Talking terror

The two men sit close, knees almost touching, in a mud-walled hut in the Congolese village of Katokota.

The thick grass roof mutes the sound of the falling rain in the room’s dim interior. Surrounded by dark earthen walls and lit only by the cloudy day’s gray window light, the scene has an intimate feel.

As if afraid to break the spell, the two men talk in low voices — low voices for serious subjects.

One man, an interviewer, asks about the other’s children, about his native tongue. He starts with easy questions before getting to the heart of the issue: horrific violence visited on women in this eastern region of the Democratic Republic of the Congo (DRC). The United Nations estimates that 200,000 women were raped here over the past 12 years, 18,000 during the first nine months of 2008 alone. The rapes have been so widespread and brutal that U.N. officials have described them as the worst in the world and tantamount to crimes against humanity.

The interviewers are Congolese social workers collaborating with the Harvard Humanitarian Initiative (HHI) through a partnership with a local nonprofit, the Centre d’Assistance Médico-Psychosociale (CAMPS). Together, the two organizations are seeking to understand the causes of the violence against women that hangs like a toxic cloud over a huge swath of this enormous country in Africa’s midsection.

The region, rich in mineral wealth and tragedy, has been the stage for one of the new century’s most awful displays of humankind’s capacity for inhumanity. Using rape as a weapon of war, dozens of armies, and rebel and militia groups regularly engage in violent assaults and sexual slavery that touch women of all ages, from the very young to the very old. Often combined with mutilation and murder of family members, these atrocities leave the women not only physically injured, but emotionally bereft, sometimes pregnant or HIV-infected, and, in the region’s still-traditional societies, outcast.

The DRC has long been a place of turmoil. Rebels backed by Rwanda and Uganda attacked the government in two separate wars that began in 1996 and 1998. The first toppled dictator Mobutu Sese Seko and resulted in the nation, then called Zaire, being renamed the Democratic Republic of the Congo. Mobutu’s successor, Laurent Kabila, was assassinated in office in 2001. The latter clash, which involved eight nations and came to be known as “Africa’s World War,” resulted in 5.4 million deaths, largely from starvation and disease.

A 2002 peace treaty ended the conflict, but the resulting government remains too weak to project power into its eastern border region. Into the vacuum have stepped more than 20 armed groups struggling for power and control of the region’s minerals: tantalum, tin, copper, and diamonds.

The plight of the eastern DRC’s women is no secret. It has been the subject of front-page newspaper stories, it has become a major focus of a hospital in the Congolese city of Bukavu, and it has prompted an outpouring of condemnation from around the world.

But to solve a problem one must first understand it. And to understand the problem of rape in the DRC, one must understand not just the suffering women but also the men fighting the endless wars.

That truth occurred two years ago to Jocelyn Kelly, a Harvard School of Public Health (HSPH) graduate and research coordinator for the Harvard Humanitarian Initiative (HHI), an interfaculty program that applies the expertise of Harvard’s various Schools to the world of disaster relief. Though it’s easier to simply condemn the men responsible and turn one’s attention to the women — whose needs are almost beyond imagination — it is not enough, Kelly realized. The men, brutalized themselves, living in the forest, and often starving, are at the root of the problem and so hold its key.

“By demonizing them, you make them incomprehensible,” Kelly said. “Instead of saying these men are demons and how can they do these terrible things, we say, these are men, and why are they doing things that should never happen?”

That belief is what brought Kelly and a small contingent from HHI and CAMPS to the village of Katokota, just a short distance from the Rwandan border in the eastern DRC. The visit, which occurred in February 2009, drew dozens of soldiers from the Mai Mai-Shikito militia to Katokota to be interviewed. The Mai Mai-Shikito is one of roughly 13 homegrown Mai Mai groups, originally formed to fend off attacks on their homes by other soldiers but which have themselves been implicated in horrible sexual assaults.

The day was a strange, silent one in Katokota. Almost two dozen soldiers sat on long benches under billowing tarps that kept the rain off, talking among themselves in subdued tones. Another half-dozen in full uniform, automatic weapons ready, paced around the perimeter of the small compound of beaten earth.

Villagers gathered to silently watch the proceedings: old men, women, and groups of children, dirty in tattered clothing. Though they were familiar with the men — some lived in the area — the villagers knew something unusual was happening.

Two Swahili-speaking interviewers from CAMPS worked inside a nearby hut, while Kelly and HHI Co-Director Michael VanRooyen, associate professor at the Harvard School of Public Health and at Harvard Medical School and director of Brigham and Women’s Hospital’s Division of International Health and Humanitarian Programs, talked to Mai Mai commanders and advised CAMPS national coordinator Justin Kabanga about the conduct of the interviews.

