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Female Genital Mutilation: sacred cultural practice or human rights violation?

21st September 2020/in News/by CSAG

Background

The World Health Organisation estimates that 3 million girls, residing in only 30 countries, mainly in Africa, as well as in the Middle East and Asia, are at risk of undergoing female genital mutilation (FGM) every year[1].

Historically, an estimated 120 million girls and women have undergone FGM, and approximately 2 million procedures are performed annually on girls under the age of 11[2]. Most commonly performed in Africa, FGM is also practised in parts of Southeast Asia, the Middle East and in Central and South America. In countries such as Somalia, an estimated 70% to 90% of women have undergone FGM[3].

It is unknown when this practice first developed, but evidence exists that it dates back to the fifth century B.C. preceding Christianity and Islam[4]. In addition to citing religious requirements, proponents of the practice cite several other reasons, one of them being that the procedure aids in preserving cultural identity – just as body piercings, body painting or tattooing are used to identify individuals as members of a particular social group[5].

Regardless of its origins, FGM is practiced as a cultural rite of passage as are virginity testing and male circumcision in some traditional settings. It has been defined as follows.

Female genital mutilation includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. The procedure has no health benefits for girls and women[6].

The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. However, more than 18% of all FGM is performed by health care providers, and this trend is increasing[7].

FGM has four major forms:[8]

Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are “the lips” that surround the vagina).
Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.
Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

There is no record that South Africa has ever practiced FGM and so in this essay there is only a focus on the harm caused by the practice on an international level.

Justifications for FGM

As mentioned above, FGM is not a small or insignificant procedure: it is the removal of all or parts of the clitoris, labia majora and labia minora, sometimes combined with the narrowing of the entrance to the vagina[9].

Apart from denoting belonging in cultural and religious contexts, the removal of external female genitalia has been part of a celebrated ritual in the lives of girls and women as an effective and acceptable method of shaping their attitudes toward sex and sexuality and as a way of ensuring their virginity and suitability for marriage. This despite a growing international campaign to abolish FGM, endorsed by both the World Medical Association[10] and the World Health Organization[11]..

Some proponents of the practice claim that FGM helps maintain good hygiene in girls and women and promotes good health. For example, some believe that the clitoris is poisonous and can not only harm man during sexual intercourse, but that it can also kill children during the birthing process[12].

Although the medical community is generally divided as to the health benefits that come with the procedure of male circumcision they are agreed on the fact that FGM has no medical benefits whatsoever[13].

Some advocates of FGM believe that the procedure increases the sexual pleasure of the husband and this therefore enriches the marriage. It is believed that the smaller the opening into the vagina the greater the pleasure that the male receives during sexual intercourse[14]. However this is contradicted by evidence that many men experience pain and frustration while attempting to penetrate a tightly circumcised female[15].

Risks

The manner in which the procedures are typically performed contributes greatly to the medical risks that may be encountered. Even under the most sterile of conditions, the procedures can cause serious medical consequences, including death. In many instances the procedure is performed on young girls any time between infancy and puberty. The age varies depending on the reason for the procedure being conducted[16].

For example in Senegal the procedure is viewed as a rite of passage into adulthood for the young woman therefore targeting girls reaching puberty[17]. In other area such as Nigeria and Burkina Faso, the procedure is performed to prevent a new-born child from touching the mother’s clitoris during the birth process.

Regardless of age, the procedure generally is performed by midwives or older village women who perform the cutting without anaesthesia, using instruments such as razor blades, knives, scissors, pieces of glass or sharp stones[18].

Apart from physical complications that are associated with this extreme procedure, there are also extreme psychological effects as well.

Among girls who live in communities where FGM carries social value, the desire to gain social status, please parents and comply with peer pressure is in conflict with fear, trauma and the after effects of the operation[19].

Furthermore, pregnant infibulated women who enter a medical facility for the birthing process typically need to undergo de-infibulation. After the birth many of these women want to be re-infibulated and go through the process of having their wounds re-stitched[20]. This act of performing such a surgery that is medically harmful raises ethical questions about the health professionals who perform it[21].

Responses

In recent years FGM has come under the international spotlight. Various international organisations have continuously advocated against FGM, believing that the medical risks associated with the cutting make them human rights violations and acts of child abuse.

