When on 20 May 2019 the Ugandan Cabinet approved the phased creation of 15 cities across the country, I was excited by the possibility that existing hospitals in those new cities would be transformed tremendously to bring them up to city standards. My optimism that I would see new “Mulago hospitals” in the newly created cities was high (Mulago is Uganda’s main national referral hospital founded in 1913). And yet, to the present day, I am left puzzling about when the regional referral hospitals in the baby cities will be elevated to national referral hospital level.

Uganda’s health facilities are classified into seven levels based on the services they offer and the operational area they are intended to serve. The lowest level is Health Centre level one (HC I), rising through levels two and three to Health Centre Level four (HC IV); Above that are General hospital, Regional Referral hospital and National Referral hospital respectively. The country is blessed with 139 general hospitals and 14 Regional Referral Hospitals. The 05 National Referral Hospitals are Mulago National Referral Hospital, Butabika National Referral Hospital, China-Uganda Friendship Hospital, Kawempe National Referral Hospital and Kiruddu National Referral Hospital. All five are situated in Kampala and within central region.

Even though northern Uganda is indisputably peaceful, a significant number of victims and survivors of the Lord’s Resistance Army (LRA) rebellion, as well as many of the refugees Uganda generously hosts, are still far from healing after decades of war. Many nurse different forms of conflict-induced physical and psychological harms that require critical rehabilitation services that go beyond the scope of generic services. For them, accessing national referral hospitals in Kampala has for decades been challenging. While suffering from ailments that cannot be addressed at the level of health centers and regional referral hospitals, the costs of accessing national referral hospitals remain extremely high for many people across Uganda in terms of transportation, feeding and medical bills. Additionally, these costs are a huge barrier to social support visitation from informal support networks such as family members, relatives, neighbors and friends that often contribute to emotional, psychological and medical recovery of patients.

While the two best known national referral hospitals in Uganda, namely Mulago and Butabika, have done wonders in providing much needed quality health care and treatment service in Uganda, the need to extend such capacity across the country is therefore great. The elevation of seven (7) municipalities into cities in July 2020 by the Parliament could offer a roadmap for strategic health service transformation and popular access to specialized services. If national referral hospitals could be unveiled in the new cities, it would decentralize specialized medical services and help in leveraging the existing national referral hospitals that are currently overwhelmed by patient numbers, in the process enabling sustainable healing and better health services in Uganda.

In addition to building the capacity to respond to the harms of the past, upgrading regional hospitals to National Referral Hospital status should also be done with an eye to Uganda’s hoped for future; just as in other developed and developing countries worldwide, urbanization and the emergence of cities is usually accompanied by a rise in industrialization. In the case of northern Uganda, the government and citizens should prepare to respond to any health hazards related to such development. Having specialized health services will help in offering preventive and therapeutic support to vulnerabilities and ailments that might emanate from exposure to pollutants and waste toxins, as well as industrial and road accidents.

Benchmarking capabilities: whether the new cities are capable of transitioning the regional referral hospitals to national referral facilities.

When a victim of the Lord’s Resistance Army (LRA) war recently asked me why she could not be treated for her problems in Gulu, I felt disempowered and stammered in my efforts to respond to her. Although she was being medically supported by the Refugee Law Project (RLP) through St Mary’s Hospital Lacor, doctors there had referred her to Mulago Hospital because they could not extract splinters that she had retained under her scull for twenty years and that had been causing her constant headache and nose bleeds. “Why”, she asked me, “do the doctors from Gulu have to refer me [to Kampala], yet I heard that some conjoined twins were separated from Soroti Regional Referral Hospital in April 2021?” In her quest for healing she had witnessed a number of surgeons support and bring about recovery in people whose cases she believed were more complicated than her own. She therefore assumes that they are also capable of helping her and is frustrated when they say they cannot.

When elevated and fully supported, the existing regional referral hospitals in the newly created cities can do wonders, as exhibited in the case of successful complex surgery performed at the former conflict-affected Soroti city (formerly district). It attracted nationwide acknowledgement and hope for more specialized surgical successes. Interestingly, the office of the former Speaker of the Ugandan Parliament (Honorable Rebecca Kadaga) invited the Senior Surgeon from Soroti Regional Referral Hospital, Dr Joseph Epodoi and his team, for heroic recognition by the Parliament after they successfully separated conjoined twins in April 2021. I suggest that such acknowledgement should be followed by elevation of the hospital’s status, as well as that of other regional referral hospitals in northern Uganda, as a contribution towards rehabilitating the general conflict-affected communities across the regions.