VanRooyen and Kabanga said the partnership benefits both their organizations. CAMPS’s deep roots in the community and connections in the military command structure are essential for HHI researchers to do their work. HHI researchers, on the other hand, provide analysis of the problems affecting the people CAMPS seeks to assist.

“We’ve been so busy, we haven’t had the time to do research,” Kabanga said. “The scientific collaboration with HHI has been indispensable for beginning to understand the complexity of the problem.”

Information gathered in the interviews is now being analyzed. Still, with 25 interviews complete, Kelly said a picture of the soldiers’ lives is emerging. Responses indicate that the men already have conversations about sexual violence and that they get their news and information predominantly from the radio. The responses also reveal where the men go to seek social support and what barriers, such as transportation costs, make it difficult for them to obtain help.

“We’ve asked a lot of soldiers why they joined. … They tell you unimaginably painful stories where they watched their father die or they watched their brother die,” Kelly said. “I don’t think I’ve ever seen a clearer example of how violence feeds on itself.”

VanRooyen knows Kelly is onto something special.

By daring to go to remote Congolese villages — where few researchers venture — and then daring to ask armed men about atrocities they or their comrades have committed, Kelly is not only showing great personal courage, she is collecting data that exists in few other places.

“These are active militia who are in the middle of it still,” VanRooyen said. “The stuff she’s doing … everyone wants to know about it, the U.N., the State Department.”

Using the information generated by HHI, VanRooyen said, aid groups, governments, and nonprofit organizations can better design programs to meet particular needs — or even decide whether to create a program in the first place.

Information, of course, is HHI’s coin in trade. The founders, VanRooyen and Jennifer Leaning, professor of the practice of global health at HSPH started the organization in 2005 with the belief that the collection and analysis of data could help improve humanitarian responses in man-made and natural disasters around the world.

Though the organization also has ongoing projects in Sudan’s Darfur region, in Chad, and in several other trouble spots, VanRooyen said the cluster of projects in the Congo provides a team-based model for how HHI would like to approach certain key issues such as gender-based violence.

An oasis for abused women

Even as Kelly was talking to militia leaders in the compound at Katokota, another HHI researcher was a two-hour drive north, at Panzi Hospital in the provincial capital of Bukavu. Jennifer Scott, a resident in gynecology and obstetrics at Beth Israel Deaconess Medical Center (BIDMC), was attacking the same problem from a different angle.

HHI’s research team is taking a multipronged approach toward sexual violence against women in the DRC. The main focus for the two-year-old effort has been Panzi Hospital, a general hospital founded in 1999 to provide medical care to the region’s women that specializes in treatment of the survivors of sexual violence.

Panzi Hospital founder Denis Mukwege said many of the women suffer not only emotional problems from the rapes, but also physical injuries. Women are sometimes mutilated during the attacks or are raped with bottles, sticks, or even knives, causing tears between the vagina and the bladder, or between the vagina and the anus. These tears, called fistulas, allow urine or feces to leak from the body, making the women incontinent. The fistulas can only be treated with surgery.

HHI’s work at Panzi Hospital began with a clinical collaboration that brought high-level medical support to the hospital. Administered through Harvard-affiliated Brigham and Women’s Hospital, the clinical work was soon joined by a Harvard-organized research effort focused on the records of patients who had suffered sexual violence. Researchers began analyzing the information included in thousands of intake forms, held in row after row of thick binders that fill a wall in the office of PMU Interlife, a Swedish aid organization that is assisting Panzi and which has become another important local partner for HHI. Day by day, the rows of documents grow longer, as raped women stream steadily to the hospital and tell their stories to intake workers, who fill out the unending forms.

Inside their pages are story after story of horrific assault that still shake Mukwege, even after a decade of hearing similar tales. Mukwege told of one woman who he said illustrates not only the viciousness of the assaults, but also the societal consequences that follow. A pastor’s wife from the village of Shabunda came into the hospital to give birth. She had been raped by an armed group in front of the entire congregation. When her two older sons tried to intervene, they were shot. Her two daughters were also raped. When the raping was done, they brought the pastor out and killed him too.

The woman became pregnant from the attack and gave birth at Panzi. Her remaining family, however, refused to let her come home unless she abandoned the child.

“It’s terrible for the woman but also for this young child,” Mukwege said. “It destroys all the family connections. Rape is not just physical destruction, it’s a destruction of the psychology, not only of the victim but of her family and all her relations. Finally, it’s a destruction of the entire society.”

