Violence against Women: An Important Global Health Priority

This is a guest post by Sarah M. Simpson.

Violence against women is a major health problem around the world and continues to be an important cause of morbidity and mortality among women.  Women suffer violent deaths either directly or indirectly, and this violence is also can important cause of morbidities such as mental, physical, sexual and reproductive health outcomes and is also linked to important risk factors for poor health, such as alcohol and drug use, smoking and unsafe sex.  The problem is so widespread that it has its own Millennium Development Goal 3 which seeks to “promote gender equality and empower women” along with Millennium Development Goal 5 which seeks to “improve maternal health”. However, in the light of several publicized acts of violence against women, this important issue is once again at the forefront of everyday discussion. Some key facts about violence against women from a United Nations factsheet:

• A WHO multi-country study found that between 15–71% of women aged 15- 49 years reported physical and/or sexual violence by an intimate partner at some point in their lives.
• These forms of violence can result in physical, mental, sexual, reproductive health and other health problems, and may increase vulnerability to HIV.
• Risk factors for being a perpetrator also include low education, past exposure to child maltreatment or witnessing violence in the family, harmful use of alcohol, attitudes accepting of violence and gender inequality.
• Risk factors for being a victim of intimate partner and sexual violence include low education, witnessing violence between parents, exposure to abuse during childhood and attitudes accepting violence and gender inequality.

In the wake of the world-wide Valentine’s Day  One Billion Rising events calling people everywhere to unite and bring an end to violence against women, The Guardian’s “Global Development podcast” has recently released a podcast proceeding  the United Nations Fifty-seventh session of the Commission on the Status of Women.

podcast

In this podcast, deputy editor of Guardian global development Liz Ford speaks with Irene Khan, head of the International Development Law Organization; Korto Williams, country director of ActionAid Liberia; Andrew Long from the U.K. Foreign Office’s prevention of sexual violence in conflict initiative; and Lakshmi Puri, deputy executive director of U.N. Women, about current global efforts to stop violence against women.

Against the backdrop of these movements to unite people world-wide, all eyes will be on policymakers at this upcoming session of the UN Commission on the Status of Women to produce and deliver results abroad and even in the United States.  Recently, two UN experts addressed the US State House of Representatives to approve the Violence Against Women Act (VAWA) which lapsed in 2011. Overall, the impact of violence against women needs to continue to be researched and explored from a public health perspective.

Rave Review of “Rights-Based Approaches to Public Health,” by our own Dr. Elvira Beracochea

Congratulations, Dr. Beracochea! A glowing review of her new book, Rights-Based Approaches to Public Health, was recently published in PsycCritiques, a collection of reviews from the American Psychological Association. I have posted the review below. This is a wonderful accomplishment for Dr. Beracochea and her fellow editors and authors of this book. The IH section is fortunate to have you!

---

Public Health and Human Rights: Realigning Approaches to Improve Global Health Problems

Reviewed by
Will Ross

At a time of heart-crushing stories of human deprivation due to regional conflict, forces of nature, or uncaring and at times immoral state policies, the world’s attention turns to the public health community for problem assessment and effective deployment of resources and programs to stabilize critical conditions on the ground. With great timing, the editors of Rights-Based Approaches to Public Health offer a targeted and innovative strategy to
combat global health problems. Balanced, comprehensive, and steeped in the historical traditions of human rights, the book persuasively moves the reader from abstract conceptions of inalienable human rights to evidence-based, pragmatic solutions that highlight the systematic integration of human rights principles in human development work.

For the audience of public health students, seasoned and novice public health
professionals, health care practitioners, and policy experts, the editors provide an overview of a rights-based approach that is elegant in simplicity and highly executable in design, referencing the UN’s (2000) General Comment 14 on the Right to the Highest Attainable Standard of Physical and Mental Health: “Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life of dignity” (para. 1).

The editors and authors present a framework for a rights-based approach that is
normatively based on international human rights standards and that cannot be easily dismissed as political in nature or hegemonic. Most important, the editors charge some of the world’s most respected public health practitioners and human rights advocates to craft sensible methods of operationalizing the basic human rights principles outlined in the UN’s (2003) Human Rights-Based Approach: Statement of Common Understanding, which posits that human rights are universal, inalienable, interdependent, and interrelated. In essence,
they have created a veritable “how-to” guide that, when implemented, can in sustainable fashion uplift the human condition worldwide.

Universality of Rights-Based Approaches: Uniting Us All?

