

The Sudanese government, UNICEF, and WHO conduct mass vaccination campaigns in non-conflict areas of Sudan. No such campaign has been conducted in rebel-held Southern Kordofan since 2010.[95]

Attacks Targeting Health Services 

Human Rights Watch documented six attacks on hospitals and clinics, including all the major health providers in the SPLM/A-North controlled area, between April and June 2014.[96]  The pattern of the attacks on healthcare facilities and the presence of drones over the facilities ahead of the attacks on three occasions, suggests that the hospitals may have been deliberately targeted, which would constitute a war crime. In these strikes, two patients were killed.

These attacks also had an impact on available health services. Soon after attacks on their hospital in Buram county in 2014, the medical NGO Médecins Sans Frontières (MSF) (Doctors Without Borders) pulled out staff, eventually forcing their Buram hospital to close.

Another major clinic, one of the few providing obstetric care, also closed in 2014 following the attacks.

In total, around 20 medical facilities have been damaged or destroyed in bombing raids over towns since 2011, according to the SPLM/A-North health secretariat. Johannes Plate, a health worker at the Loweri hospital, said that airplanes attacked the hospital area in 2014, 2015 and 2016. He said that these incidents scared people away from seeking health services: “There would be an immediate drop in outpatients, from about 200 a day to none, for about a week and then forty to fifty people a day in the following weeks. Even inpatients leave,” he said.[97]

III. Lack of Access to Reproductive Healthcare

I had a miscarriage at five months, of twins. They came out and then there was a lot of bleeding, a lot of pain. There was no car, no painkillers. I had to walk to the hospital because the bleeding would not stop.

Amal Tutu, who lives in a village in Heiban County, said her home is about a day’s walk from the nearest hospital, December 2016.[98]

The conflict has resulted in a further weakening of already sparse women’s healthcare services in the area, with tragic consequences for girls and women.

The women and girls that Human Rights Watch interviewed have few options for controlling their fertility, and many go through multiple pregnancies beginning at a young age, including as a result of child marriage. These factors raise the risk of pregnancy-related complications, as do overall poor health, including poor nutrition and Infibulation, a form of FGM common in Sudan, where the vagina is stitched or otherwise narrowed. This form of FGM can cause obstructed labor and is a main cause of obstetric fistula and maternal mortality in Sudan.

Pregnant women have extremely limited access to skilled health providers, vitamins and essential medicines, quality antenatal care, and emergency obstetric care. These factors increase the risk of being injured or dying from complications due to pregnancy and childbirth.[99]

Using population estimates from humanitarian groups working in the area and WHO estimates for Sudan’s birth rates (not disaggregated by region), we can estimate that perhaps around 33,500 births are taking place every year.[100] Bombing raids have stopped women from accessing care, including making antenatal visits. Four women interviewed by Human Rights Watch also said that they believed they had had miscarriages late in their pregnancies due to the stress and hardships they underwent when they experienced aerial bombardment. However, we were unable to confirm the medical causes of their miscarriages.

Human Rights Watch also found that women and girls had almost no access to contraception to prevent pregnancies and sexually transmitted infections.

Sexual and Reproductive Health in Protracted Crises

Hunger: this is the thing people worry about most, this and the bombing deaths and injuries they say is the ‘emergency.’ But women are dying in childbirth and there is very little healthcare, the schools are getting worse; six years of bad education is a crisis for this generation. Much more is needed to alleviate serious suffering.

— Nuba humanitarian aid worker.[101]

For situations of both acute and protracted crises such as armed conflicts or natural disasters, when regular health services may be compromised or ineffective and assistance is required to ensure access to health care, humanitarian groups have developed minimum standards of care to seek to ensure an appropriate and quality humanitarian response. The standards for sexual and reproductive healthcare are outlined below.[102]

The Minimum Initial Service Package for Reproductive Health (MISP) is “a priority set of lifesaving activities to be implemented at the onset of every emergency” recognized as a Sphere standard in 2004.[103] MISP provides that a reproductive health officer should be in place to coordinate efforts and help collect information; that reproductive health kits (containing medicines and equipment) should be available and used; that clinical care is available for rape victims; and that visibly pregnant women should be given clean delivery equipment. Referral systems for emergencies for women in labor and for newborns should be established and blood transfusions made available. Condoms should also be freely available. (See appendix for more).

While the standards foresee that these minimum services should be implemented within the first weeks of a humanitarian response, six years into Southern Kordofan’s conflict, these services do not exist.

The Sphere minimum standards in health action set out five benchmarks to assess whether minimum standards are being met:

  1. Whether all heath facilities have trained staff, sufficient supplies and equipment for clinical management of rape survivor services based on national or WHO protocols.
  2. Whether all pregnant women in their third trimester have received clean delivery kits.  
  3. Whether there are at least four health facilities per 500,000 people with basic emergency obstetric care and newborn care that women can be referred and transported to.[104]
  4. Whether there is at least one health facility with comprehensive emergency obstetric care and newborn care per 500,000 population. Comprehensive emergency obstetric care includes surgery under general anesthesia and safe blood transfusions.
  5. Whether the proportion of deliveries by caesarean section is not less than 5 percent or more than 15 percent.

In the rebel-held areas of Southern Kordofan, only one of these indicators is being met, and only partially. The Mother of Mercy (in Gidel) and the GED (in Loweri) hospitals both provide comprehensive emergency care, but neither are easily accessible, or sometimes at all accessible, for most of the population. As shown below in more detail, the other minimum indicators are not being met. There are no delivery kits in the area. Aside from clinics run by either the Diocese of El Obeid or GED, few facilities have basic obstetric medicines or equipment. Authorities and doctors told Human Rights Watch that probably over 99 percent of births take place at home, without skilled or equipped providers. Only two health providers perform caesarean surgeries in their facilities. Between them, the two facilities perform about 100 caesarean sections a year, about 0.2 percent of our roughly estimated number of births in the rebel-held areas, significantly below the Sphere minimum standard benchmark of 5 percent.[105]

Humanitarian organizations should – and increasingly do -work to provide not only emergency services but also help restore or create working healthcare systems.[106] Sexual and reproductive healthcare should be included in these efforts.[107]

Maternal Mortality and Morbidity

My aunt died in childbirth, they took her to the hospital and she died on the way with the baby in her womb, it was an hour by car.

— Aisha Hussein, Tongoli village, Delami county, December 2016.[108]

Low women’s status and poor access to health care has a devastating effect on maternal health. This is accentuated in conflicts: maternal mortality in humanitarian crises and in fragile settings is 1.9 times the world average, and represents 61 percent of the total number of maternal deaths worldwide.[109] 

Access to antenatal care, skilled healthcare during labor, and emergency obstetric care are critical for preventing maternal deaths and injuries. In the Nuba region, unless pregnant women live within reach of one of the two hospitals or the clinics these two institutions support with staff visits, supplies, and training, these services are out of reach.

There are no reliable recent estimates of the number of women and girls dying in childbirth (maternal mortality), or experiencing long-term infections, pregnancy or childbirth-related injuries or disabilities (maternal morbidity), for the rebel-held areas of Southern Kordofan.[110] However, previous estimates show elevated rates in the state. A joint research effort by the UN and the Sudanese government in 2006 put Southern Kordofan’s maternal mortality rate at 503 per 100,000 live births, compared to 91 per 100,000 births in Northern state and 213 in Southern Kordofan’s neighboring Northern Kordofan state.[111] Maternal mortality decreased nationally in Sudan from 744 per 100,000 live births in 1990 to 311 in 2015, but there is little reason to believe that the figure would have declined to the same extent in war torn, rebel-held Southern Kordofan.[112]

The little information that is available suggests that maternal mortality remains high. The Mother of Mercy Hospital documented two maternal deaths at their hospital in 2016 and three in 2015, out of about 260 to 280 births a year.[113] GED recorded two maternal deaths at their hospital in 2016, out of 193 deliveries and six maternal deaths that took place at women’s homes in areas near their outreach clinics.[114] Johannes Plate from GED wrote to Human Rights Watch that, “to get confirmed numbers is quite a challenge. But I had a meeting with the SoH [the SPLM/A-North Secretariat of Health] recently, and they showed me a statistic. There [sic] have confirmed, that around 350 women died in 2016, and were guessing that most of them were pregnant.”[115]

Most maternal deaths are preventable. Johannes Plate from GED said:

Unfortunately, most cases are arriving in the hospital too late; an unknown number is dying at home or on the road...  We figured out, that the main complication is prolonged delivery. That is caused by many reasons, but most of them would be treatable, if the woman previously had been examined by a midwife or would come to deliver at the hospital.

To sort out high-risk pregnancies, like twin pregnancies, suspected eclampsia, narrow pelvic, teen pregnancies or multipara, regular ANC’s [antenatal care] are needed. But most of the women are only visiting the ANC, once they are feeling sick. The undiscovered cases will deliver at home, in case of a complication the next health unit is too far and the means of transport are rare. [116]

Lack of Access to Adequate Antenatal Care

Pregnant women in rebel-held Nuba Mountains who live within access of either the GED hospital or Mother of Mercy Hospital, or one of their outreach clinics, can access antenatal care from trained and equipped providers.[117] Others must make do with little or no care at all.

Between a third to half of all maternal deaths are due to causes, such as hypertension (pre-eclampsia and eclampsia) and hemorrhage, directly related to inadequate care during pregnancy.[118] The World Health Organization recommends that during each pregnancy women make a minimum of four antenatal care visits that provide them with essential evidence-based interventions.[119]

Essential medical assistance includes identification and management of obstetric complications such as pre-eclampsia, tetanus toxoid immunizations, treatment for malaria and sexually transmitted infection identification and management (for example, syphilis). A visit at the end of the pregnancy is important to help find and manage complications such as multiple births and abnormal positions of the baby. Antenatal care is also important to connect the pregnant woman to healthcare providers and to provide her with information on where contraception is available, the importance of skilled attendance at birth, breastfeeding, early care for the baby, and birth spacing.  In Nuba, most village clinics (run by the rebel administration) in the rebel-held area lack the staff, the vitamins and medicines (at least in consistent supply), and the equipment to provide full antenatal care.