Some authors suggest that FGM should be considered a violation of the right to life from the perspective of reproduction.

When the very organs that allow human beings to reproduce and to give life to future generations are mutilated, there has been a violation of one of the fundamental human rights[22]

In 1959 the United Nations adopted the Convention on the Rights of the Child and stated that States party to it should take effective and appropriate measures to abolish traditional practices that are prejudicial to the health of children.

Only much later in 1982 did the United Nations Human Rights Sub commission of the World Health Organisation condemn the practice.

African countries have attempted to curb the practice of FGM but legislative efforts have not been as successful as in European countries. In 1983 Nigeria ratified the Convention on the Rights of the Child[23]. This charter contains several articles that can be interpreted to condemn female circumcision.

Apart from international legislative efforts there have been a number of interesting cases dealing with FGM in the United States of America.

Firstly, in 1994 a Nigerian woman by the name of Lydia Oluloro was living illegally in Oregon but asked the courts for political asylum[24]. She feared that her return to her homeland would mean that her two daughters would be forced to undergo the procedure. A federal immigration judge annulled her expulsion order but she was not granted refugee status. The order was merely a mechanism through which her deportation was stayed[25].

The following year two women from Sierra Leone requested political asylum after their genitals had been partly cut off[26]. They claimed that they would be prosecuted in their native land if they opposed the procedure. The woman living in Virginia was granted her request. The judge in that case believed that the woman had suffered an “atrocious form of persecution”[27]. However the second woman living in Maryland was denied her request for political asylum. The judge in her case suggested to the woman that she could “choose to support the practice to maintain tribal unity”[28].

Surprisingly, woman have not been the only ones to seek asylum on the basis of fear of FGM. In the case of Imohi v Immigration and Naturalization Serv[29], Azeez Jimmy Imohi was a male native of Nigeria who sought asylum in the United States on the basis that his home country practiced FGM. He claimed that his return to the country would infringe on his reproductive rights by jeopardizing any female offspring he may have in the future. The Board of Immigration Appeals ruled that the application should be denied and it was confirmed in the United States Court of Appeals for the 9^th Circuit.

FGM has been illegal in the United Kingdom since 1985. In November of 1993 a medical practitioner was brought before the General Medical Council, charged with performing multiple female circumcisions, knowing the operation to be against the law. He was struck off[30]. Despite this case, 2019 was the first time that there was a successful prosecution in the case of R v N[31] where a woman who mutilated her three-year-old daughter became the first person in the United Kingdom to be found guilty of FGM.

The United Nations General Assembly in December of 1948 adopted the Universal Declaration of Human Rights. Among the articles included in the Declaration is that of Article 3: “Everyone has the right to life, liberty and the security of person.” Article 5 reads “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” And Article 15 states that “Everyone has the right to a standard of living adequate for the health and well-being of himself.”

FGM pertains to all of these articles.

Similar articles are included in the African Charter on Human and People’s Rights, unanimously adopted in 1981 by the Assembly of Heads of State and Government of the African Organization of Unity (OAU), coming into force on 21 October 1986.

The articles or portions that are relevant to FGM include Article 4: “Every human being shall be entitled to respect for his life and the integrity of his person. No one may be arbitrarily deprived of this right”; Article 5: “All forms of exploitation and degradation of man, particularly slavery, slave trade, torture, cruel, inhuman or degrading punishment and treatment shall be prohibited”; Article 16: “Every individual shall have the right to enjoy the best attainable state of physical and mental health . . .”; and finally Article 18: “The State shall ensure the elimination of every discrimination against women and also ensure the protection of the rights of the woman and the child as stipulated in international declarations and conventions”.

Impact

As seen by the above laws and cases, the countries that have effectively enacted preventative methods to abolish practices of FGM are Western. However, for the most part legislation has been ineffective. Laws that prohibit a behaviour that is deeply embedded in a culture are most likely not going to find support amongst the people it aims to protect. This leaves little room for change.