As detailed by the editors, a cardinal feature of a rights-based approach is its timelessness and universality, increasing its appeal to professionals who labor to keep the plight of marginalized communities on the global radar screen. By using the universal language of rights-based approaches, public health professionals may be better positioned to leverage greater social and political capital and enhanced resource allocation for their cause. Striking examples of rights-based approaches in diverse settings are outlined in the book, from demands for water rights in Haiti to conflict-affected settings such as the Gaza Strip and advocacy of children’s rights in Kosovo.

If the dramatic contemporary examples outlined in the book are not sufficient, the authors could easily extend the discussion further and call attention to the severe drought and attendant famine in Somalia, where the UN’s Food Security and Nutrition Analysis Unit (2011) found that nearly 250,000 people continue to face imminent starvation, or the Democratic Republic of the Congo, where U.S. researchers note that more than 400,000 women are raped each year (Peterman, Palermo, & Bredenkamp, 2011). In all instances a rights-based approach can reverse the erosion of socioeconomic stability that fosters such
injustices while holding the state accountable for protecting and fulfilling the rights of individuals in affected communities.

Inherent in a rights-based approach claim that individuals have the right to the highest attainable standard of health is the realization that health professionals cannot disentangle physical health from the myriad social and economic factors that influence health. If a rights-based approach empowers rights holders in asserting that human rights are universal and inalienable, then it is the incumbent responsibility of the duty bearer—entities sanctioned to protect society—to ensure the fulfillment of those rights. This conceptual framework is in contradistinction to traditional needs-based approaches, whose altruistic intent and actions may be perceived as both patronizing and lacking in accountability, and thus not amenable to legal redress in the event of adverse outcomes.

Marrying Rights-Based Approaches to Health Care Reform

A critical chapter for U.S. readers (Chapter 4) is “A Rights-Based Approach to Health Care Reform.” In the United States, profligate health care spending has not translated into improved health outcomes when compared with those of other developed countries. A fundamental, if not fatal, flaw in the U.S. health care delivery system is the disconnect between the high-quality acute, specialty care available to some who have the ability to pay in a system rooted in free enterprise and the haphazard primary and preventive care that is unevenly distributed across locales. Although unintended, this result is not unexpected in a country that has failed to embrace a full definition of health.

The divide on the proper role of government in health care in the United States was presaged in the response to the World Health Organization’s (1946) definition of health, promulgated in the 1948 UN convention:

a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity. . . . Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. (p. 2)

This provision was rebuffed on the grounds that it was outwardly socialistic in intent and lacked legal standing, on the basis of the interpretation that health care was not among the enumerated rights in the U.S. Constitution.

The perennial argument surrounding the government’s role in health care has since devolved into rants about market-based reforms as opposed to moral-based claims of health care as a right for every citizen. Such a false dichotomy only promotes greater social division; consensus will be gained when every country affirms the connection between health and human rights. A rights-based approach to health, which has been relatively absent from the contemporary discourse on health reform, could effectively realign staunch political forces around the unassailable conceptual framework of health as a public good rather than a commodity.

The rights-based approach permits a more nuanced view of the roots of health
inequities; consequently, more systematic steps can be taken to ameliorate inequities since a framework exists that addresses the social determinants of health. Rights-Based Approaches to Public Health outlines several international treaties, such as the 1977 International Covenant on Economic, Social, and Cultural Rights, which would reduce stillbirth rates and infant mortality by paving the way for special protection for mothers in the childbirth period. Although the United States signed the treaty, it did not ratify it and so failed to allocate the requisite resources to enforce the treaty.

Hopefully there will be greater U.S. embrace of the UN’s Millennium Development Goals—explicit milestones for the realization of global human development that offer an opportunity to reduce health inequities by spurring economic development. The United States, in its effort to reduce health inequities as outlined in the Centers for Disease Control and Prevention’s (2011) “Health Disparities and Inequalities Report,” will find willing partners in realizing two seminal Millennium Development Goals: reducing child mortality
and improving maternal health.

Limitations of Rights-Based Approaches

The authors and editors of Rights-Based Approaches to Public Health rightfully
acknowledge that the still-nascent field of rights-based public health has limitations that have constrained its widespread adoption. Rights-based approaches rest on the belief that individual empowerment and restored human dignity can be ensured through programmatic efforts that address the social determinants of health. Social determinants of health, as espoused by the World Health Organization’s Commission on Social Determinants of Health (2008, p. 2 of Executive Summary), are “the conditions in which people are born, grow, live, work and age . . . . In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics.”