Almost half of the interviewed women that had given birth in the last four years said they had relied on village midwives for antenatal care, or did not have any antenatal care at all during their pregnancies. Most of the midwives in the area are traditional birth attendants, rather than trained midwives.[120]

None of the midwives or traditional birth attendants who treated the women interviewed in their home villages had equipment such as stethoscopes. “[The midwife] has no equipment, only her hands. She did not listen to the baby. I had no medicines or vitamins and she did not have anything to give me either,” Samia said.[121] In some cases, midwives had advised women interviewed that they should go to the hospital to give birth, either because of the patient’s history or because the midwife was able to determine that she might face problems. “Sometimes [midwives or traditional birth attendants] can feel that the baby is not in the right place and then can send mother to Gidel [Mother of Mercy Hospital],” Hadara village clinic manager, James Atai, said. “But normally when they decide to go to Gidel, the mother already has problems.”

Health officials said that folic acid, a vitamin supplement in pill form, is the only supplement delivered regularly to the secretariat of health clinics; iron and other vitamins are provided irregularly. Anemia from a lack of iron, often a cause of maternal mortality, may be very common, one doctor said, based on high rates of anemia amongst his patients.[122] Clinics are also usually supplied with quinine, which can be given to women in their first trimester for malaria. However, the main doctor in Loweri hospital said that malaria was still suspected to be the main cause of stillbirths at his facility.

Hypertension, pre-eclampsia or eclampsia is another major cause of illness and death during pregnancy (as well as delivery).[123] But very few clinics have instruments to measure blood pressure; for example, in Delami county, none of the secretariats of health clinics have a sphygmomanometer, which uses an inflatable cuff wrapped around the patient’s upper arm.[124] None of the clinics have received basic instruments such as weighing scales, stethoscopes, or fetoscopes since the war began.

Most women we interviewed said they experienced hunger at least at some point during their pregnancy. A lack of food and nutrition during pregnancy can cause illnesses in pregnant women, including anemia, and lead to low birth weights and poor early development for their babies.[125] There are no supplemental feeding programs in the rebel-held areas.[126] “Because of the fighting, we had to flee. I was often hungry in the last three months [of my pregnancy],” Afaf Saeed, a 25-year-old former cleaner said, “many days there was only a handful of food.”[127]  

Women who live close to one of the two hospitals or their outreach clinics, or who can find transport or walk to visit the facilities, said they received antenatal care. GED recorded 14,371 antenatal visits to its hospital and outreach clinics in 2016.[128] The Mother of Mercy Hospital said they had 777 admissions to their maternity ward in 2016, mostly commonly for miscarriage, prolonged labor, antepartum bleeding, malaria and neonatal sepsis.[129]

Several of the women interviewed ensured they got checkups, despite considerable distances to hospitals. Ten of the women interviewed went to about four checkups during their pregnancies, and had waited for cars or walked to Mother of Mercy Hospital or the Cap Anamur - German Emergency Doctors (GED), – which is usually around a day there and a day back walking.

“Gidel [Mother of Mercy] is about one or two hours if you can get a car from Heiban to there. I was hungry a lot at the time [when walking and staying there],” Afaf Saeed, a 25-year-old woman with two children said, but added it turned out to have been crucial, perhaps life-saving, that she made this strenuous effort. She found out during the checkups that she should give birth in the hospital because her blood was “too weak” to safely deliver at home.[130]

Of all the 25 women interviewed, only those who had used the Mother of Mercy’s antenatal care had slept under a mosquito net, given to them at their first visit, while pregnant. No other organization provides subsidized or free nets, in large part because of the high cost of transporting these bulkier items.[131]

Sonograms are available in both hospitals. Khadija el Hajj told Human Rights Watch that visiting the Mother of Mercy Hospital for a sonogram might have saved her life. The doctor was able to see that her baby had a swollen head. Under his advice, she went to the hospital for a cesarean section where she had a safe delivery. At the time of the interview, the baby was still in treatment.

Babies born in the GED Loweri hospital receive a Hepatitis B vaccine when they are born – as well as the usual early childhood vaccines – because health workers found after testing that 12.5 percent of women using the facility over nine months in 2016 have the disease.[132] The Mother of Mercy Hospital in Gidel recently began testing all pregnant women for hepatitis B in their antenatal clinic and found about 20 percent of these women were positive.[133] “We immunize those babies immediately after birth and are encouraging their mothers to deliver at the hospital,” said , the senior doctor working there.[134] 

Pregnant women or girls who visit Diocese of el Obeid facilities, including six outreach clinics, have checkups that include measuring the mother’s weight and blood pressure, testing (and if necessary, treatment) for HIV and hepatitis B, and provision of medicines to prevent malaria and tetanus immunization.[135] Six GED outreach clinics also provide consultations that include blood pressure and weight measurements and most also provide tetanus vaccines and anti-malarials.[136] Vaccinations are not available in most places as few clinics have refrigerators to store them.

Human Rights Watch spoke to four women who attributed their miscarriages and early births to the hardships and stress they underwent while experiencing aerial bombardment. The causes of miscarriage are complex and Human Rights Watch does not have the information or medical expertise to assess what happened in these cases. However, many people in the community said they felt there was a link.

A medical organization working in areas in Syria where aerial bombardment is common told Human Rights Watch “our field teams have documented both miscarriages and pre-term births as a result of ongoing bombing.”[137] A doctor from another medical organization was more circumspect, saying “traumatic events like bombings and attacks are creating stressful situations leading to early births, that occasionally can result in miscarriages.”[138] A 2013 news release from Médecins Sans Frontières said that “amongst pregnant women, miscarriages and pre-term births are on the rise because of the stress caused by the conflict,” but did not directly attribute the increase in miscarriages to bombardment, although this stressor was mentioned.[139] 

“It happened to me, in 2013, I was seven months pregnant. I ran to the foxhole when the plane came, came out and two days later I gave birth,” 41-year-old Aisha Hussein said, “the baby died.”[140] Another woman, Mujuma Hamad, working as a medicine dispenser in Hadara village in Delami county, said she miscarried immediately after an Antonov attack when she was eight months pregnant.[141] She said that she knew six other women in the village who miscarried at or around the time when aerial bombardments had taken place.

A social development administration worker in charge of women’s affairs in Heiban town said that since the war began in 2011, she knew at least seven women who had miscarried soon after aerial bombardment. The information manager for the secretariat of health said that she recorded three miscarriages in Kauda town in 2014 that had taken place when planes flew over threatening an attack, and that she also received a report that four women miscarried during aerial bombardment attacks in Mendi in 2015.[142]

Emergency Obstetric Care: The Three Delays

Hundreds of thousands of women live too far from the GED hospital or Mother of Mercy Hospital to be able to access emergency obstetric care. But even for those who do live within reach of the two hospitals, delays stop them from accessing these services.

Health experts highlight the importance of having a skilled health care provider during and after childbirth, and typically explain the contributing factors to maternal deaths and morbidity using the “three delays model.”[143]

The first delay follows the failure to recognize the need for emergency obstetric care, or when a decision is made, to not access emergency services. Undertrained midwives, or family members in the absence of health workers, can be slower than fully trained personnel to notice danger signs and ensure timely referral. In the rebel-held areas of Southern Kordofan, the extreme difficulties of finding and organizing transport and at times bombing raids, may stop women and their families from quickly choosing to get the patient to a hospital or clinic as soon as possible.

The second delay is when women arrive late to the referral facility, including when the facility is too far away to access quickly or when transportation is unavailable. A woman experiencing postpartum hemorrhage, which accounts for around 25 percent of maternal deaths globally, is at high risk of dying within two hours of onset without immediate intervention.[144] Women experiencing other problems, such as hypertension or obstructed labor, may have a longer window, of up to two days, to reach lifesaving care, in most cases.[145]

In the rebel-held areas, if women and girls face emergency complications during childbirth, they may be many hours or days away from lifesaving assistance. “In many cases women come from far to give birth, sometimes two days walking, sometimes the baby died on the way,” a GED midwife, Dahabaya Khamis, said.[146]

There are no ambulances in the region and mobile phone networks only work on some of the fringes of rebel-held areas. Since the war began, the number of cars has declined and authorities in places Human Rights Watch visited said there are typically only one or two cars even in the main towns and usually no cars in villages. “If I have an emergency when I give birth, if I find a car I am about an hour from the hospital,” Aisha Hussein, one of the women interviewed, said. “There were a lot of cars before the war. Now it’s hard to find one.”[147]

Families often end up carrying women in obstructed labor on a bed, local officials told Human Rights Watch. Four women told researchers that this would be their only option if they faced complications in labor. The head of the health secretariat in the county of Delami said this is a fairly common practice. “We can do nothing here … there is a car usually in Tujur to then go to Gidel, about three hours by foot, by bed, with a group of not less than 10 men. And sometimes the cars are not there, or one is broken down,” he said.

The executive director of Heiban county said:

It is very common that women can’t reach in time and die in childbirth at home. To get to Gidel is about six to seven hours if you climb across the hills, a one-day walk if you go through Kauda way. The child often dies. We use a bed to carry the woman to the hospital, a group of men carry her. Sometimes from the villages to here like this, and then they try and find a car. They go to the commissioner, but he’s not always here and sometimes he has no fuel. This happens between 5 and 10 times a month. Then we face a lack of blood when they give birth.[148]

“Sometimes we see a woman who has been in labor for three days and she’s just arrived,” a foreign doctor told Human Rights Watch.[149] One woman, Amal Tutu, miscarried twins and then had to walk a day to the hospital when the bleeding did not stop even though she was weak.[150] “There was no car, no painkillers. I was in pain but I knew that the local clinic would not be able to deal with it,” she said. She was treated at the hospital. Hawa Zeitoun, who is about 14 or 15 years old, spent the last two months of her pregnancy at the Mother of Mercy Hospital because she had complications, and she feared if she waited at home, she would not be able to manage the one-day walk to reach the facility.[151]  

The third delay is caused when the facility does not have sufficiently trained staff or is inadequately equipped. In rebel-held areas of Southern Kordofan, the only facilities fully equipped to handle obstetric emergencies are Loweri or the Mother of Mercy hospitals. The Mother of Mercy Hospital has a blood bank and a team of experts including anesthesiologists, and both hospitals can provide women with transfusions. Both the Mother of Mercy and GED Loweri can perform cesarean sections as well as provide all basic emergency care, including specialized antibiotics, oxytocin and anticonvulsants, manual removal of the placenta and assisted vaginal delivery.