The above victorious surgery was performed in the case of conjoined twins delivered through caesarian section from Amuria Health Center IV to a senior three student who became pregnant during the Covid-19 induced lock-down. It triggered optimism that similar miracles could still happen to war victims with long-standing surgical dilemmas, as well as other citizens with urgent surgical needs, particularly if the government can vertically transform the hospitals in the new cities. Despite the scientific explanation that conjoined twins occur when the hormones responsible for separating the twins are faulty, the case reminded me about ordeals from Obalanga massacre survivors during a memory dialogue in 2019 where they said they are anticipating seeing more complex impacts of the war such as birth deformities due to the chemical effects of combat explosives and bombing.

Similarly, since 2013 to present (2021), Refugee Law Project (RLP) has been involved in screening and supporting surgical treatment and rehabilitation of war victims with serious profound war harms at Lacor hospital. A number of critical surgical cases have been referred to Mulago National Referral Hospital, particularly cases involving hip replacement, bullets/splinters stuck in between bones, near the heart or brain and other delicate organs/body parts. Lacor have been working closely with Gulu Regional Referral hospitals by making cross referrals.

The recent establishment Gulu, Arua and Lira as cities is a huge blessing for post-conflict northern Uganda. I view it as a golden opportunity to be tapped and fronted to steer sustainable rehabilitation services for war victims grappling with disturbing unaddressed wartime injuries that require specialized services that are currently far from reach. Post-conflict communities struggle with unique vulnerabilities and multiple health challenges to the point where some have almost turned health centers and general hospitals into their homes due to the frequency of their visits. Unaddressed medical war ailments in the north have contributed vehemently to daunting disability and poor health, as well as bitterness among victims and survivors struggling to reintegrate and rebuild life amidst the ruins created by war. Having specialized national referral hospitals in post-conflict communities would revive hope among the many wartime victims of injustices who have lost faith that they will ever access specialized medical, surgical and mental health services they need.

Due to lack of national referral hospital in post-conflict communities in greater northern Uganda, some NGOs and mass media have been stretching their helping hands and playing a pivotal role in advocating for financial support towards transportation, feeding and treatment of vulnerable critically ill patients for specialized health services in Kampala and abroad. Decentralizing multiple specialized health services from the capital to newly created cities will reduce burdens on well-wishers and Samaritans’ purses.

Stakeholders should remember that good health is indispensable and critical for productive participation of citizens in national development and peace building. Further, good health boosts individual, household and national levels of income, which in turn can help in reducing income inequality and increase the governmental tax base of productive, healthy citizens. The government should prioritize health sector reforms and consolidate institutional reforms to elevate and equip health facilities, and to craft alliances for appropriate health financing to accelerate Uganda’s progress towards better health indices. The journey is demanding and the struggles should embrace public support and stakeholders’ participation as well as good political will.

The right to health is fundamental and my dream of seeing many needy Ugandans accessing quality health services from national referral hospitals by foot, boda-boda, bicycle or simple taxi services is still alive.

By Okot Benard Kasozi, Senior Psychosocial Research and Advocacy Officer

Conflict, Transitional Justice & Governance Programme, Refugee Law Project, Gulu Office

Refugee Law Project (RLP)

Gulu Field Office

Looking forward to your comments on: This email address is being protected from spambots. You need JavaScript enabled to view it.

A brief version of this blog was published as an opinion piece in The Monitor, 11 September 2021

When leaders from government, business, and civil society met on 23 September 2019 to announce potentially far-reaching steps to confront climate change at the United Nations Secretary-General’s Climate Action Summit in New York, Refugee Law Project (RLP) had just completed its 9th Institute for African Transitional Justice (IATJ) under the theme: ‘Environmental Destruction: The Transitional Justice Issue of the Future?’. 

On 6 December 2016, Dominic Ongwen’s trial before the ICC in The Hague began. He was charged with 70 counts of war crimes and crimes against humanity, allegedly committed during LRA attacks on Internally Displaced Persons (IDP) camps Lukodi, Odek, Pajule and Abok in Northern Uganda. He denied all charges. More than four years later, the Court reached its verdict: Guilty on 61 of the 70 charges.