Criticism abounds that such an approach is too costly, time intensive, and inherently difficult to measure since it involves restructuring the social fabric of disadvantaged communities and raises the potential for conflicts due to encroachment on national sovereignty. There is correspondingly a lack of solid evidence supporting the effectiveness of rights-based approaches. Finally, a rights-based approach in public health can come across as canonical, even prescriptive in its assertion that individual rights warrant the same protection as societal ones (Berman, 2008).

The book concludes, in powerful tones, that rights-based approaches provide public health professionals the framework and the infrastructure to address the needs of vulnerable populations and society at large. Public health students, academicians, and both medical and public health practitioners should feel empowered to act with this transformative approach that asserts the dignity of humankind.

References
Berman, G. (2008). Undertaking a human rights-based approach: Lessons for policy, planning, and programming. Bangkok, Thailand: UNESCO Asia and Pacific Regional Bureau for Education.

Centers for Disease Control and Prevention. (2011, January 14). CDC health disparities and inequalities report—United States, 2011. MMWR: Morbidity and Mortality Weekly Report, 60(Suppl).

Peterman, A., Palermo, T., & Bredenkamp, C. (2011). Estimates and determinants of sexual violence against women in the Democratic Republic of Congo. American Journal of Public Health, 101, 1060–1067. doi:10.2105/AJPH.2010.300070

United Nations. (2000). The right to the highest attainable standard of health. Retrieved from http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En

United Nations. (2003). Human rights-based approach: Statement of common
understanding. Retrieved from http://www.unicef.org/sowc04/files/AnnexB.pdf

United Nations Food Security and Nutrition Analysis Unit. (2011, November 18). Famine continues: Observed improvements contingent on continued response. Retrieved from http://www.fsnau.org/in-focus/famine-continues-observed-improvements-contingentcontinued-response

World Health Organization. (1946). Constitution of the World Health Organization. Geneva, Switzerland: Author.

World Health Organization Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization.

“Driving out Trash”: Five years brings only more evictions for Harare’s slum-dwellers

Flickr, Sokwanele - Zimbabwe

The Shona word murambatsvina means “to drive out trash.” This was the word used to describe the Zimbabwean government’s campaign to forcibly clear out the slum areas around the country, under the pretense of combating illegal housing and reducing the spread of infectious disease. Zimbabwe’s current president has described the “urban renewal campaign” as “a vigorous clean-up campaign to restore sanity.” UNHCR has estimated that the forced evictions have directly affected at least 700,000 people, and that approximately 2.4 million more could have been indirectly affected in some way. The campaign was condemned by the UN and was called a crime against humanity.

Five years later, the evicted slum-dwellers still remain homeless. The few houses that were built as part of the re-housing scheme were given to government employees. Obvious human rights abuses aside (like torching people’s houses and belongings) aside, the campaign had serious health consequences for the evicted populations. HIV patients were cut off from clinics and antiretroviral medications. Thousands of IDPs are still living under emergency plastic sheeting with no medical services or clean water, no schools, no sanitation, and no source of income. Amnesty International has reported a shockingly high neonatal mortality rate among babies born to evicted mothers: in five months, there were 21 newborn deaths in Hopley, a settlement 10 km south of Harare. Most of the babies died within 48 hours of birth. The women have said that they were fully aware of the importance of maternal healthcare, and they all wanted to give birth in a hospital or with a trained birth attendant, but many could not afford the $50 required to register for antenatal care. The nearest maternity clinic is 8 km away. Some thought their babies had died because of minimal access to healthcare, while others suspected they had died of cold because they live in plastic shacks.

Amnesty International and other human rights groups have called for an investigation of the newborn deaths, but there seems to be little hope of a serious inquiry. Meanwhile, there are growing concerns of another eviction campaign: residents are again being forced to leave their homes because they cannot afford a(n arbitrarily-imposed) $140 “lease renewal fee.” Zimbabwe’s government of course denies this, but it a bit difficult to argue when the evidence consists of shacks on fire. Several MEPs have called for the Zimbabwean diplomat to the EU to be sent home in response to the evictions – but will it be enough?

This was also posted on Jessica’s Refugee Research Network blog.

One Step Forward, Two Steps Back: Court Decision in China Upholds HIV Employment Discrimination

China always seems to find its way into human rights headlines these days. Now that the sound and fury of Liu Xiaobo’s Nobel Peace Prize has died down, the People’s Republic is in the news again: this time for a landmark court decision in which a man lost a discrimination case for being denied a teaching job based on his HIV status. Wu Xiao (an alias that means “Little Wu”), a 22-year-old college grad, passed a series of written tests and an interview for the position, so he should have been perfectly qualified for the post. However, when his mandatory blood test revealed his HIV status, the local education bureau in Anqing rejected his application. The court ruled that the criteria for hiring civil servants (which disqualifies HIV-positive individuals from being hired) overrules a 2006 law that prohibits discrimination against persons with HIV and their families. The verdict is highly discouraging to Chinese AIDS advocates.