GED provides support to six outreach clinics and only one does not have a midwife on staff who is trained to manage manual removal of the placenta, umbilical cord prolapse (when the umbilical cord emerges in birth before the fetus), breech delivery and other complications; in two clinics, staff can remove material from inside the uterus.[152]  Six other clinics are supported by the Diocese of El Obeid, who also run the Mother of Mercy Hospital in Gidel, where midwives on staff provide manual placenta removal, although they do not perform assisted (i.e. vacuum or forceps assisted) deliveries. Oxytocin and antibiotics are available, including via a drip in one clinic.[153] 

Otherwise, few health facilities are equipped to manage emergencies even if women can reach them. For example, misoprostol, which can be a life-saving medicine in cases of post-partum hemorrhage or miscarriage, is generally not available except in the two hospitals and a few clinics.[154]  Midwives are often inadequately equipped and trained.

Most women in Nuba give birth at home. All but four of all the women interviewed by Human Rights Watch gave birth where they were living, either permanently or while displaced by fighting, usually on the ground but sometimes on a bed. “There was dust blowing all over me,” Afaf Saeed, who was living in displacement near a riverbed a few hours’ walk from Heiban town because of aerial bombardment at the time, remembered.[155] Often women said in their interviews that they delivered with the assistance of family members, but in about half the cases a midwife was present. “I gave birth at home, I was afraid I would die I was in so much pain, but it was not for too long. The baby was the wrong way around, but the midwife could adjust the baby before the birth,” Samia Mohammed said.[156]

Even when a trained midwife can attend a birth, she often does not have access to equipment, like forceps, sometimes lost or destroyed in the war. For example, the midwife in Hadara village in Delami county said her kit burned with all her possessions when much of the town was burned in May 2015 by government forces.[157] There has been no large-scale training or re-training of midwives in the area, or in neighboring South Sudan, and no large effort to resupply them with equipment since the war began.[158]

In humanitarian crises where women tend to give birth at home rather than in facilities, humanitarian organizations try to provide women who are visibly pregnant with clean delivery kits (containing soap, a razor blade and cloth among other items). There has been no large-scale distribution of delivery kits for pregnant women in the rebel-held areas since the war began.[159] Simple UN-supplied midwife kits that each cover 50 deliveries and contain basic lifesaving equipment and medicines, are also not available in the rebel-held area.

Access to Contraception and Protection against Sexually Transmitted Infections

No, no condoms here. We’ve never had them. … Yes! We know what they are, but we’ve never seen them here, no family planning since the war.

— Staff members of Heiban town’s main clinic, Heiban county, December   2016.[160]

Every year we women get really tired of being pregnant and giving birth and there’s not enough food either, not enough vegetables to feed all the children. So, they are hungry and we’re worried about the situation all the time, there’s no option for a change.

— Raja Ibrahim, women’s rights and civil society leader, December 2016.[161]

What is a ‘condom’?

— Khadija al Haj, mother of one, Lula village, Heiban county, December 2016.[162]

Family planning, including access to condoms, is largely unavailable in rebel-held Southern Kordofan state, largely due to the overall gaps in health infrastructure and services, and in part because the major healthcare provider does not provide contraception. This has meant that women are unable to control the number and spacing of their pregnancies or plan their families either individually, or together with partners, to the detriment to their well-being and health.[163] The area’s apparently high number of early marriages makes the lack of access to contraception even more dangerous; for girls between 15 and 19 years old, complications due to pregnancy and childbirth is the second leading cause of death globally.[164] Multiple births can endanger the mother’s health and women who have more than four children are at increased risk of maternal mortality.[165]

The low levels of condom availability in the areas also means men and women are less able to protect themselves from sexually-transmitted infections.

Access to Contraception in the Rebel-Held Area

There is nothing you can do if you don’t want to get pregnant.

— Khadija al Haj, Lula village, Heiban County, December 2016.

Human Rights Watch interviewed all the main health providers and found that women and girls have few or no options for controlling their fertility. Overall access to reproductive health information and services is weak. The largest hospital and main health center is run by Catholic providers who do not provide contraception. To the extent that limited quantities of contraception are available, a local rule and cultural norms dictate that women must first get the permission of their husbands.[166] There is also a social stigma around using contraception, according to NGO workers and some of the women interviewed.

In many settings, women prefer long-acting contraceptives, especially if it is difficult to access health services and supplies easily. Only one provider, GED, provides such services –a three-month injectable contraception.[167] GED also regularly distributes a limited amount of condoms from its small hospital in Loweri, and six outreach clinics.[168] GED recorded 519 visits related to family planning in 2016 in its hospital and outreach clinics.[169] Johannes Plate, who works in the GED hospital, said that women often prefer long-lasting contraception to using condoms but that GED does not provide other options such as intrauterine devices (IUDs) or oral contraceptives as women may be displaced or unable to return to the clinic for other reasons. He also said they do not provide contraceptives in pill form as women often do not use it correctly.[170]

The Mother of Mercy, the region’s main hospital, does not provide any contraception because the organization is Catholic.  None of the rebel secretariats of health clinics provide family planning information or services, and only very occasionally stock condoms, which are not included in regular distributions.[171] One SPLM/A-North clinic visited by Human Rights Watch did have some condoms but the manager said that he only gives them away one at a time because he is uncertain when or if he will get more. MSF, which provided family planning services, closed its clinics after they were bombed in 2014 (see above). 

Local informal rules stipulate that women cannot access family planning without first getting permission from their husbands, and GED doctors are only able to provide three-month contraception, when women bring their husbands. Men sometimes beat their wives for using contraception, NGO workers in the region said. “This is because women are supposed to take permission from their husbands to get family planning and men don’t want them to. We need awareness to change this,” Leila Karim, the head of the SPLM/A-North women’s association, said.[172]

Condoms are not widely available in the markets, health workers and authorities said, but two women interviewed by Human Rights Watch also reported that they felt ashamed of buying them as, they said, it is widely perceived that only a “bad” woman would need one. “I want family planning. I don’t want to give birth all the time … (but) condoms are just for women who have affairs with other people,”19-year-old Rania Haidar, already a mother of two, said.[173]  A lack of knowledge and understanding about contraception is also a barrier. “Women are afraid of infertility, that it will be permanent. The other problem is that men are worried about other men, that their wives will go and have sex with other people, especially when he is away,” Umjuma Al Sheikh, one of the midwives working at the Loweri hospital said.

None of the women Human Rights Watch interviewed were currently using or had access to contraception where they lived and only one woman had accessed the GED hospital in Loweri, a day’s walk away for her. None of the other women knew that family planning was available there. Twelve of the 25 women interviewed did not know what a condom was and another three knew what they were but had never seen one.

“There is no way to control, no choice, you just have babies,” Afaf Saeed said.[174] Magda Dorjwaat, also interviewed in the same displaced community, echoed her: “There is no way to control births, you just have to give birth.”[175] Most had given up on trying to control pregnancy but two of the women interviewed were using the “calendar” method.[176]

A few women said that they were uninterested personally in using contraception because they felt they needed to, as one woman put it “replace the people lost in the war.”[177] But all saw the advantages of having family planning available. “Women want fewer children now, four is ideal so that you can feed and educate them,” a former worker at an NGO, said.[178] Fatima Abdelrahman, a 27-year-old woman displaced after government forces attacked and mostly destroyed her village, and struggling to feed her children, said:

Our clinic was looted and destroyed. In Kau there is a clinic, but it is one hour walking from here. But even before they were destroyed there are no condoms here, no family planning. Almost every year I give birth, it would be better if I could space it, it’s tiresome trying to feed all my children already.[179]

More widely available contraception, together with comprehensive sexuality education, could also help prevent early pregnancy leading to marriage or a loss of education for girls and young women.

Women interviewed in December 2016 said that, even though they were already married, they could perhaps complete more of their education if they could space pregnancies. “I would like family planning. I dropped out from school, I would like it so I could go back,” Samia Ramadan, 20 years old and a pregnant mother of two, said sadly.[180] Knowledge of family planning methods was low, and some interviewees did not know that it is possible to space births.

Difficulties Preventing Sexually-Transmitted Infections

The lack of condoms has made fighting sexually transmitted infections (STI), such as syphilis and gonorrhea, more difficult in Nuba. Local authorities have distributed some condoms as protection for both women and men against transmission of some STIs, including HIV, but even at the time of the distribution, supplies were limited. “We gather people and do awareness on HIV. But [because there are so few condoms] all we can recommend is abstinence and monogamy,” the rebel secretariat of health head, Tutu Mustapha Turkash, said.[181]

Testing for HIV is available in a few locations but only one place, the Mother of Mercy Hospital, can check white blood cell counts and then provide antiretroviral medicines in the right doses.

The number of syphilis and gonorrhea cases have increased in recent years, according to all the medical and NGO officials interviewed for this report.[182] No information is available about the overall incidence of the diseases, but, for example, the Mother of Mercy Hospital and clinics saw 64 cases in 2012, 74 in 2013, 107 in 2014, 142 in 2015 and 178 in 2016. Gonorrhea cases also increased, even more sharply, from 39 in 2013, 139 in 2014, 296 cases in 2015 and 896 cases in 2016.[183]  A health worker at the GED Loweri hospital said that they had seen an increase in both diseases in 2016 compared to the year before, and that they regularly treat newborns with congenital syphilis and conjunctivitis caused by gonorrhea.

In the 40 clinics supported by a local NGO, 3,199 cases of STIs were reported in 2014 and 3,462 cases in 2015. Health officials said they saw a much lower number of cases before 2014. Since none of these clinics have labs, these numbers of syphilis and gonorrhea cases, and patients’ treatment, are based on symptoms alone.