When a victim of gross human injustice reacted to the ICC’s verdict in the Dominic Ongwen case by saying that “Today, the Justice manna has fallen from The Hague to the people of Lukodi”, the statement raised intriguing questions about the possible therapeutic gains for victims the Lord’s Resistance Army (LRA) terror in Northern Uganda. Will 4th February 2021, the day the ICC verdict criminalized Dominic Ongwen for 61 of the 70 counts against him, come to be seen as marking a turning point in the lives of victims and survivors? One survivor certainly believed so:

“Even though I cried too much today while listening to the ruling on radio, today is my healing day and I feel psychologically relieved because the court has wiped away my tears by confirming that someone by the name Ongwen is responsible for the killing of my 6 family members and ugly deeds that people cannot forget in Lukodi here”

Such feedback from affected victims speaks volumes about their pursuit of justice and psychological recovery, and powerfully elucidates the depth of their feelings and perspectives on criminality, justice and mental health recovery. Previously unasked questions about the role of ICC trial and its possible implications for a paradigm shift in victims’ mental health in post-conflict can now, following the verdict, be examined and showcased.

Wounding the wounded

Like other war victims in Northern Uganda who have long been waiting for the fulfilment of promises and pledges of compensation and reparation made by top leaders in Uganda, victims in Ongwen’s case have also had their own share of frustration with the ICC and have been demanding a speedy court process. Indeed, bearing and nursing the pain and the wound of waiting for the verdict and conclusion of the case was a nightmare for many victims. The delays were psychologically aggravating as they also saw some of their distressed colleagues pass away before receiving redress. During Refugee Law Project outreach and counseling sessions, some clients have reported developing hypertension, heart attack and symptoms of psychopathology such as; post-traumatic stress disorders, psycho-somatization, anxiety disorders, depression and unending harmful imagination and other psychiatric manifestations during the “wait for ICC ruling”. One can only imagine what that means for victims involved in the even longer-running trial of Thomas Kwoyelo at the International Crimes Division (ICD) of Uganda’s High Court. And what of the thousands whose tormentors either have not yet defected the rebellion or - the victims claim – have come out of the bush and been gainfully compensated with “bread and butter” by the Government through integration into para-military/military, as well as given Amnesty for their perpetration of crimes against civilian population?

In short, there are thousands for whom still unaddressed gross human rights abuses and violations during the protracted armed insurrection between the LRA and the GoU continue to generate daunting individual and collective trauma associated with different kinds and layers of victimization and violations witnessed, experienced or heard about in conflict-affected communities across the region. Moves towards sustainable psychological recovery and trauma healing have largely stagnated, as exhibited by relapses, haunting narratives of traumatic memories, common post-traumatic stress reactions, and unending bitterness associated with traumatic experiences. All of these suggest a lag in recovery and that trauma survivors have not yet psychologically recovered from their hostile and unjust past.

However, when on 12 November 2020 a press release from the ICC stated that the verdict would be read out in public on 4 February 2021, and that this would either acquit or convict the accused, the emotional terrain changed and longstanding public complaints that the court was taking too long or even forever reduced. This time round, optimism was high among conflict-affected people in the region.

The Psychology of a Legal Process

In recent years, the pathology of trauma has gained wider acknowledgement as a major psychosocial, psychological and public health burden in conflict-affected societies across the globe. Trauma healing and mental health recovery for victims of violence have been associated with the application of psychotherapeutic approaches to assess, diagnose, treat and/or manage symptoms.

As a transitional justice researcher and practitioner, the recent ICC verdict is starting to make me think that psychological recovery is not entirely a product of psychological therapy such as counseling: It can also arise from various combinations of psychotherapeutic and non-psychotherapeutic interventions in a manner which is satisfactory and attested to by the persons concerned. Victims from Lukodi, for example, said they were involved in the ICC court processes from pre-trial to conviction, and are now happy with the ruling.

As a trained counselor who has worked with RLP for over 10 years, I can confirm that clients’ presented complaints are sometimes too complex to counsel, especially when client themselves believe that talk therapy cannot aid their psychological recovery. For example, I still remember a genuine challenge from a physically disabled female survivor of massacre, gunshot and sexual violence in 2019. During a victims’ consultation in Lukodi on the ICC proceedings, she broke down in tears and said;

“Benat (instead of Benard), I know that counseling is good but I don’t think this counseling will repair my war wounds, it will not resurrect my boy whose name is on the monument among the people brutally killed in Lukodi in 2004, and neither will it address the pain associated with guilt and humiliation brought by the rebels who slept with me like an animal in the bush. I will be happy when God answers my prayers to see Ongwen serving sentence and if he is not the one responsible, the same God should show us or report the person to ICC Court - but many people say that he is the one”.

Notwithstanding the existence of deeply divergent views among LRA victims and affected communities over forgiveness and prosecution, it is apparent that, for those who support prosecutions, the verdict offers potential psychological gains. For them, given the nature, magnitude and impacts of crimes committed in the region, impunity in this case would be seen as reinforcing the prevailing prevalence and magnitude of wartime trauma in northern Uganda.