The phrase “female genital mutilation” elicits mixed emotions across the globe in medical communities, as well as in small villages. Yet, despite the apprehension many feel about openly communicating about FGM, communication and education are the keys to eradicating this tradition that plagues millions of women throughout the world. By understanding what FGM is, the historical background behind the practice, and the medical risks associated with such procedures, African countries can follow the lead of the Western countries that have for the most part effectively banned FGM[32].

A comforting thought is that year on year, the conversation surrounding FGM has been amplified. Recently, there has been a ban on FGM in Sudan where it is estimated that 9 in 10 women have undergone the life-changing practice[33] .

Looking into the future

It is important to note that this practice is deeply entrenched in culture and as a result, despite countless laws that may outlaw it, there needs to be more activism on the ground level. There is a necessity for “collective abandonment”, in which an entire community chooses to no longer engage in FGM. This has proven to be an effective way to end the practice. It ensures that no single girl or family will be disadvantaged by the decision[34].

In 2008, UNFPA and UNICEF established the Joint Programme on FGM, the largest global programme to accelerate abandonment of FGM and to provide care for girls and women living with its consequences. To date, the programme has helped more than 3 million girls and women receive FGM-related protection and care services. More than 30 million individuals in over 20,000 communities have made public declarations to abandon the practice[35].

The most common motivation is the strong association with marriageability of a young woman and so there is an expectancy to conform to your community in order to marry[36]. Perhaps the discussion surrounding FGM should then be moved to the social requirement of marriage and the status that it affords women.

In the end abandonment of the practice must be rooted in the communities which practice it.

“The people who practice Female Genital Cutting [FGM] are honourable, upright, moral people who love their children and want the best for them. That is why they practice [FGM] and that is why they will decide to stop practicing it once a way of stopping is found…” (Mackie, 2000: 280)[37]

Footnotes

[1] World Health Organisation https://www.who.int/reproductivehealth/topics/fgm/prevalence/en/ (accessed on 14 May 2020)

[2] Federal Interdepartmental Working Group on Female Genital Mutilation “Female genital mutilation and health care” (1999) Health Canada

[3] Federal Interdepartmental Working Group on Female Genital Mutilation “Female genital mutilation and health care” (1999) Health Canada

[4] Morgan in “Female Genital Mutilation” (2009) 94 Southern Illinois University School of Law

[5] As above

[6] World Health Organisation: https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation (accessed on 15 May 2020

[7] As above

[8] As above

[9] Clayman (ed) (1989) The American Association Encyclopaedia of Medicine 282

[10] Richards in “Female genital mutilation condemned by WMA” (1993) 307 BMJ

[11] WHO in “A traditional practice that threatens health — female circumcision” (1986) 33 WHO Chronicle

[12] Etru in “What’s culture got to do with it? Excising the harmful traditional of female circumcision,” (1993) 106 Harv.L.Rev (Belief that the child will die if it touches the clitoris during the birthing process originated in the 15^th century in the Bini village of the Bendel state, when it was decreed by a king following ‘consultation with an oracle regarding his wives’ stillbirths and infant deaths’)

[13] Burstyn (1995) 30

[14] Bashir (1996) 427

[15] Bashir (1996) 415 and 427

[16] Morgan (1997) 100

[17] Kopelman (1994) 58

[18] Morgan (1997) 101

[19] Toubia, Female Circumcision as Public Health issue. 331 New England. J. med. 712 (1994)

[20] Above: Morgan

[21] Above: Toubia at 715

[22] Female Circumcision: a critical Appraisal, Alison t slack: human rights quarterly volume 10 number 4 (November 1988) page 31

[23] 20 November 1989

[24] Rev in “Female Genital Mutilation and Refugee Status in the United States, A Step in the Right Direction” (1996) 353 B.C. INT’L & COMPL

[25] As mentioned above

[26] Rev (1996) 354

[27] As mentioned above

[28] Rev (1996) 356

[29] No. 94-70705, 1996 WL 297612 (9^TH Circ. June5, 1996)

[30] Hartley in “Female Genital Mutilation: a dilemma in child protection” (1994) 443 Archives of diseases in childhood Bryan Hartley, archives of disease in childhood . 1994: 70: 443