In a small town, Hadara, the local nurse said that he sees about two cases a week of suspected gonorrhea or suspected syphilis, and that last year there were more cases for these two diseases than anything else except for malaria.[184]

IV. National and International Legal Obligations

At all times during the conflicts in Sudan, both international human rights law as well as international humanitarian law – as a lex specialis - apply. In this context, Sudan is a party to both the International Covenants – the Covenant on Civil and Political Rights (ICCPR), and the Covenant on Economic, Social and Cultural Rights (ICESCR) – as well as the Convention on the Rights of the Child (CRC), and is a party to the Geneva Conventions and Additional Protocols I and II.[185] Nevertheless, civilians living in rebel-held parts of Nuba mountains have not had access to adequate life-saving humanitarian supplies since the conflict began 6 years ago.

The Sudanese government’s obstruction of humanitarian access flouts its obligations under both national and international law. The SPLM/A-North’s rejection of impartial humanitarian assistance also contravenes its obligations as a party to the conflict.

Obligations to Allow Unhindered Humanitarian Aid

The conflicts between the government and rebel forces in South Kordofan, Blue Nile and Darfur are non-international armed conflicts under international law, and governed by the body of international humanitarian law applicable to internal conflicts.  Sudan is a party to Additional Protocol II, relating to the Protection of Victims of Non-International Armed Conflict, and is also bound by customary international humanitarian law.[186] Under international humanitarian law, a civilian population suffering undue hardship is entitled to receive impartial humanitarian relief essential to its survival, and consent for provision of such relief may not be arbitrarily withheld. [187] All parties to an internal armed conflict, government forces and non-armed groups alike, must allow and facilitate rapid and unimpeded passage of impartial humanitarian assistance for civilians in need. While international humanitarian law permits parties to a conflict to take certain measures to control the content and delivery of humanitarian assistance, they cannot deliberately or willfully impede its delivery.[188]

Parties to an armed conflict must also ensure that humanitarian workers have the freedom of movement to conduct humanitarian operations.  Only in the case of “imperative military necessity” may their movements be restricted; these restrictions should be limited and temporary, such as when relief operations interfere with military operations and could endanger humanitarian workers.[189] The UN Security Council adopted a resolution in 2000 on the protection of civilians in armed conflicts in which it called upon governments and opposition armed groups to “ensure the safety, security and freedom of movement” of humanitarian relief workers.[190]

The rebel SPLM/A-North group’s leadership has the same obligations to allow humanitarian assistance as the government.

Serious violations of the laws of war are war crimes, and in both international and non-international conflicts, attacks deliberately targeted on aid workers or their property are prosecutable as war crimes under the International Criminal Court (ICC) statute.[191] Starvation as a method of warfare, including by willfully impeding relief supplies to deprive civilians of objects indispensable to their survival, is prohibited in all conflicts, although only prosecutable as a war crime before the ICC in an international conflict.[192] Nevertheless, “the intentional infliction of conditions of life, inter alia, the deprivation of access to food and medicine, calculated to bring about the destruction of part of a population,” constitutes the crime against humanity of extermination, when committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack, also in a non-international armed conflict. [193]

Actions by the Sudanese government and SPLM/A-North to block independent and impartial aid agencies to civilians in need in the Nuba mountains violate their obligations under international humanitarian law.

Sexual and Reproductive Health Rights

International and regional laws and treaties ratified by Sudan protect the right to health for all in Sudan, including the rights of women and girls to reproductive healthcare. These include the ICESCR, the African Charter on Human and People’s Rights and the CRC.[194]

The ICESCR articulates the right to health as “the right to the enjoyment of the highest attainable standard of physical and mental health.”[195] The 1981 African Charter on Human and People’s Rights also recognizes this right.[196] Governments have an obligation to take concrete and targeted steps to realize this right using available resources, including international assistance, as expeditiously and effectively as possible.[197] Governments should also ensure a minimum level of access to the essential material components of the right to health, such as the provision of essential medicines and maternal and child health services.[198]

The UN Committee on Economic, Social and Cultural Rights (CESCR) has identified the provision of maternal health services as a core obligation which cannot be derogated from under any circumstances, and which governments should take immediate steps towards fulfilling in the context of pregnancy and childbirth.[199] Such steps include safeguarding the freedom to decide if and when to reproduce, having access to safe and affordable methods of family planning and the healthcare services that will enable women to go safely through pregnancy and childbirth.

The CESCR has also articulated to governments the importance of the availability, accessibility, affordability, and acceptability of sexual and reproductive health care. It has outlined the importance of an adequate number of functioning health care facilities, and ensuring availability of trained and skilled health providers, noting that:

…essential medicines should be available, including a wide range of contraceptive methods, such as condoms and emergency contraception, medicines for abortion and for post-abortion care, and medicines, including generic medicines, for the prevention and treatment of sexually transmitted infections and HIV.[200]

And:

Unavailability of goods and services due to ideologically based policies or practices, such as the refusal to provide services based on conscience, must not be a barrier to accessing services; an adequate number of health care providers willing and able to provide such services should be available at all times in both public and private facilities and within reasonable geographical reach.[201]

International humanitarian law also highlights that expectant and nursing mothers, together with children, are “particularly vulnerable” and should be provided with specific protection.[202]

Women and girls enjoy a right to access health-related information under the ICCPR and IESCR, while the Convention on the Rights of the Child also has a right to health education that includes access to information on preventing early pregnancy.[203]

The Convention for the Eradication of Discrimination Against Women (CEDAW) protects the right of women and girls to decide the number and spacing of their children.[204] Sudan is not a party to CEDAW and despite advocacy by national and international human rights groups and UN agencies, President al-Bashir has said that Sudan will never join it.[205] Nevertheless, as one of the most widely ratified treaties (one hundred and sixty-five states parties, with only 22 countries including Sudan opting out), parts of the law may be considered to reflect standards of customary international human rights law. 

International law stipulates that states should ensure that all can access healthcare without discrimination, for example because of their race or sex.[206]  The civilian population in the Nuba mountains are facing discrimination based on their ethnic identity.

Acknowledgments

This report is written by Skye Wheeler, emergencies researcher in the Women’s Rights Division of Human Rights Watch, based on research conducted in Sudan and South Sudan in December 2016 together with Jonathan Pedneault, researcher in the Africa division.  Alexandra Kotowski, associate with the Women’s Rights Division assisted with logistical support, and Savannah Tryens-Fernandes, associate with the Africa division, provided editorial assistance.

This report was reviewed and edited by Nisha Varia, advocacy director of the Women’s Rights division; Leslie Lefkow, deputy director of the Africa division; Jehanne Henry, senior researcher in the Africa Division; and Diederik Lohman, acting director of the health and human rights division. Babatunde Olugboji, deputy program director, and Aisling Reidy, senior legal advisor, provided program and legal reviews.

Youssef Zbib, the Arabic language website and translation coordinator, arranged for translation of this report into Arabic. Olivia Hunter, publications and photography associate, Fitzroy Hepkins, and Jose Martinez prepared the report for publication. Multimedia production was coordinated by Pierre Bairin, multimedia director at HRW, and Sakae Ishikawa, senior video editor, with additional footage from Anthony Fouchard, freelance journalist and videographer.

Human Rights Watch wishes to thank the scores of women, victims and witnesses in Sudan, and their relatives, who talked to us, despite stigma surrounding sexual and reproductive health, and the courageous Sudanese activists who continue to document and report on abuses.

 

[1] Official population numbers are not available and the conflict has led to mass displacement since a 2010 census took place. Humanitarians working for INGOs in the area estimate that there are 998,780 people living in rebel-held areas. Only roughly 650,000 of them are accessible to aid workers.

[2] Human Rights Watch, Sudan: Eradicating the Nuba, Africa Watch Calls for the United Nations to Investigate Killings, Destruction of Villages and Forced Removals, vol.4, issue 10, September 1992. In this report, Human Rights Watch argued that a systematic campaign by the Sudanese government to remove the Nuba ethnicity from the Kordofan area was in place, and that forced movement of Nuba civilians from their home areas to government-controlled camps, killings and detentions as well as other abuses together amounted to ethnic cleansing. See also Human Rights Watch, Human Rights in Africa and US Policy, July 1994. Human Rights Watch, In the Name of God: Repression Continues in Northern Sudan, vol. 6, no. 9, November 1994.  

[3] The Nuba Mountains Ceasefire Agreement (2002), available at  http://www.sudantribune.com/spip.php?article41880 (accessed February 8, 2017). Southern Kordofan, distinguished by its numerous rocky hills, is one of Sudan’s 18 states and had seen on-off conflict for decades. The SPLA-North currently hold four areas in Southern Kordofan and in next door Western Kordofan, all traditional home areas of Nuba tribes, the “Nuba mountains.” The main town of the rebel-held area is Kauda, which lies in the largest rebel-held area, that includes much of Heiban, Um Dorein and Buram counties. Other rebel held areas lie to the north east and north west of this area and a fourth to the south east, bordering South Sudan. The area is poorly developed, even by Sudanese standards. 

[4] Human Rights Watch, Under Siege: Indiscriminate Bombing in Sudan’s Southern Kordofan and Blue Nile States, December 2012, https://www.hrw.org/report/2012/12/11/under-siege/indiscriminate-bombing-and-abuses-sudans-southern-kordofan-and-blue. For more on the causes of the conflict, see International Crisis Group, “Sudan’s Spreading Conflict (I): War in South Kordofan,” https://www.crisisgroup.org/africa/horn-africa/sudan/sudan-s-spreading-conflict-i-war-south-kordofan (accessed February 8, 2017).

[5] International Criminal Court, Warrant of Arrest for Ahmad Harun, May 1, 2007, https://www.icc-cpi.int/pages/record.aspx?uri=279813 (accessed February 8, 2017).

[6] Comprehensive Peace Agreement between Government of Sudan and the SPLM/SPLA, available at http://peacemaker.un.org/node/1369 (accessed February 8, 2017). The Comprehensive Peace Agreement between the SPLA/M and the government of Sudan included a protocol on the resolution of the Southern Kordofan/Nuba and Blue Nile conflicts, signed in 2004. The protocol promised elections, a popular consultation process and mechanisms to deal with wealth sharing, governance and land tenure problems. Both parties failed to fulfil security commitments and the consultative process was indefinitely postponed in 2011. 

