Looking horror in the face

Imani was just 15 when soldiers from the rebel group Interahamwe found her on the road in a remote region in the eastern Democratic Republic of the Congo (DRC).

The rape that followed devastated her, but in this troubled corner of the world, the sexual assault of a teenage girl by armed men is hardly unusual.

The eastern DRC has been swept up in a maelstrom of violence against women that has swirled for more than a decade. An outgrowth of the armed strife that, since 1996, has involved a bewildering array of actors, from national armies to rebel groups to homegrown militias, the region’s sexual violence ranks among the worst in the world, going beyond that which often accompanies war, experts say.

The rapes are epidemic and horrific in their details. Women are gangraped in public, taken into sexual slavery, and violated with guns, knives, bottles, and sticks. They are sometimes mutilated, with limbs chopped off by machetes, or raped while husbands and children are killed, houses razed, and crops burned.

Through the efforts of the Harvard Humanitarian Initiative (HHI), researchers and physicians from Harvard and its affiliated hospitals are at work in the midst of the crisis, providing care for the women whose bodies are fractured by their experiences, reviewing the records of thousands of sexual assault victims, and conducting focus group interviews with members of the community.

The researchers are also engaged in a project that focuses on the military men who are responsible for many of these assaults. In a pilot program they hope to expand to encompass as many combatants as possible, researchers travel to remote villages to talk to rank-and-file soldiers. Researchers acknowledge there is risk involved, but say they take appropriate precautions and rely heavily on local partners who have solid contacts, both in the community and in the military’s command structure. The work is essential, researchers say, if the problem is to be truly understood.

“I know people make assumptions that [those] who do this are monsters, but if you close your mind to possible reasons people commit atrocities, you’re never going to understand why they happen,” said Jocelyn Kelly, research coordinator for HHI’s Gender Based Violence Program and the lead researcher probing soldiers’ attitudes.

Understanding what’s going on in the DRC — the vast, turbulent nation that occupies Africa’s heart — is key if the problem is to be solved, according to HHI Co-Director Michael VanRooyen, associate professor of global health and population at the Harvard School of Public Health, associate professor of medicine at Harvard Medical School, and director of Harvard-affiliated Brigham and Women’s Hospital’s Division of International Health and Humanitarian Programs.

The fighting in the eastern DRC began with a 1996 rebellion that ultimately led to the overthrow of longtime dictator Mobutu Sese Seko. A second conflict that began in 1998 led to the overthrow of his successor, Laurent Kabila, and claimed millions of lives, largely through disease and starvation. That second conflict ultimately involved eight African nations and has become known as “Africa’s World War.” Though a 2002 peace treaty ended the fighting across much of the nation, it has continued in the mineral-rich east.

The ongoing violence has alarmed the international community. Some relief and aid organizations have been operating in the eastern border region for over a decade, along with troops from MONUC, the United Nations peacekeeping mission, which has been there since 1999.

While the relief work is under way, VanRooyen said there have been few efforts to systematically gather data that can inform relief, recovery, and rehabilitation programs. That’s where HHI comes in, he said.

“By looking at the data, we can learn things that the international community doesn’t know about how to characterize this abuse,” VanRooyen said. “We can learn from the data where the women come from, the types of militia involved, what happened afterward — whether they were rejected by their communities, which is a huge vulnerability — and how many women have physical problems related to their assault, such as incontinence and chronic pain.”

HHI was founded in 2005 to do just such work. VanRooyen — an emergency physician with a long resume of relief work in crisis areas such as Kosovo, Rwanda, and Darfur — and Jennifer Leaning, professor of the practice of global health at the Harvard School of Public Health and a human rights expert who also has long experience in disaster and crisis situations, came together to found the organization.

The two believed there was a disconnect between the hands-on crisis management practiced by relief organizations and the dispassionate collection of data and information that highlights the academic endeavor. Marrying the two, Leaning and VanRooyen believed, would provide an avenue for improving humanitarian and human rights work by both informing ongoing programs and collecting a body of best practices that groups in the field could draw upon.

Since its founding, HHI has worked in trouble spots around the globe, such as Sudan’s Darfur region, and has ongoing projects with roughly 20 nongovernmental organizations, such as Doctors Without Borders, CARE, and Oxfam.

“We work with their data, analyze it, and get [the results] back to them,” VanRooyen said. “At any one time we’ll probably have two or three students, faculty, or fellows in the field.”

As a University initiative rather than a School-based program, HHI seeks to draw on Harvard’s strengths in a broad array of disciplines by working with faculty in several Schools. Today, HHI has a core of 10 faculty members and 12 to 14 fellows.

An oasis from the violence

HHI’s project in the Democratic Republic of the Congo began as an effort to support the mission of a hospital in the provincial capital of Bukavu. Panzi Hospital was founded in 1999 to provide maternity care to the region’s women. It quickly became apparent, however, that something sinister was affecting the area’s mothers, daughters, and sisters.

“Our first patient was not a woman who needed care because of pregnancy. She was a victim of sexual violence and she was fractured and destroyed in the pelvic region and in the region of the vagina,” said Denis Mukwege, a Congolese gynecologist and the hospital’s founder. “We saw the numbers increasing, increasing, and increasing and now our clinic sees more than 3,000 women a year.”