“We can now sleep” was a common phrase uttered by victims from Lukodi after the declaration that Ongwen was responsible for 61 counts. To me, it reflected a mental satisfaction that doubled as a sleeping pill delivered as a by-product by the court to victims who had been grappling with sleeping problems and crime-induced nightmares. For them, sleeping peacefully when their justice dilemma remained unresolved was unimaginable. Equally, once the verdict was delivered, they could not miss the opportunity to share their happiness and thoughts about it.

Similarly, the reaction of people of Lukodi, many of whom are massacre survivors, seemed to reflect the common Christian phrase that “the truth will set you free”. They responded to the verdict by arguing that the ICC’s “fair judgement” will heal them and set them free from the bondage of physical war injuries, prolonged trauma, grief and psychological distress associated with gross human rights violations by the rebels of the Lord’s Resistance Army (LRA) under the command of Ongwen. Further, they expressed optimism that they would benefit from the ICC-ordered reparation and rehabilitation benefits for those people whose wellbeing has been constrained by the violations. This, therefore, will potentially promote and consolidate the psychological benefits arising from the ruling.

Is the ICC ruling a substitute or complementary to psychotherapy for victims of trauma in Northern Uganda?

I believe psychological recovery is a work in progress. The potential of courts to manage and even leverage any psychological gains attained from a particular verdict depends upon progressive use of multidimensional and multi-disciplinary approaches that touch the broad spectrum of impacts related to human rights violations, including their psychological/emotional, economic, political, religious and cultural dimensions.

Appropriate post-conflict trauma healing and rehabilitation can be envisioned in pragmatic efforts by different stakeholders to approach healing according to their mandate, expertise and ability as well as appropriate mainstreaming and integration of formal and informal mechanisms. While psychotherapy and psychiatric interventions are indispensable in their pursuit of critical specific healing and recovery-tailored objective(s), the psychological healing that is a by-product of other interventions such as legal remedy and livelihood support should be more proactively appraised. In short, the most effective remedies will require a range of stakeholders to walk with the victims throughout the pre- and post- verdict/punitive periods, and to follow-up on ICC remedy to victims of the crimes through the Trust Funds for Victims (TVC).

Take-home from the process - building for the future!

The ambiguities involved in the prosecution of a former child soldier (abductee) need further analysis and comprehension by the legal regime. This will help ensure that people who are pro-Ongwen and who see forgiveness, Amnesty or a lenient sentence as more appropriate, are also accommodated in the psychological recovery process.

Given that formal courts are structured around a win-lose structure (for criminal cases), it is important to embrace victim protection not from only a legal angle but also from a more psychological point of view. This requires the help of psychosocial and mental health professionals deployed specifically to aid throughout and after the court process to ensure that victims and witnesses are involved all through the process and psychologically prepared to face the reality of the court ruling, whichever way it falls. This will help them learn to control and manage their excitements, expectations and hopes in a manner that will protect them from eventual shocks, re-traumatization, possible self-harm, aggression or over excitement and its possible negative resultant consequences. This is particularly the case if there are appeal applications that could result in court overturning the first verdict, as happened in the case of Jean-Pierre Bemba.

The judgement should set a precedent for combating impunity and promotion of human rights protection as well as respect for the laws of war. Further, the court should clarify and allay fears among formerly abducted people about any future potential collective prosecution. It should encourage proper rehabilitation, reintegration and demilitarization of minds and behaviors for peaceful co-existence, and lasting enjoyment of Amnesty given by the Ugandan Government. I believe that the trial will contribute substantially to promoting trust and hope in the formal justice processes at local and international levels so that people begin to appreciate legal redress for justice concerns beyond wartime injustices.

By Okot Benard Kasozi, Senior Psychosocial Research and Advocacy, under Conflict, Transitional Justice & Governance (CTJG) Programme, Refugee Law Project, Gulu Field Office
This email address is being protected from spambots. You need JavaScript enabled to view it./okotbkasozi&gmail.com

Every 30^th August is commemorated as the International Day of the Disappeared. In the wake of conflict or other situation of human rights violations the fate of many remains a mystery; thousands of individuals and families are unaware of the fate of their loved ones; are they still alive or have they died as a result of war or conflicts?

Uganda is not without its fair share of enforced disappearances of people from Independence to date. Indeed, nearly every part of Uganda has suffered conflicts which have led to thousands of missing persons.