[7] Human Rights Watch, Under Siege. See also, United Nations Office of the High Commissioner for Human Rights, “Thirteenth periodic report of the United Nations High Commissioner for Human Rights on the situation of human rights in the Sudan, Preliminary report on violations of international human rights and humanitarian law in Southern Kordofan from 5 to 30 June 2011,” August 2011, http://www.ohchr.org/Documents/Countries/13thSouth_Kordofan_report.doc (accessed February 8, 2017).

[8] Compiled from Sudan Consortium reports. See for example, http://sudanconsortium.org/darfur_consortium_actions/
reports.html
(accessed February 8, 2017).  

[9] Human Rights Watch interview with Diana Angelo, Heiban town, Heiban county, December 12, 2016.

[10] Rocco Nurri, “Five Years Into Conflict, Refugees Still Flee into South Sudan,” United Nations High Commissioner for Refugees news story, http://www.unhcr.org/news/latest/2016/6/575176254/five-years-southern-sudan-conflict-refugees-still-flee.html (accessed February 8, 2017).

[11] Human Rights Watch, “Sudan: Repression Intensifies After Border Violence,” media release, May 17, 2012, https://www.hrw.org/news/2012/05/17/sudan-repression-intensifies-after-border-violence.

[12] Mohammed Amin, “Sudanese Peace Talks Suspended for the 10th Time,” Africa Review, November 24, 2016.  http://www.africareview.com/news/Sudanese-peace-talks-suspended/979180-2970262-14i5knfz/index.html (accessed February 8, 2017)

[13] United Nations Security Council Resolution 2046 (2012), S/RES/2046 (2012), http://unscr.com/en/resolutions/2046 (accessed February 8, 2017).  The resolution mostly concerned relations between Sudan and South Sudan but also called for peace negotiations between Sudan and the SPLM/A-North and “to permit humanitarian access to the affected population in the two areas, ensuring in accordance with applicable international law, including applicable international humanitarian law, and guiding principles of emergency humanitarian assistance, the safe, unhindered and immediate access of United Nations and other humanitarian personnel, as well as the delivery of supplies and equipment, in order to allow such personnel to efficiently perform their task of assisting the conflict-affected civilian population.”

[14] African Union Higher Implementation Panel, Roadmap, March 21, 2016, http://www.peaceau.org/uploads/auhip-roadmap-signed-080816.pdf (accessed February 15, 2017). The roadmap, which was also eventually signed by Darfur rebel groups, restates the parties’ intentions to end the conflicts in Southern Kordofan, Blue Nile and Darfur, and sign a cessation of hostility agreement leading to a permanent cessation. The parties agreed to negotiate immediate access for humanitarians at the same time as the cessation of hostilities.  

[15] Human Rights Watch interviews with witnesses, displaced people, SPLM/A-North army and administrative officials, December 2016.

[16] For example, government forces stayed in Karkaraya village, Um Dorein county, for seven days after an attack in March 2016 and killed elderly residents who were unable to flee, broke into the town’s small clinic then looted and partly destroyed the premises. The forces also destroyed Karkaraya’s secondary school by driving over it with tanks, and looting the town’s primary school. In nearby Um Serdiba, the primary school was reportedly destroyed by government forces around the same time. Human Rights Watch interviews with civilians, including witnesses and victims, and local authorities in Heiban, Um Dorein, Buram and Delami counties, December 7-14, 2016.

[17] Human Rights Watch interviews, December 2016. For example, in July, SAF-aligned militias attacked the Lima village, west of Kadugli town, on two occasions. In late November, at least two bombs were dropped by Sudanese air force planes near civilian houses in Hajar Bako, and shelling took place in the Ard’Kanan and Nyakima villages, reportedly in retaliation for a SPLA-North attack on government positions in Al-Azraq. During HRW’s visit in December, Antonov aircrafts could be heard circling above Heiban and Delami counties and ongoing shelling was reported in Um Dorein county.

[18] The United States first imposed “comprehensive economic, trade and financial sanctions against Sudan due to its support for international terrorism, ongoing efforts to destabilize neighboring governments, and the prevalence of human rights violations.”  Further sanctions against individuals who were allegedly complicit in violence in Darfur and on government owned or managed companies were then imposed in 2007. See: US Department of State, US Relations with Sudan, https://www.state.gov/r/pa/ei/bgn/5424.htm (accessed February 8, 2017).

[19] “Treasury to Issue General License to Authorize Transactions With Sudan,” US Treasury Department Office of Public Affairs news release, https://www.treasury.gov/resource-center/sanctions/Programs/Documents/sudan_fact_sheet.pdf (accessed February 8, 2017).

[20] Amended Directives and Procedures, Humanitarian Aid Commission, December 15, 2016, On file with Human Rights Watch.

[21] Human Rights Watch interview with senior UN official based in Khartoum, name withheld, February 27, 2017. The visit, connected with UN efforts to prevent the use of child soldiers in conflicts, had still not taken place by mid-May 2015, apparently because negotiations with the SPLM/A-North were still ongoing.

[22] Human Rights Watch, Human Rights Benchmarks for Sudan: Eight Ways to Measure Progress, April 2017, https://www.hrw.org/news/2017/05/03/human-rights-benchmarks-sudan

[23] Human Rights Watch, ‘Sudan’s Human Rights Record and US Sanctions, Testimony of Jehanne Henry at the Tom Lantos Human Rights Commission’, April 4, 2017, https://www.hrw.org/news/2017/04/04/sudans-human-rights-record-and-us-sanctions.

[24] Human Rights Watch interview with H.S., Lula village, Heiban County, December 9, 2016.

[25] Human Rights Watch, Under Siege.

[26] Southern Kordofan, Blue Nile Coordination Unit, Flash Update #14 – February 11, 2017, “Deteriorating Food Security Outlook Following Poor Harvest Assessment.” On file with Human Rights Watch. “Sixteen percent of the population of Blue Nile and 6% of the population of the central region of South Kordofan were identified as severely food insecure during the traditional early harvest season.”

[27] Ibid.

[28] Famine Early Warning Systems Network, “Emergency (IPC phase 4) likely in parts of Southern Kordofan, Jebel Mara,” February 2017, http://www.fews.net/east-africa/sudan/food-security-outlook/february-2017 (accessed April 26, 2017).

[29] Sudan Relief and Rehabilitation Agency (SRRA) SPLM/A-North controlled areas, “Food Shortage in Kau and Warne”, March 11, 2017 (on file with Human Rights Watch). The news release also called “upon United Nation and to the people of good heart and all humanitarian agencies to get and intervene to rescue the needy people in Kau and Warne, and indeed to put more pressure on both parties in Sudan to give humanitarian access to the affected people in SPLM-A/N held areas, in Nuba Mountains, Southern Kordofan and Blue Nile states.”   

[30] Human Rights Watch interview with S.O.B, (name withheld), Tongoli town, Delami county, December 10, 2016.

[31] “Sudan: Bombing Campaign’s Heavy Impact on Children,” Human Rights Watch news release, May 6, 2015. Government bombing has damaged or destroyed at least 22 schools since the conflict began. Only 400 students were in secondary education in the entire region, because of a lack of secondary schools. Human Rights Watch did not research the impact of the conflict, abusive tactics such as aerial bombardment by the government of Sudan and obstruction of humanitarian aid on education but Nuba civil society, authorities and interviewees repeatedly expressed concern that a generation of children were missing out on education. One humanitarian estimated, using figures from a 2010 census, that some 400,000 children in Southern Kordofan and Blue Nile state are out of education or are unable to access quality education. 

[32] Rocco Nurri, “Five Years into southern Sudan conflict, refugees still flee.”

[33] “Sudan: Southern Kordofan Civilians Tell of Air Strike Horror,” Human Rights Watch news release, August 30, 2011, https://www.hrw.org/news/2011/08/30/sudan-southern-kordofan-civilians-tell-air-strike-horror; see also “Sudan Announces Truce in Southern Kordofan,” Al Jazeera, August 23, 2011 http://www.aljazeera.com/news/africa/2011/08/2011823151035653492.html (accessed February 8, 2017).

[34] Ibid, Human Rights Watch. After fighting subsided in the government-controlled Southern Kordofan state capital Kadugli, the government did not permit international humanitarian groups, including UN agencies, to conduct assessments of displaced people even within the town. International humanitarian workers were forbidden from traveling out of government towns to assess humanitarian needs.

[35] Human Rights Watch telephone and Skype interviews with humanitarians (names withheld), November 2016 to February 2017.

[36] Humanitarian Aid Commission (HAC), “Directives of Humanitarian Action 2016,” May 5, 2016, on file with Human Rights Watch. 

[37] Human Rights Watch, Famine in Sudan, 1998: The Human Rights Causes, (New York: Human Rights Watch, 1999), and “Darfur: Humanitarian Aid Under Siege” (Human Rights Watch, May 2006) at https://www.hrw.org/report/2006/05/08/darfur-humanitarian-aid-under-siege; Mark Duffield, Susanne Jaspers et al, Operation Lifeline Sudan: A Review (July 1996). Operation Lifeline Sudan was established following the 1988 famine and was viewed as a groundbreaking model for cross-border humanitarian assistance during ongoing conflict.

[38] Alex de Waal, “Food and Power in Sudan, A Critique of Humanitarianism,” (Africa Rights, 1997), p183-193. Civilians who fled hunger and bombardment into other areas of Sudan were forced to live in ‘peace villages’ where they were starved, tortured, indoctrinated and forced to work on large farms. See also, Human Rights Watch, Human Rights in Africa and US Policy. ‘Despite the residents' desperate need for assistance, the Nuba Mountains have been placed off limits to all but those allied with the government's counterinsurgency scheme.’

[39] Human Rights Watch, Darfur: Humanitarian Aid Under Siege.

[40] “Sudan: Expelling Aid Agencies Harms Victims,” Human Rights Watch news release, March 5, 2009, https://www.hrw.org/news/2009/03/05/sudan-expelling-aid-agencies-harms-victims The government made the announcement shortly after the ICC issued arrest warrants for President al-Bashir for war crimes and crimes against humanity. 

[41]“Khartoum expels Foreign Aid Agencies from Eastern Sudan,” BBC, June 1, 2010, http://www.bbc.com/news/world-africa-18296430 (accessed February 21, 2017). The agencies were allowed to continue to operate in other areas of Sudan.