[31] https://perma.cc/6BFR-PX4H

[32] Above: Morgan

[33] https://www.nytimes.com/2020/04/30/world/africa/sudan-outlaws-female-genital-mutilation-.html (accessed on 25 May 2020)

[34] https://www.unfpa.org/news/top-5-things-you-didnt-know-about-female-genital-mutilation

[35] https://www.unfpa.org/news/top-5-things-you-didnt-know-about-female-genital-mutilation

[36] https://www.hart-uk.org/blog/fgm-story-worlds-oldest-patriarchy/

[37] https://www .hart-uk.org/blog/fgm-story-worlds-oldest-patriarchy/

CSA&G

Black Queer Visibility: Finding Simon | 17 July to 9 August 2019

5th July 2019/in Events, News/by Johan Maritz

The Simon Nkoli Collective is a partnership with the Dean’s Office – Faculty of Humanities, the Centre of Sexualities, AIDS and Gender (CSA&G), the Centre for Human Rights (CHR), and the Sociology Department. The Collective aim is to use this exhibition to open debates on transformation, social justice and ideas of memory 25 years into democracy. Moreover, the exhibition is also a celebration of the Faculty of Humanities Centenary through which Simon Nkoli’s memory is evoked as a site for reflecting on Black queer resilience. The desire to inhabit the past through Simon’s journey is to map this existence within the contradictions of (in)equality.

Why Simon: The aim is to provide an interesting and engaging introduction to the history of LGBTIQ activism rooted in Black narratives. In the excavation of the earlier narratives of black queer visibility it is difficult to overlook the much-documented life of Simon. It is undeniable that he championed many efforts. When Simon Nkoli’s memory is revisited, three images are often portrayed: his anti-apartheid, HIV/AIDS, and LGBTI activism. Some argue that he was an internationalist. Nonetheless, Nkoli remains one of the prominent internationally celebrated South African black queers.

The photographic exhibition profiles a series of thirty images, eleven awards, one video installations and a kanga designed by Kenyan visual artist Kawira Mwirichia. The nature of the installation requires minimal narration with the material intended to solicit the participatory presence of a spectator. Visitors will absorb, critically analyse and construct for themselves the Simon they prefer.

Dates: 17 July to 9 August 2019

Viewing times: 9:00 to 16:00

Venue: New Student Gallery, Javett Art Centre, UP Hatfield Campus

Queries: simonnkolicollective@gmail.com

USHMM

The Good, the Bad and the Deadly

25th September 2018/in News/by Johan Maritz

Mr Lubabalo Mdedetyana, Dr Glen Ncube & Prof Laurel Baldwin-Ragaven

Text by: Jennifer McKellar

As part of the Deadly Medicine exhibition that was on display at the Merensky Library in September, the University of Pretoria’s Centre for Sexualities, AIDS and Gender (CSA&G) hosted a range of speakers whose topics have engaged staff, students and members of the broader community in debates on ethics and medicine. These thought provoking seminars included presentations from UP’s Dr Glen Ncube, lecturer in the Department of Historical and Heritage Studies, and Prof Laurel Baldwin-Ragaven, from the Faculty of Health Sciences at Wits, on the history of medical ethics in South Africa.

Dr Ncube made the point that as well as its troubled history, South Africa has also been home to leaders in the fields of medical ethics and community-based health services. In the post war era, for example, Cape Town based researcher Dr Michael Gelford shone a light on unethical research practices involving African participants who had not given informed consent. Gelford’s interest in medical ethics stemmed from his Jewish background and the awareness of the ‘Deadly Medicine’ practiced by the Nazi’s during the second World War.

Community healthcare was also a feature of progressive South African mid twentieth century health systems. Examples include the Pholela Community Centre established by Emily and Sidney Kark in what is now KwaZulu Natal, and the mobilization of rural women to deliver health care in the Transvaal by Selina Maphorogo and Erika Sutter. These efforts were largely dismantled by the apartheid State, and attempts to re-establish community healthcare in more recent times have been grossly mismanaged, as evidenced by the Life Esidimeni debacle.