HHI’s collaboration with Panzi began after HHI visiting scientist Julie VanRooyen met Mukwege during a trip to New York. In their talk and in his subsequent speech at New York University Law School, Mukwege detailed the plight of the eastern DRC’s women.

“I heard the stories he was telling and I just couldn’t go back to Boston and pretend I hadn’t heard them. I couldn’t forget about them and I really felt compelled to try to do something about them,” said VanRooyen, a urogynecologist and pelvic surgeon.

The story she heard was of a seemingly inexhaustible stream of victims of sexual violence coming to the hospital with terrible injuries from their attacks. The hospital averages roughly 10 admissions from sexual violence each day, week in, week out, year in, year out.

Once admitted, the women’s treatment often includes surgery to repair internal injuries. The violent rapes can tear the tissue separating the vagina from the bladder or anus. The result is incontinence, with the women constantly leaking urine or feces until the tears, called fistulas, are repaired.

“Sadly, the weakest can’t get to us,” Mukwege said. “They are suffering from paralysis, from broken legs, from compound fractures, and so they’re not able to walk to us.”

HHI’s clinical program at Panzi, administered through Brigham and Women’s Hospital, aims to support Panzi’s surgical staff. The HHI program brings highly skilled surgeons both to further train Panzi’s doctors and to augment the staff’s expertise.

While important, the clinical program was quickly joined by the research initiative, which has the potential to affect far more lives.

“We can keep sending doctors over and they can keep repairing fistulas, but ultimately, we’re putting a huge Band-Aid over a terrible wound,” said Julie VanRooyen, who directs HHI’s clinical program with Panzi. “It’s so much better to prevent the fistulas in the first place.”

Records of terror in black and white

In February 2009, Imani — a pseudonym used to protect her identity — was again at Panzi Hospital. Though it had been 10 years since her rape by the Interahamwe at age 15, she had found it difficult to put the experience behind her. The firestorm of sexual violence wracking the region’s women had found her again and again. The most recent attack, in November 2008 in the city of Goma, was the fourth time it had happened.

A few hundred yards from where Imani sat is the office of PMU Interlife, the humanitarian and development arm of the Swedish Pentecostal Church, which is helping support Panzi and HHI’s research mission there. One wall of the office is filled with shelves holding row after row of thick, 3-inch binders filled with thousands upon thousands of intake forms from victims of sexual violence.

When the women are admitted, intake workers fill out forms on which they describe the attack, with details such as the woman’s age; the date, location, and nature of the assault; and whatever description of the assailants the women can provide.

The records review has so far encompassed more than 1,000 cases from 2006 and is expanding to include other years. It – and other projects at Panzi — has been conducted by a team that includes Kelly, who is a Harvard School of Public Health graduate, Jennifer Scott, a resident in obstetrics and gynecology at Beth Israel Deaconess Medical Center (BIDMC); Susan Bartels, associate director of the International Emergency Medicine Fellowship at BIDMC; and Sadia Haider, division director of family planning at BIDMC.

The records show that no age is safe, with attacks reported on girls as young as 3 and women as old as 80. They reveal that while women in other countries are most vulnerable when they leave home — going to the market or the river to get water, for example — that isn’t the case in the DRC. There, half of all attacks occurred at night in a woman’s own home.

“If a woman can’t feel safe at home, while sleeping with her husband and children, where can she feel safe?” asked Scott.

Other results show that women wait for months before seeking medical care, with an average time between an attack and arrival at Panzi of 16 months. Six percent of women reported becoming pregnant from their rape and 12 percent were concerned about sexually transmitted diseases or HIV/AIDS. Twenty-three percent of women lost possessions while just over one in 10 lost a child or husband.

The research into the roots of the DRC’s gender-based violence has caught the attention of policymakers at the highest level. Kelly and Michael VanRooyen last year spoke with representatives of the United Nation’s Security Council to discuss their work and to suggest the kinds of information the council might seek to inform future action.

The focus on the Congo — by HHI and a host of other organizations — has begun to pay dividends, VanRooyen said. In June 2008, the Security Council redefined sexual violence in the eastern DRC from a human rights issue to a security one, making it a candidate for Security Council review and action.

“Our goal is to … better characterize the sexual violence happening in the Congo,” VanRooyen said. “We can bring it … to many organizations that work in the area, to serve victims of sexual violence and rape.”

In Imani’s case, her physical injuries were healing under the care of Panzi’s physicians, though the HIV she contracted in one assault will require lifelong treatment. Her psychological wounds remain deep, however. She talks of suicide and of anger toward her only child, a little girl born from another of the attacks.

Orphaned herself by the violence and with one dead sister, Imani doesn’t know the whereabouts of her remaining family. When it is time to leave the hospital, she doesn’t know where she’ll go or what she’ll do.

Imani speaks of the life she wanted and now believes she’ll never have: with a husband and children born of love, not violence. In the eastern DRC’s traditional society, both she and her child are seen as contaminated, and her marriage prospects are poor. Her only family now is a child who reminds her of the most horrible days of her life.

“At night when I sleep, I cry,” said Imani. “You see, my life is just rape, every day.”