[42] “Statement attributable to the Humanitarian Country Team in Sudan on the de facto expulsion of UN senior official and OCHA Head of Office Mr. Ivo Freijse,” United Nations Office for the Coordination of Humanitarian Affairs news release, May 22, 1016, https://docs.unocha.org/sites/dms/Sudan/Press_Releases/2016/Sudan_HCT_Statement_on_the_de_facto_expulsion_of_UN_senior_official_and_OCHA_Head_of_Office_Mr._Ivo_Freijsen_22_May_2016_EN.pdf (accessed February 21, 2017).

[43] “Ambassador Rice at U.N. on Sudan, Syria and Russia: Remarks by Ambassador Susan E. Rice, U.S. Permanent Representative to the United Nations, at the Security Council Stakeout on Sudan,” United States at the UN press release, January 17, 2012. https://geneva.usmission.gov/2012/01/18/ambassador-rice-at-u-n-on-sudan-syria-and-russia/ (accessed February 8, 2017). See also, “UN relief chief voices concern over worsening humanitarian situation in Sudan”, UN news release, http://www.un.org/apps/news/story.asp?NewsID=42355#.WJuHmDsrKUk (accessed February 8, 2017). During this press briefing the then-head of OCHA, Valerie Amos, said: “the Government has laid out operational conditions that do not allow for the delivery of assistance by neutral parties in SPLM/A-North-controlled areas.”

[44] “No Crisis in South Kordofan, Sudan Says as Aid Deal Lapses,” French Press Agency, November 6, 2012, http://www.dailynewsegypt.com/2012/11/06/no-crisis-in-south-kordofan-sudan-says-as-aid-deal-lapses/ (accessed February 8, 2017).

[45] The main aim was to provide polio vaccinations, but humanitarians hoped they would get a window of opportunity to also vaccinate against measles. In 2015, more than 4 million children under five years of age were vaccinated against polio in other parts of Sudan. See OCHA, Humanitarian Bulletin Sudan, Issue 47, 16-22 November 2015. http://reliefweb.int/sites/reliefweb.int/files/resources/OCHA_Sudan_Weekly_Humanitarian_Bulletin_Issue_47_(16_-_24_November_2015).pdf (accessed February 8, 2017). Children in Sudan are at risk of the polio virus which remains active in the area in recent years; 196 polio cases were reported in the horn of Africa region in 2013, for example. 

[46] “Security Council Press Statement on Polio Vaccination in Sudan,” UN news release, October 11, 2013, http://www.un.org/press/en/2013/sc11145.doc.htm  (accessed on February 8, 2017).

[47] Human Rights Watch telephone interview with senior UN official (name withheld), December 18, 2014.

[48] Human Rights Watch telephone and in person interviews with UN and NGO workers, January – April 2017, all names withheld.

[49] Under international humanitarian law, consent for delivery of assistance that is exclusively humanitarian, impartial in character and conducted without any adverse distinction, cannot be arbitrarily withheld. However, consent is not arbitrarily withheld if a party to the conflict can prove that the assistance offered is neither exclusively humanitarian or is partial.

[50] For example, “One step forward, two steps back: understanding Sudan’s collapsed peace talks”, Nuba Reports, August 18, 2016 https://nubareports.org/one-step-forward-two-steps-back-understanding-sudans-collapsed-peace-talks/ (accessed April 27, 2017).

[51] Human Rights Watch interview with SPLM/A-North head, Yassir Arman, Whatsapp conversation, March 8, 2017.

[52] Nuba Reports, “Hopes of Possible Peace Dashed as Latest Negotiations Collapse,” August 15, 2016, https://nubareports.org/hopes-of-peace-dashed-as-latest-negotiations-collapse/ (accessed February 19, 2017).

[53] For more on the proposed deal, see Steven Koutsis, Charge d’Affaires, U.S. Embassy, Khartoum, “We urge the SPLM-North to allow humanitarian assistance”, editorial, Sudan Tribune, March 3, 2017, http://www.sudantribune.com/spip.php?article61783 (accessed April 27, 2017),

[54] Human Rights Watch interview with Yassir Arman. See also “Sudan Envoys fail to convince SPLM/A-North to accept U.S. humanitarian proposition,” Sudan Tribune, January 16, 2017. http://www.sudantribune.com/spip.php?article61419 (accessed February 19, 2017),

[55] Amended Directives and Procedures, Humanitarian Aid Commission, December 15, 2016, on file with Human Rights Watch; “USA welcomes Sudan’s new humanitarian directives,” Dabanga, https://www.dabangasudan.org/en/all-news/article/usa-welcomes-sudan-s-new-humanitarian-directives

[56] Human Rights Watch interview with S.M. (name withheld), Lula village, Heiban County, December 9, 2016.

[57] Human Rights Watch interview with N.S., Lula village, Heiban County, December 9, 2016.

[58] The Sudan Consortium, African and International Civil Society Action for Sudan “Gender Under Bombardment: Gender Disparities in SPLA/M-N Controlled Areas of Nuba Mountains, Southern Kordofan,” 2016, p17, http://sudanconsortium.org/darfur_consortium_actions/reports/2016/GenderUnderBombardmentPR.pdf  (accessed April 27, 2017). The authors of the report also found that despite women taking on additional work in the home and as farmers because many men were on the frontline, added responsibilities have not led to any social recognition or additional power in decision-making at home or in the public sphere.

[59] Human Rights Watch interview with Yassir Arman. See also, UN Security Council, Resolution 1325 (2000), S/RES/1325 (2000) http://www.un.org/womenwatch/osagi/wps/ (accessed February 8, 2017). The resolution called for all parties to conflicts to ensure “women’s meaningful inclusion at all levels in further peace negotiations and state-building initiatives.”

[60] Human Rights Watch interview with NGO worker (name withheld), Kauda, Heiban county, December 13, 2016.

[61] This association has worked on domestic violence, advocated against child marriage, and supported women farmers. See also “Gender Under Bombardment,” p38-9. 

[62] Human Rights Watch interview with Hanasi Mohsin, Social Development secretariat, Heiban town, Heiban county, December 12, 2016.

[63] Girls not Brides, “An information sheet: child marriage around the world,” November 2016, http://www.girlsnotbrides.org/wp-content/uploads/2017/01/Child-marriage-around-the-world-Nov-2016.pdf (last accessed March 30, 2017).

[64] Human Rights Watch interview B.B. (name withheld), Tongoli village, Delami county, December 10, 2016.

[65] Human Rights Watch interview N.S. (name withheld), Lula village, Heiban county, December 9, 2016.

[66] Human Rights Watch interview H.S. (name withheld), Lula village, Heiban county, December 9, 2016.

[67] Human Rights Watch interview S.A. (name withheld), Heiban town, Heiban county, December 12, 2016.

[68] Individuals interviewed in other locations did not talk about female genital mutilation, and when asked said that they did not know of any recent cases of FGM in their communities.

[69] Sudan Central Bureau of Statistics/Ministry of Health, “Sudan: Multiple Indicator Cluster Survey 2014, Key Findings,” April 2015, http://reliefweb.int/report/sudan/sudan-multiple-indicator-cluster-survey-2014-key-findings (accessed February 15, 2017). According to the UN Fund for Population (UNFPA), most women and girls undergo FGM before their twelfth birthday. Infibulation, the most severe form of FGM, was banned in 1946 through a change in the penal code. Other forms of FGM are not addressed in Sudan’s laws.

[70] Human Rights Watch interview with Ali Nour, acting head, Social Development and Women’s Rights Secretariat, Kauda, December 8, 2016

[71] Human Rights Watch interview with G.I. (name withheld), Hadara village, Delami county, December 11, 2016.

[72] Human Rights Watch interview with Hanasi Mohsin.

[73] Human Rights Watch interview with S.A. (name withheld), Heiban town, Heiban county, December 12, 2016.

[74] Laws of the New Sudan, The Penal Code, 2003, section 317, https://www.unodc.org/tldb/pdf/Sudan/Penal_Code_2003.pdf (accessed February 15, 2017). The “New Sudan” laws were used during Sudan’s long north-south civil war in areas controlled by the Sudan People’s Liberation Army/Movement (SPLA/M) in defiance of Sudanese Islamic law, before the south Sudanese rebel SPLM/A-North and the government of Sudan signed a peace deal in 2005, which eventually led to South Sudan’s secession. The SPLM/A-North have continued to use these laws in areas they control.

[75] Human Rights Watch interview with Col. Hassan Idris, head of police, Dec 8, 2016

[76] Human Rights Watch interview with Kodi Abd Rahman Harik, head of judiciary, Dec 8, 2016.

[77] In general, women facing domestic violence first turn to other family members and then to community chiefs. Police get involved only when men seriously injure their wives. Some men have been jailed, sometimes for the period the victim is in the hospital.

[78] Human Rights Watch interview with Z.M. (name withheld), Tongoli village, Delami county, December 10, 2016.

[79] Human Rights Watch interview with N.S. (name withheld), Lula village, Heiban county, December 9, 2016.

[80] Laws of the New Sudan, The Penal Code, 2003, section 316, https://www.unodc.org/tldb/pdf/Sudan/Penal_Code_
2003.pdf
(accessed February 15, 2017).

[81] World Health Organization, Guidelines for Medico-Legal care for Victims of Sexual Violence, (Geneva: World Health Organization, 2003), http://apps.who.int/iris/bitstream/10665/42788/1/924154628X.pdf (accessed February 15, 2017), p64.

[82] Population figures in the two areas, estimates from local authorities and service providers in the area, September 2015. On file with Human Rights Watch.

[83] Ibid.

[84] Human Rights Watch interview with a medical doctor (name withheld), Heiban county, December 8, 2016.

[85] World Health Organization, “Universal Truth: No Health Without a Workforce”, 2014, p. 17, http://www.who.int/workforcealliance/knowledge/resources/GHWA-a_universal_truth_report.pdf?ua=1 (accessed March 31, 2017).

[86] Ibid

[87] Human Rights Watch interview with Tutu Mustapha Turkash, head of Health Secretariat, Kauda, Heiban county, December 9, 2016.

[88] Ibid.