HHI researcher Susan Bartels, associate director of Beth Israel Deaconess’ International Emergency Medicine Fellowship, began the records review in 2007. With assistance from Scott, Kelly, and Sadia Haider, BIDMC’s division director of family planning, the study has already produced results that describe more than 1,000 assaults that took place in 2006. The researchers have also conducted a survey of 225 women and mounted an effort to collect qualitative data through focus groups conducted with both women and men from the community.

Together, the statistical data and the focus groups paint a picture of what’s going on outside the chain-link fence that surrounds the hospital. According to the charts, the violence strikes women and girls of virtually any age. The average age of women who were attacked in 2006 was 36, but girls as young as 3 and women as old as 80 were also assaulted. Further, the charts show that there is virtually no safe haven, as more than half of the attacks happened at home, at night.

Three-quarters of the women reported being gang-raped and just over a third said they were abducted during the attack. Nearly two-thirds reported that the attackers wore uniforms of some type, and 11 percent said they lost a husband or child, either through death or disappearance.

The region’s poverty and lack of access to medical care were reflected in the statistics and the women’s narratives. The average time from the attack to presentation at Panzi Hospital was 16 months, far beyond the 72 hours within which emergency contraception or treatments to guard against sexually transmitted diseases can be administered. In explaining why they waited so long, almost half the women said they had to travel more than a day to reach medical services. Further, many said they couldn’t afford the transportation, while others said that they didn’t know the services existed. Still others said they didn’t want people to know they were seeking sexual assault care.

The data show that the attacks’ repercussions continue long after the violence ends. About 13 percent of women became pregnant from the rapes. Nearly one in four said they were forced to leave their families, while 6 percent said they were forced to leave their communities.

“I always say women are punished for being punished. They’re kicked out of their own homes for being raped,” Kelly said. “Women who are raped are no longer [considered] useful members of society and, without women, society disintegrates.”

During their February visit, Scott, Kelly, and VanRooyen worked to expand the study of Panzi Hospital’s patient records. The three met with officials from Panzi and PMU Interlife to solidify partnerships, and Scott and Kelly trained three local Congolese data entry technicians to enter information from the intake forms. The extra help will add information to the study from almost 4,000 attacks that occurred in 2005, 2007, and 2008.

An eye to the future

Though the records review is ongoing, that phase of the project is nearing its end. Despite that, VanRooyen said that HHI’s work in the Congo will continue. Future projects are being considered that will focus on mining communities, on demobilized soldiers, and on children of rape, who are outcast and at risk. Data gathering on the victims of sexual violence may also continue both at Panzi and elsewhere. New Panzi data would be gathered prospectively this time though, with trained intake workers asking carefully prepared questions of new patients as they come in. The records review project might expand to other hospitals, including a large medical center north of Panzi, in the city of Goma.

VanRooyen said the work with the military will also continue. The interviews so far are enough for a pilot study whose results can be evaluated and used to both seek funding and design follow-up studies. VanRooyen already believes that the questions in the interviews have to be changed. For example, more background questions should be asked early on to warm up interviewees before moving to questions about sexual violence.

VanRooyen also wants to expand the project to other military groups, such as the Congolese national army, Hutu fighters who banded together after the Rwandan genocide, and various splinter factions, some of whom are known to be particularly violent in their assaults.

Such an effort will require close coordination with CAMPS and careful planning. The meeting in CAMPS’s Bukavu office with a Mai Mai colonel to set up the Katokota interviews illustrates the logistical and security problems that researchers face operating in the Democratic Republic of the Congo. During discussions, the colonel checked repeatedly on the fluid security conditions on the road. He concluded that if researchers wanted to go to their preferred site — just five hours away — they would have to travel with him, because the roads were too dangerous to pass alone. Even then, the five-hour trip would require an overnight stay with uncertain accommodations, since travel back to Bukavu at night would be out of the question.

After talking it over, VanRooyen and Kelly selected a closer meeting site, Katokota, which is not only located along safer roads, but which would also allow a return to Bukavu the same day.

VanRooyen, who has a large amount of experience working in conflict zones, from Somalia to Rwanda to Kosovo, acknowledged there is risk in working in troubled places like the DRC, but said it could be done, together with good local partners like CAMPS.

“You try to be smart about the places you go,” VanRooyen said. “In general, if you listen to the news or the State Department reports, you’d never go to any of these places. But … people are going to market every day, they’re living every day, and if you’re smart about the way you engage and go in with reputable organizations, you can go.”