Prof Baldwin-Ragaven challenged her audience to consider what conditions are necessary to permit the sort of evil seen in Nazi Germany and Apartheid South Africa to occur. She outlined the social construction of medical ethics following the publication of the pivotal Flexner report in 1910[1], which was highly influential in determining who should be a physician (white, male, educated in scientific method), and how they should act. Medicine became standardised and grounded in “science and empiricism” – and ultimately a source of global hegemonic power.

Those that perpetrate medical evils are, as Prof Baldwin-Ragaven points out, generally banal, and it is this ordinariness – the “often subtle, not overly harmful” nature of their transgressions which permit their perpetration on vulnerable populations. The treatment of refugees by Australia, and more recently the United States, whereby those seeking asylum are imprisoned, separated from family, denied medical treatment and made to endure such extreme psychological stress they are routinely prescribed anti-depressants and anti-psychotics[2] represent more recent instances of State abuses which have been inflicted by democratically elected governments.

Physicians are expected to uphold the maxim primum non nocere – first do no harm – but their accountability to the patient becomes compromised when they are also expected to have loyalty to the State. This is exacerbated under conditions of fear and intimidation, and the “othering” of particular populations, and medical training which dehumanises the patient. Finally, engagement in “patriotic science” was a feature of both Nazi and Apartheid era medical human rights abuses. This makes the recent speech by Donald Trump at the UN General Assembly which made clear his adherence to “an ideology of patriotism”, rejecting an “ideology of globalism”[3] extremely troubling.

[1] For a more in-depth overview of the report and its impacts see Duffy TP. The Flexner Report ― 100 Years Later. The Yale Journal of Biology and Medicine. 2011;84(3):269-276. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858/

[2] See report from Human Rights Watch https://www.hrw.org/news/2016/08/02/australia-appalling-abuse-neglect-refugees-nauru. No action has been taken to address these issues since this report.

[3] See overview of the speech in The Atlantic at https://www.theatlantic.com/international/archive/2018/09/donald-trump-united-nations/571270/

USHMM

Reflections on the Deadly Medicine, Creating the Master Race Seminar: 20 September

21st September 2018/in News/by Johan Maritz

What follows below are reflections of the second seminar in the series of seminars that were hosted as part of the Deadly Medicine exhibition at UP. [ed.]

Text by: Pierre Brouard

Dr Rory du Plesis, Attorney Sasha Stevenson, Dr Tlaleng Mofokeng & Prof Catherine Burns

First do no harm, medics are exhorted. Yet history tells another, more complex, story.

Rory du Plessis of the Department of Visual Arts at UP started this engrossing seminar by exploring depictions, visual and textual, of two black women who were inmates at the Grahamstown “Lunatic Asylum” in the late 1800s. “How do we humanise photographic portraits, to bring into view an understanding of patients as individual subjects”? he asked. The two women had been declared insane – Boitumelo had “claimed the mealie fields as her own” and Vuyelwa was a victim of “homelessness, poverty and loneliness”. Rory noted that they were deemed by the authorities as “being unable to cope with civilisation” and were examples of “cultural and physical degeneration”.

Rory spoke movingly of the ways in which the complex subjectivity of Boitumelo and Vuyelwa was reduced to a “mugshot” of abjection, thus debasing them, in contrast to case books of white patients, which to some extent filled in the missing pieces of their lives, a partial act of “resurrection”. The texts in the casebooks allowed those described to “explode into subjectivity and personhood”, even while archival material is itself always incomplete.

For me, the role of the psychiatric professional was raised in this paper: in the execution of their duties, and in the ways in which they depicted their patients, were they guilty of a form of deadly medicine, reducing their patients’ humanity? Similar questions, over a 100 years later, arose at a recent psychology congress I attended, where we were challenged to think about what an “African” psychology could look like. In a time of land hunger, poverty and disconnection, perhaps we need to ask where the mental unwellness lies; in the individual, in the system that produces their distress, or in the discipline which labels and categorises in ways which are sometimes decontextualized?

Tlaleng Mofokeng, a medic and activist for sexual and reproductive justice, began her paper by drawing on the story of Henriette Lacks, an African-American woman whose cancer cells are the source of one of the most important cell lines in medical research, to outline one of her major theses, that gender and racial biases in medicine are well documented. Henrietta’s cells were taken from a tumour biopsied during her treatment for cervical cancer in 1951. No consent was obtained to culture her cells, nor were she or her family compensated for their extraction or use. As a black women, she was an object, not a subject.