[89] The rebel-held areas are not contiguous, there are four ‘islands’ of control. Some areas have even fewer clinics and schools than areas visited by Human Rights Watch and no on-ground international support at all. The deputy governor of the rebel-held area, Sulieman Jabon, said that perhaps as many as 300,000 people live in the ‘Western Jebels’ area, a small area controlled by the SPLM/A-North to the north-west of Kauda, and perhaps 30,000 people live in the Rashad/Abasia/Tagali area and some 35,000 in the Abu Jubeiha area, to the north of Kauda. The Western Jebel area is accessible in the dry season by car but the other two areas are extremely hard to access. Tutu Mustapha Turkash, the rebel civilian administration’s secretariat of health head told Human Rights Watch that medicines are only delivered to some of these two areas once or twice a year and are often carried in on volunteers’ backs, including over front lines. In December 2016, he said that some 50 clinics in the Western Jebels areas have all run out of medicines after the last delivery in June 2016 and that he expects that clinics in Abu Jubeiha area have also run out as no deliveries there have been possible since January 2016.

[90] Human Rights Watch interviews with health staff from SPLM/A-North administration and NGOs, December 2016.

[91] For example, a clinic near Lula village only had amoxicillin and some vitamins for children. The main clinic in Heiban town had run out of all drips and injections. Staff there said they often ran out of key medicines such as antibiotics or antimalarial medicines.

[92] Human Rights Watch interview with James Atai, nurse and head of clinic, Hadara town, Delami county, December 11, 2016.

[93] Human Rights Watch interviews with health staff from SPLM/A-North administration and NGOs, December 2016.

[94] These cases were only those collected by the Mother of Mercy Hospital, and in two of the clinics the hospital supports. “Sudan: Bombing Campaign’s Heavy Impact on Children”, Human Rights Watch news release, May 6, 2015.

[95] “Security Council Press Statement on Polio Vaccination in Sudan,” UN news release, October 11, 2013, http://www.un.org/press/en/2013/sc11145.doc.htm  (accessed on February 8, 2017).

[96] Ibid. In a series of aerial attacks in April and June 2014 on eight separate locations of health facilities and humanitarian supply storages, the circumstances suggest deliberate targeting.

[97] Human Rights Watch interview with Johannes Plate, health worker Cap Anamur - German Emergency Doctors, Loweri, Heiban county, December 13, 2016.

[98] Human Rights Watch interview with S.A. (name withheld), Heiban town, Heiban county, December 12, 2016.

[99] World Health Organization, Maternal Mortality factsheet, updated November 2016, http://www.who.int/mediacentre/factsheets/fs348/en/ (accessed April 26, 2017).

[100] Figure calculated using estimated fertility rates from Sudan, and rough estimates of population of rebel-held areas. World Health Organization, Global Health Observatory data repository, last updated June 17, 2015, http://apps.who.int/gho/data/node.main.CBDR107?lang=en (accessed April 3, 2017). 

[101] Human Rights Watch interview with Nuba humanitarian aid worker, Juba, South Sudan, December 6, 2016

[102] These are standards for humanitarians to determine the extent and quality of any response, not as assessment of government obligations.

[103] UNFPA, “What is the Minimum Initial Services Plan?” undated, http://www.unfpa.org/resources/what-minimum-initial-service-package (accessed February 19, 2017); The SPHERE Charter and Minimum Standards, have global “soft law” status according to the International Federation of the Red Cross, Code of Conduct, 1994, http://www.ifrc.org/en/publications-and-reports/code-of-conduct/ (accessed February 19, 2017). The Sphere Project, Humanitarian Charter and Minimum Standards in Humanitarian Response, 2017, http://www.spherehandbook.org/en/what-is-sphere/ (accessed December 19, 2017).

[104] All primary healthcare facilities should have basic emergency obstetric care – including parenteral antibiotics, parenteral (uterotonic drugs oxytocin), parenteral anticonvulsant drugs (magnesium sulfate), manual removal of retained products of conception, manual removal of placenta, assisted vaginal delivery (vacuum or forceps delivery).

[105] Figure for number of births calculated using estimated fertility rates from Sudan, and rough estimates of population of rebel-held areas, numbers of caesearean sections from Mother of Mercy Hospital and Cap Anamur- German Emergency Doctors. See World Health Organization, Global Health Observatory data repository, last updated June 17, 2015, http://apps.who.int/gho/data/node.main.CBDR107?lang=en (accessed April 3, 2017). 

[106] The “Granada consensus” emerged after a meeting of the World Health Organization (WHO), the UN Population Fund (UNFPA) and the Andalusian School of Public Health. Four priority areas were developed to improve long-neglected sexual and reproductive healthcare in protracted crisis and recovery. See World Health Organization, “Sexual and Reproductive Health During Protracted Crises and Recovery”, Geneva, 2011, http://www.who.int/reproductivehealth/publications/emergencies/hac_bro_2011/en/ (accessed February 19, 2017).

[107] World Health Organization, Sexual and Reproductive Healthcare during Protracted Crises and Recovery, Granada Report, 2011, http://apps.who.int/iris/bitstream/10665/70762/1/WHO_HAC_BRO_2011.2_eng.pdf (accessed March 1, 2017). 

[108] Human Rights Watch interview with B.B, name withheld, Tongoli village, Delami county, December 10, 2016

[109] United Nations Population Fund (UNFPA), Maternal Mortality in Humanitarian Crises and in Fragile Settings, factsheet, November 12, 2015, https://www.unfpa.org/sites/default/files/resource-pdf/MMR_in_humanitarian_settings-final4_0.pdf (accessed February 16, 2017). In conflict or other crisis situations, healthcare infrastructure breaks down and often continues to corrode even after the worst violence in over; communities are forced into displacement away from services, states often are unable (because of access problems or resource shortages), or are unwilling, to provide comprehensive services.  A woman’s lifetime risk of maternal death is 1 in 4900 in developed countries, versus 1 in 180 in developing countries. In countries designated as fragile states, the risk is 1 in 54; showing the consequences from breakdowns in health systems. See World Health Organization, Maternal Mortality factsheet, November 2016.

[110] Globally, most maternal deaths are caused by direct obstetric causes including hemorrhage, sepsis (severe infection spreading through the bloodstream), eclampsia (a pregnancy complication characterized by seizures or coma), unsafe abortions, and prolonged or obstructed labor. Other indirect causes include malaria, tuberculosis, and HIV/AIDS. See World Health Organization, Maternal Mortality factsheet, November 2016, http://www.who.int/mediacentre/factsheets/fs348/en/ (accessed February 15, 2016).

[111] Government of National Unity and Government of South Sudan, “Sudan Household Health Survey,” December 2007, file:///C:/Users/wheeles/Downloads/SHHS%202006-%20Final%20Report%20(English).pdf (accessed April 26, 2017).

[112] “Maternal Mortality Ratio,” The World Bank Group, Maternal Mortality Ratio, 2016 http://data.worldbank.org/indicator/SH.STA.MMRT?locations=SD (accessed 16 February 2017). Research in 2006 suggested that in two parts of Southern Kordofan state MMR, during peacetime, was about 680 per 100,00o births. See A. Bayoumi, “Maternal and childhood mortality in the Nuba mountains, Sudan: A pilot study”, January 2006, http://www.popline.org/node/197013 (accessed February 20, 2017).

[113] The causes of death included “eclampsia, sepsis/shock following prolonged labor at home, shock following ruptured uterus after prolonged labor at home in a multigravida mother.” Email from the director of the hospital, Diocese of El Obeid, Mother of Mercy Hospital, Gidel, to Human Rights Watch, April 1, 2017.

[114] Most of the maternal deaths were attributed to infection and hemorrhage. Email from Johannes Plate, Cap Anamur - German Emergency Doctors, to Human Rights Watch, April 14, 2017.

[115] Email from Johannes Plate, Cap Anamur - German Emergency Doctors, to Human Rights Watch, April 14, 2017.

[116] Email from Plate, April 14, 2017.

[117] The Diocese of El Obeid (who also run the Mother of Mercy Hospital) and Cap Anamur – German Emergency Doctors (GED), each support six outreach clinics. The GED outreach clinics are located in Debbi, Nyukur, Ard Kanan, Korongo, Cambarra and Kororak.

[118] Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF, “WHO analysis of causes of maternal death: a systematic review,” Lancet 2006; 367:1066-1074.

[119] Women who are unwell or need specialist care should have more antenatal visits. See also World Health Organization and others, “Opportunities for Africa’s Newborns”, Geneva,  http://www.who.int/pmnch/media/publications/oanfullreport.pdf (accessed February 20, 2017).

[120] Human Rights Watch interview with Tutu Mustapha Turkash, December 9, 2016.

[121] Human Rights Watch interview with S.M. (name withheld), Lula village, Heiban county, December 9, 2016.

[122] Human Rights Watch interview with health staff from Cap Anamur - German Emergency Doctors, Loweri, Heiban county, December 13, 2016.

[123] World Health Organization, “WHO Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia,” Geneva, 2011, http://apps.who.int/iris/bitstream/10665/44703/1/9789241548335_eng.pdf (accessed February 20, 2017).

[124] Human Rights Watch interview with Gadam Ali, head of health secretariat for Delami county, Delami county, December 10, 2016.

[125] World Health Organization, “Essential Nutritional Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition,” 2013, http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf (accessed February 20, 2017). In emergencies, supplementary feeding with vitamin-fortified foods are often offered to women and children where possible.

[126] Human Rights Watch interview with Tutu Mustapha Turkash, December 9, 2016.

[127] The John Hopkins and the International Federation of the Red Cross and Red Crescent Societies, “Public Health Guide for Emergencies,” chapter 4, reproductive healthcare, 2007, http://reliefweb.int/sites/reliefweb.int/files/resources/Forward.pdf (accessed February 20, 2017).

[128] Email from Plate, April 14, 2017.

[129] Email from hospital director, April 1, 2017.

[130] Human Rights Watch interview with N.S. (name withheld), El Dorein, December 14, 2016.

[131]  Human Rights Watch interviewed all the medical providers working in the area.

[132] Email from Plate, April 14, 2017.

[133] Email from hospital director, April 1, 2017.

[134] Ibid.

