Mysterious visitors started drifting in on the second morning of a mid-December training for Tanzanian reproductive health providers. First, organizers said, a woman entered the conference room of the Dar es Salaam hotel, announced herself as a BBC journalist and took a seat. Then unidentified men started coming and going.
“It should have been a big red flag for us,” said Nguru Karugu, health and rights consultant for the Open Society Initiative for Eastern Africa, a human rights-focused grant-maker that organized the meeting.
Despite the interruptions, organizers continued the sessions helping representatives from eight different NGOs chart development strategies. Their organizations had been selected for the training because they provide health services to key populations — vulnerable communities such as sex workers and men who have sex with men, who often face discrimination in public facilities. Though local NGOs, organizers said some of the groups receive funding that originates with major bilateral donors, including the United States.
As the participants broke up for lunch, non-uniformed security officials swarmed the hotel, according to organizers and witnesses. Together with the unexplained attendees, they shut down the meeting and detained eight of the participants.
“They were put in police cars with sirens and everything,” Karugu said.
All eight detainees were released later in the day and no charges have been brought, but police officers have retained some of their identification documents and have summoned four Tanzanian participants for follow up questioning several times since, according to Joan Chamungu, a health activist who is involved in organizing their legal defense.
Karugu said it appears the shutdown was the latest in a string of Tanzanian government actions against organizations that are or appear to be providing services and assistance to the country’s homosexual community. Over the past year, officials have raided a well-known civil society group, suspended HIV projects aimed at men who have sex with men and banned the distribution of lubricants.
As a result of the apparent crackdown, the groups at the December meeting as well as others working in the sector are dramatically restricting the health services they offer — not just to MSM but to all key populations, out of fear that they will draw the government’s ire.
Experts warn that this will have significant consequences for the health of all Tanzanians. The moves are also pitting the government against donors and organizations that have invested heavily in improving it. That includes the United States and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which make outsized contributions to Tanzania’s health sector.
A policy of access
In fact, Tanzania’s health sector has shown a willingness recently to engage with the gay community, said OSIEA’s Executive Director Mburu Gitu. This is due, in part, to the influence of the donor governments and international bodies that foot nearly 40 percent of the country’s health budget, according to the most recent statistics, as well as an understanding that marginalizing one community jeopardizes the health of the entire country.
The country’s HIV epidemic lays this reality bare. The general adult HIV prevalence rate is 5.1 percent, according to the ministry of health but much higher in key populations. Within Tanzania’s MSM population, for instance, officials estimate it to be at least 22 percent. Many of those men — more than half by some estimates — also maintain heterosexual relationships.
Ostracizing those individuals from health facilities and effectively blocking them from treatment — which both extends their lives and dramatically reduces their risk of transmission — makes it more likely they will spread the disease to their partners, regardless of gender.
“If we want to have a country free from HIV infection, we should increase the rate of tolerance to marginalized groups,” said Chamungu, who is also the executive director of the Tanzanian Network of Women Living with HIV/AIDS. “We should make sure all commodities are available to all groups, regardless of people’s sexuality.”
Tanzania’s national HIV/AIDS framework, released in November 2013, echoes that logic. It calls for the “review and improvement of the legal policy and social environment that encourages access for under-served and key populations.” Chamungu credits improved services to key populations with contributing to a 20 percent drop in new infections between 2010 and 2015.
Change in course?
That policy appears to be undergoing a reversal.
President John Magufuli has made no public comments about homosexuality, but high-profile anti-gay episodes — especially in the health sector — have become increasingly frequent since he took office in November 2015.
One of the first of those incidents might also have been one of the most telling. In July, his government banned the importation and sale of lubricants, even though UNAIDS encourages the distribution of water-based lubricants to reduce the risk of condom failure. Minister of Health Ummy Mwalimu justified the move by arguing that the products encourage homosexuality.
This marked a turning point for the ministry, Gitu said: Being perceived as counteracting homosexuality supplanted best public health practices, at least in this instance.
“Tanzania has, like many other parts of this region, found a way of living with these difficult debates,” he said. “They recognize that there are different views about the key populations, but governments have tended to say they have every right to access public health services. This sudden reversal doesn’t make sense to any of us.”
Around the same time, the regional commissioner of Dar es Salaam, Tanzania’s largest city, called publicly for a crackdown on homosexuality. Days later security forces raided the offices of local NGO Community Health Education Services and Advocacy, which provides health education and services to key populations, including MSM.
“The point was to see if they were promoting homosexuality,” said Karugu, whose organization has provided support to CHESA in the past. Instead, security forces found government policy documents that laid out strategies for improving health care access for key populations, including MSM. Those policies include improving HIV counseling and testing in remote communities and then linking patients to facilities that can provide services.
In October, Mwalimu announced she was suspending HIV prevention programs for MSM until the government developed a standardized package of services. In a statement, she wrote the government would continue to collaborate on HIV interventions that are “internationally acceptable but which are in line with the country’s laws, traditions and customs.”
A system on lock down
Following the October statement, health organizations and civil society groups say they are unclear what services are still allowed — or disallowed. They were only further confounded when police raided the December meeting, which was focused broadly on reproductive health for all key populations, not exclusively MSM.
In the absence of a statement from the Magufuli’s office, advocates are not even sure who is driving the anti-homosexuality agenda. The president has gained international recognition — and increasing blowback — for his unilateral moves to address corruption. There is some suspicion the anti-homosexuality efforts might be an example of fellow officials launching individual initiatives they hope might also gain them popularity.
Regardless of the source, the effect is devastating health access for the country’s already-marginalized communities.
“There are populations who are not willing to access services,” Karugu said. “I cannot see any provider in Tanzania now providing a [key population] program for fear they may be raided.” This extends to internationally backed programs. At least one U.S.-funded MSM outreach program was shuttered following the minister’s pronouncement, according to The Washington Post.
Closing down services is especially dangerous for patients receiving HIV or tuberculosis treatment, an interruption of which could generate drug resistance. But it also means, Karugu said, that people might not seek out basic medical care, which could just as easily prove life threatening.
OSIEA is hoping the most recent incident might finally prompt a full-throated response from the bilateral donors and international agencies that buoy Tanzania’s health system. The United States, through its President’s Emergency Plan for AIDS Relief, funneled more than $290 million in the country in the 2015 fiscal year for HIV activities, alone.
A U.S. official, speaking on background because of the sensitivity of the issue, said the American government has “been consistent in expressing concern on the statements and actions taken by certain Tanzanian officials targeting health care providers and civil society organizations that provide services to key populations at risk of HIV/AIDS.”
Gitu and others are still waiting to see the results of this diplomacy, even as they worry it might already be too late.
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