Many examples of sexism, racism and objectification were linked by Tlaleng: gynaecological experiments performed on African American slaves; Saartjie Baartman’s treatment as an object of cruel humiliation; and black women in apartheid subjected to reproductive control as an act of racist anxiety and hatred.

Even in post-apartheid South Africa there are challenges: the role of Depo Provera, used mostly by black women, is questionable; and the agency of many black women was limited by a health system which both coerced them into HIV tests as a requirement of ante-natal care, and at the same time denied them ARVs which could save them and protect their children.

When teaching slides of sexual infections are mostly of black genitalia, poor trans youth self medicate to find some congruence between gender identity and appearance, and women still die of abortion-related complications because of state and practitioner ambivalence, we need to ask tough questions about society’s views on sexuality in general, and that of black people in particular.

Tlaleng was at pains to point out that systems of oppression are intersectional and that race and gender need to be seen through the lenses of class, ability, sexual orientation and gender identity.

Health professionals may elide these complexities, or are complicit in acts of omission or commission which limit women’s rights, produce research which is decontextualised, allow global funders to limit funds for abortion work, or develop curricula which reflect colonial notions.

Tlaleng thus made a compelling case for a form of contemporary “deadly medicine”. Yes there are systemic and structural hangovers from apartheid, but in current-day South Africa we still shame and police black women’s bodies and label and shame sexual and gender minorities. We have to look forward with imagination, she argued, holding in mind that women are navigating these intersections on a daily basis in a society steeped in patriarchy.

Catherine Burns of UP challenged us to think of the possibilities of medicine beyond binary forms of thinking; medicine does not have to be either liberatory or “poisonous”. How do we break down the split between traditional medicine and “bio” medicine? What do we do when good medicine comes out of unethical work?

The work of J Marion Sims on slave women, for example, helped to educate a generation of gynaecologists who came to work in South Africa, many of them good practitioners. In her work in the Medical Humanities, and as a historian, Catherine has been able to explore histories of medics who were complicit in acts of dubious morality or who stood up for justice: an example of the former was the use of Depo Provera as a tool of control in the apartheid state. And in the 1970s the story of Steve Biko’s brutal torture and death was an example of both. Just as Ivor Lang and others were found to have breached their ethical codes in how they lied for the state’s actions, other medics of conscience brought this to the public awareness, sometimes at great personal cost.

In the early years of HIV forms of denialism (and the relationship between medics and the state) colluded and collided with each other. Thabo Mbeki refused to acknowledge that “a virus could cause a syndrome”, supported by famous denialist and biologist, Peter Duesberg. And despite his cynicism of ARVs, his government sanctioned Virodene research at UP as an “African” cure for HIV. This research grossly flouted accepted ethical practice and the doctors concerned were dismissed by UP.

Finally, Section 27 lawyer Sasha Stevenson, using the Life Esidimeni tragedy as illustrative, spoke powerfully of how the law can be used to realise health rights, with legal advocacy and activism being enabled by South Africa’s powerful constitution.

Referencing the Treatment Action Campaign’s legal activism around PMCTC and the provision of ARVs to all who needed it, Sasha illustrated how mobilisation of affected communities was a tool to challenge abuses of political (and medical) power by those in authority. The fact that these abuses occurred in the post-apartheid state is depressing, and a sign that power needs always to be held to account, as was even more powerfully illustrated by the Life Esidimeni matter.

And this was made possible by coalitions of psychiatrists, psychologists, mental health NGOs and the families of those affected, who came together to challenge the state’s foot dragging, indifference, bloody mindedness and callousness. Ultimately the findings of the Health Ombudsman and the subsequent arbitration under retired former Deputy Chief Justice Dikgang Moseneke were scathing about the state’s actions and made provision for significant redress and the restoration of dignity to the families of those who died.

Ultimately, we are forced to ask whether Life Esidimeni shows we still debase and dehumanise the vulnerable in South Africa; whether health system inequalities are a form of violence; who classifies as human; and how we all have a role to play in ensuring medicine is not deadly but democratic.

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