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The Hidden Consequence of War

"We need to provide an alternative for those so ripped and hopeless they can no longer think for themselves." —Ruth Kennedy, The Addis Ababa Fistula Hospital

Goma, the Democratic Republic of Congo (DRC)—Zola, a six-year-old girl, was lying in her mother’s arms as they sat in their yard at dusk. Suddenly, a group of five militiamen came in shooting and tore Zola away.

Her mother begged the men to take her in exchange for her daughter, but they refused; they had come for the little girl.

The child was found the next day in her school, her tiny legs tied to two benches, bathed in blood. As a result of the rape, Zola had suffered a devastating traumatic fistula injury. While the doctors in Goma said that Zola would survive, her mother lamented that she could never marry.

The stories of girls like Zola have remained hidden in the shadows of the world’s most violent conflicts. While global awareness about fistula resulting from prolonged childbirth has increased, less is known about traumatic fistula, a condition that can occur as the result of sexual violence—rape so brutal (often using gun barrels, beer bottles, or sticks) that a tear develops between a woman’s vagina and her bladder or rectum, or both.

Often barely clinging to life, these survivors are plagued by an emotional and physical nightmare. Unable to control their urine and/or feces, they are frequently divorced by their husbands, shunned by their communities, and unable to work or care for their families.

Despite the tragedy of traumatic fistula, the condition—much like the women who suffer from it—has received little attention from the international health community. In response to this silence, a partnership including EngenderHealth/the ACQUIRE Project, the Addis Ababa Fistula Hospital, the Ethiopian Society of Obstetricians and Gynecologists, and the Network of Women for Victims of Sexual Violence convened the first-ever international meeting on the issue.

In September 2005, experts gathered at this landmark event in Addis Ababa, Ethiopia, to discuss what is known about traumatic gynecologic fistula, review efforts to address it, and determine the best course of action for countries facing this public health horror. Reflecting the complexity of the issue, the meeting included fistula surgeons, psychologists, social workers, and lawyers from countries where traumatic fistula is known to exist, as well as from the global reproductive health community.

An estimated one in three women worldwide will experience physical or sexual abuse by one or more men at some point in their lives.3

“Sexual violence is inevitably worse during times of war,” explained Dean Peacock, of EngenderHealth/South Africa. “There is decreased accountability for acts of brutality, and rape becomes a means of intimidation, humiliation, and dominance.”

Sexual violence during times of conflict is a phenomenon that crosses all generations and cultures, impacting women and girls of all ages. “We met a woman of 80 years who had been raped by seven armed men,” explained Justine Masika, from the Network of Women for Victims of Sexual Violence, in the DRC. “Left in the bush, she was found two weeks later by a hunter, who brought her to a village where they had no means to cure her. The woman had no money for treatment and died as a result.”

“We saw another woman who’d been raped and whose husband and eldest son were killed. When she exposed the perpetrators, they returned to her home and cut off her lips,” recounted Ms. Masika.

These horror stories highlight many of the challenges faced by health workers and advocates worldwide. Exact numbers of traumatic fistula cases and the geographic scope of the problem are difficult to assess, due to the shame surrounding sexual assault, which is compounded by the isolation and stigma caused by fistula. Women who have been raped also often remain silent for fear of retaliation from their aggressors.

Based on the meeting’s findings and an extensive review of the literature conducted by EngenderHealth/the ACQUIRE Project, the DRC appears to have the largest number of documented cases of traumatic fistula. Reports have also emerged from Chad, Guinea, Rwanda, Sierra Leone, Sudan, and Uganda, but there is little information to confirm the extent of the problem.

Dr. Longombe Ahuka, from Doctors On Call For Service (DOCS) in eastern DRC, received more than 3,550 rape survivors between 2003 and 2005 and has performed 600 fistula repairs. Of those fistulas, more than three out of four were the result of sexual assault.

An unpublished study conducted at DOCS Hospital found that among 76 women with fistula, 40% of the cases were caused by rape—specifically, collective rape and/or assault with foreign elements. These numbers represent the tip of the iceberg, as most women with traumatic fistula have no access to medical care or remain too ashamed of their condition to ask for help.

As such brutal evidence comes to the fore, countries continue to grapple with the urgency and complexity of addressing traumatic fistula.

In certain African countries, such as Uganda, a small but growing number of doctors are adequately trained to provide the necessary surgical repair to close a woman’s fistula. Through the efforts of EngenderHealth, Ugandan surgeons have been trained in fistula repair and hospitals have been provided with the necessary supplies and equipment to ensure quality services.

Other countries, such as Liberia, are not yet providing adequate or consistent fistula treatment to women, relying instead on the efforts of external relief groups such as Mercy Ships. “Women suffering from fistula say ‘Why should I go to the hospital? I won’t be helped,’” reported Hh Zaizay, Program Director for the Liberian Society for Women Against AIDS.

While the physical consequences of traumatic fistula are shocking, they only scratch the surface of the emotional trauma experienced by these women.

“A recent study reported that some 91% of survivors suffer behavioral side effects that include constant fear, shame, and self-loathing, sweating, insomnia, nightmares, memory loss, and aggression,” according to Andrew Sisson, Director of USAID’s Regional Economic Development Services Office (REDSO).

Addis Ababa meeting participants acknowledged that women with traumatic fistula need far more than just surgical repair. They require psychological and legal services as well.

“Women are often raped and then thrown into holes or ditches, so it can take time before they arrive at the center,” explained Dr. Boya Gratcharska of the Seruka Center in Burundi. (“Seruka” translates as emerging from the shadow of darkness.) Burundi has fallen prey to a decade-long civil conflict that has ravaged the country’s economic and social support system. The NGO community has reported brutality against women throughout the country; as a result, Seruka was founded to meet the entire spectrum of women’s needs.

While survivors of sexual violence are in great need of counseling, efforts must also target the potential perpetrators of this violence. Recognizing this, EngenderHealth is working with men in South Africa to change attitudes and behaviors and mobilize them in the fight against restrictive gender roles and violence.

Interviews with 2,500 men and women in Soweto revealed that 82% of participants thought that it was not normal for men to sometimes beat their wives. Results from EngenderHealth’s efforts show that support for gender equity is very high, although most men who feel this way assume that they are in the minority, with some men doing housework from behind closed doors and curtains.

Despite the progress of such programs, lack of awareness and entrenched cultural beliefs remain obstacles to prosecuting rape offenders. In many countries, the stigma associated with rape prevents survivors from coming forward. If a woman does present her case, long and arduous trials, lack of privacy, and prohibitive legal fees may further discourage her.

The Addis Ababa meeting provided a first opportunity for discussion among individuals working tirelessly to fight sexual violence and heal the wounds of women suffering from traumatic fistula. Participants revealed a wealth of knowledge and success stories and also shared their difficulties in addressing this neglected issue. Experts developed country-specific strategies that address the clinical, psychological, social, and legal aspects of traumatic fistula.

“The challenges to eliminating traumatic fistula are formidable,” said Mary Ellen Stanton, Senior Reproductive Health Advisor with USAID/Washington. “Organizations must not only care for survivors, but also rise to meet the larger challenge of prevention—ensuring security for all girls and women in conflict settings.”

Zola is lucky enough to have received surgical treatment for her fistula. While her physical wounds have healed, Zola still needs a great deal of time and care to restore her dignity and hope for the future. Meanwhile, throughout the world, an unknown number of women and girls still suffer in silence and live in shame.

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