[135] Ibid.

[136] Email from Plate, April 14, 2017.

[137] Email to Human Rights Watch interview (name withheld), medical NGO working in Syria, April 18, 2017.

[138] Email to Human Rights Watch interview (name withheld), medical NGO working in Syria, April 25, 2017.

[139]  “Syria: Women and children paying a high price in conflict” Medicins Sans Frontiers press release, January 28, 2013, https://www.msf.ie/article/syria-women-and-children-paying-high-price-conflict (accessed April 27, 2017).

[140] Human Rights Watch interview with B.B. (name withheld), Tongoli town, Delami county, December 10, 2016.

[141] Human Rights Watch interview with Mujuma Hamad, Hadara town, Delami, December 11, 2016.

[142] Human Rights Watch interview with Fatna Al Nur, head of information gathering in secretariat of health, Kauda, Heiban county, December 13, 2016.

[143] The John Hopkins and the International Federation of the Red Cross and Red Crescent Societies, “Public Health Guide for Emergencies,” chapter 4, reproductive healthcare, 2007, http://reliefweb.int/sites/reliefweb.int/files/resources/Forward.pdf (accessed February 20, 2017).

[144] Ibid.

[145] Ibid.

[146] Human Rights Watch interview with midwife Dahabaya Khamis, Cap Anamur - German Emergency Doctors, Loweri, Heiban county, December 13, 2016.

[147] Human Rights Watch interview with B.B. (name withheld), Tongoli village, Delami county, December 10, 2016.

[148] Human Rights Watch interview with the executive director of Heiban county, Heiban town, Heiban county, December 9, 2016.

[149] Human Rights Watch interview (name withheld), Heiban county, December 8, 2016.

[150] Human Rights Watch interview with S.A. (name withheld), Heiban town, December 12, 2016.

[151] Human Rights Watch interview with K.A.H (name withheld), Lula village, Heiban County, December 9, 2016.

[152] Email from Plate, April 14, 2017.

[153] Email from hospital director, April 1, 2017.

[154] Human Rights Watch interview with Tutu Mustapha Turkash, December 9, 2016.

[155] Human Rights Watch interview with N.S. (name withheld), Lula village, Heiban county, December 9, 2016.

[156] Human Rights Watch interview with S.M. (name withheld), Lula village, Heiban county, December 9, 2016.

[157] Human Rights Watch interview with James Atai, December 11, 2016.

[158] Human Rights Watch interview with Tutu Mustapha Turkash, December 9, 2016. 

[159] Cap Anamur – Germany Emergency Doctors (GED), have provided 1, 776 delivery kits to women using their outreach clinics.

[160] Human Rights Watch interviews with staff members of Heiban town’s main clinic, Heiban county, December 9, 2016.

[161] Human Rights Watch interview with Raja Ibrahim, KODI organization, Kauda, Heiban county, December 13, 2016.

[162] Human Rights Watch interview with K.A.H (name withheld), Lula village, Heiban County, December 9, 2016.

[163] Being unable to plan families and experiencing multiple pregnancies can negatively impact women’s wellbeing in many ways. Becoming pregnant again soon after giving birth, before the body has had a chance to recuperate and build up stores of iron again, can negatively impact a woman’s health and make it more likely that a woman dies in childbirth. The World Health Organization recommends a 24-month interval between the birth of one child and the conception of the next “to reduce the risk of adverse maternal, perinatal and infant outcomes. WHO recommends that after a miscarriage or induced abortion, women wait six months before getting pregnant again. Multiple births are dangerous, women who have already had many births are advised to prevent further pregnancies. Evidence suggests that women who have more than 4 children are at increased risk of maternal mortality; World Health Organization, Contraception and family planning, fact sheet, December 2016, http://www.who.int/mediacentre/factsheets/fs351/en/ (accessed December 19, 2017); World Health Organization, “Report of a WHO Technical Consultation on Birth Spacing,” June 2005, http://apps.who.int/iris/bitstream/10665/69855/1/WHO_RHR_07.1_eng.pdf (accessed February 19, 2017).

[164] World Health Organization, “Adolescent Pregnancy,” fact sheet, September 2014, http://www.who.int/mediacentre/factsheets/fs364/en/ (accessed February 19, 2017). WHO campaigns to “create understanding and support to reduce pregnancy before the age of 20.”

[165] World Health Organization, “Report of a WHO Technical Consultation on Birth Spacing.” ;World Health Organization, “Adolescent Pregnancy.

[166] Cap Anamur - German Emergency Doctors told Human Rights Watch that because of this rule, they only give injectable contraception to women when their husbands come with them to the clinic and agree. The humanitarian wing of the SPLM/A-North, the Sudan Relief and Rehabilitation Agency, said that this rule is in effect, but Human Rights Watch could not confirm it was formalized into a law or written regulations.

[167] Human Rights Watch interview with health staff from Cap Anamur - German Emergency Doctors, December 13, 2016.

[168] About 5,000 every 6 months.

[169] Email from Plate, April 14, 2017.

[170] Ibid.

[171] Human Rights Watch interview with Tutu Mustapha Turkash, December 9, 2016.

[172] Human Rights Watch interview, Leila Karim, head of women’s association, Kauda, Heiban county, December 13, 2016.

[173] Human Rights Watch interview with M.S., Um Dorein county, December 14, 2016.

[174] Human Rights Watch interview with N.S., Lula village, Heiban county, December 9, 2016.

[175]Human Rights Watch interview with S.M., Lula village, Heiban county, December 9, 2016.

[176] The calendar method, also called the rhythm method or the calendar rhythm method, is a form of natural family planning. To use the rhythm method, women track their menstrual history to predict when they will ovulate to determine when they are most likely to conceive.

[177] Human Rights Watch interview with S.W. (name withheld), Heiban town, Heiban county, December 12, 2016. 

[178] Human Rights Watch interview with N.S., Lula village, Heiban county, December 9, 2016.

[179] Human Rights Watch interview with S.J. (name withheld), Karkarai, Um Dorein county, December 14, 2016.

[180] Human Rights Watch interview with R.H. (name withheld), Gidel, Heiban county, December 12, 2016.

[181] Human Rights Watch interview with Tutu Mustapha Turkash Kauda, December 8, 2016.

[182] Human Rights Watch interview, (name withheld), Heiban county, December 8, 2016.

[183] Email from hospital director, April 1, 2017.

[184] Human Rights Watch interview with James Atai, December 11, 2016,

[185] Sudan became a party to the ICCPR and ICESR in 1986 and the CRC in 1990. Sudan became a party to the Geneva Conventions and their Additional Protocols in 1957 and 2006 respectively.

[186] Sudan became a party to the Additional Protocol (II) to the Geneva Conventions of 1977, on July 13, 2006.

[187] Article 18(2) of Protocol II, applicable in non-international armed conflicts, states: “If the civilian population is suffering undue hardship owing to a lack of the supplies essential for its survival, such as food-stuffs and medical supplies, relief actions for the civilian population, which are of an exclusively humanitarian and impartial nature and which are conducted without any adverse distinction, shall be undertaken subject to the consent of the High Contracting Party concerned.”

[188] ICRC, Customary International Humanitarian Law, rule 55.

[189] ICRC, Customary International Humanitarian Law, rule 56.

[190] U.N. Security Council Resolution 1296 (2000).

[191] Rome Statute of the International Criminal Court articles 8(2)(b)(iii) and 8(2)(e) (iii).

[192] Rome Statute of the International Criminal Court article 8(2)(b)(xxv).

[193] Rome Statute of the International Criminal Court (1998), articles 7(1)(b) and (2)(b).

[194] Sudan acceded to the International Covenant on Economic, Social and Cultural Rights (ICESCR) on March 18, 1986. See United Nations Treaty Collection, International Covenant on Economic, Social and Cultural Rights page, https://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV-3&chapter=4&clang=_en (accessed February 14, 2017); Sudan signed the African Charter on September 3, 1982 and ratified the charter on February 18, 1986. See African Commission on Human and People’s Rights, Ratification Table: African Charter on Human and People’s Rights,  http://www.achpr.org/instruments/achpr/ratification/ (accessed February 14, 2017); Convention on the Rights of the Child, art. 28. Sudan signed the convention on July 24, 1990 and ratified it the following month, on August 3, 1990. See United Nations Treaty Collection, Convention on the Rights of the Child page, https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV-11&chapter=4&clang=_en (accessed February 14, 2017). 

[195] International Covenant on Economic, Social and Cultural Rights (ICESR), article 12 (1), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976.

[196] African [Banjul] Charter on Human and People’s Rights, article 16 (1), adopted June 27, 1981, OAU Doc. CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), entered into force October 21, 1986.

[197] ICESCR, art. 2 (1), and see General Comment No. 3, The nature of States parties’ obligations (art. 2, para. 1, of the Covenant), January 1, 1991.

[198] ICESCR, art. 12.

[199] UN Committee on Economic, Social and Cultural Rights, “CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art 12), http://www.ohchr.org/EN/Issues/Education/Training/Compilation/Pages/e)
GeneralCommentNo14Therighttothehighestattainablestandardofhealth(article12)(2000).aspx
, paragraph 14, (accessed March 1, 2017).

[200] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 22 (2016) on the Right to sexual and reproductive health (article 12 of the International Covenant on Economic, Social and Cultural Rights)” http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovLCuW1a0Szab0oXTdImnsJZZVQfQejF41Tob4CvIjeTiAP6sGFQktiae1vlbbOAekmaOwDOWsUe7N8TLm%2BP3HJPzxjHySkUoHMavD%2Fpyfcp3Ylzg, para.13, (accessed March 1, 2017).

[201] Ibid. para 14.

[202] Article 23 GC IV and Article 70 (1) AP1

[203] CRC, art. 28.

[204] CEDAW, art.16 (1)(e)

[205] “Sudan: Bashir says Sudan will not sign CEDAW Convention”, Panafrican News Agency, Dakar, January 14, 2001, http://allafrica.com/stories/200101140001.html (accessed February 16, 2017).

[206] Report of the special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, February 2004, E/CN.4/2004/49, para. 41; See also CEDAW, ‘States parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services including those related to family planning’.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am
Posted: January 1, 1970, 12:00 am