Discrimination against persons with HIV is nothing new. The history of the disease is littered with horror stories of stigma, persecution, and invasion of privacy, and discrimination continues all over the world in various forms, including cultural norms and, in some cases, even laws. In Chile, HIV-positive women are frequently pressured to get sterilized, and some are even sterilized without consent. Twenty-two countries, including Russia, Egypt, and South Korea, will deport foreign nationals based solely on HIV status, and other countries (such as Malaysia and Syria) will not allow students with HIV to apply for study. Gugu Dlamini, a SouthAfrican woman, was beaten to death after speaking openly about her HIV status at an AIDS awareness gathering on World AIDS Day in 1998.

China is certainly no stranger to HIV/AIDS discrimination. From the government’s frantic cover-up of the “Bloodhead Scandal” (in which 30,000-50,000 people were infected through blood transfusion programs in the 90s) to present-day violations of patient privacy laws, Chinese HIV patients face harsh stigma from healthcare providers, government officials, and their friends and neighbors. On the surface, the country has been somewhat proactive in mitigating this: it passed its first laws regarding HIV patient privacy in 1988, and it is illegal to disclose personal information of HIV-positive individuals. Chinese President Hu Jintao and Prime Minister Wen Jiabao make visible appearances with people with AIDS every year on World AIDS Day, and ARVs are available to AIDS patients for free. However, privacy laws are routinely violated, and people with HIV are ostracized from their families and communities. The government routinely harasses and often imprisons AIDS activists (Hu Jia, for example, was held under house in 2006 and has been in jail since 2008). Fear, ignorance and the threat of discrimination discourage individuals from getting tested and deter many who already know their status from seeking treatment. Chinese AIDS patients are encouraged by their providers to use fake names and IDs when seeking treatment and picking up medicines.

Wu’s lawyers plan to appeal the decision, but advocates are frustrated. “The entire H.I.V. community had high hopes, but now the door appears to be shutting for people who want to use the courts to fight against discrimination,” said Yu Fangqiang, whose organization represented Wu in his case. Others, however, urge patience, and point out that the fact that the case was even heard demonstrates progress. Either way, it is crucial to end the institutionalization of discrimination against HIV. Cultural norms will not change until the official government position changes, and, along with it, its laws. People will not seek treatment until they are no longer afraid to come out of hiding.

Rohingya Refugees: Where do you go when everyone just wants you to go away?

Rebel groups in the Congo.  Religious radicals in Iraq.  Mercenaries in Darfur.  Starvation in North Korea.  Natural disasters in Haiti and Chile.  Every region in the world has something to run from, and the people running from them are dispersed far and wide.  Refugees, while pitied, are often treated with a mild neglect, or sometimes with disdain or outright hostility.  Still, many of them find the means to survive in less dangerous conditions.  Some try to make a life for themselves by emigrating, while others do their best to scrape a life together in refugee camps dotting the borders of their more peaceful neighbors.  The public health and medical challenges in refugee camps are many and daunting: unsanitary conditions, no running water, little to no food security, scant medical care. 

From "Rohingya in Bangladesh: Unrecognized, Unprotected, and Unassisted," a slideshow by MSF

The Rohingya are suffering from these conditions perhaps more acutely than most.  They are an ethnic Muslim group from Myanmar, but they are not recognized as one of the country’s 135 “national races” by the military junta.  About 750,000 currently live in Myanmar, where they are oppressed by the military and not allowed to own property, vote, travel, or marry; one million have fled persecution and emigrated to other parts of the world.¹  There are refugees in each of the country’s five neighbors – China, India, Laos, Thailand, and Bangladesh – with the largest refugee camps in Bangladesh.²  While 28,000 in the official Kutupalong camp have recognized refugee status in Bangladesh,³  another 220,000 are illegal immigrants with no official status and no assistance.^3,4  Many live in a makeshift camp just down the road from Kutupalong with no water, power, schools, or medicine.¹  When Médecins sans Frontières (Doctors without Borders) made its initial assessment of the camp in March of 2009, they found that 90% of the more than 20,000 residents were severely food-insecure; malnutrition and mortality rates were past emergency thresholds; and people had little access to safe drinking water, sanitation, or medical care.^3,5  MSF immediately began offering basic health care and treating malnourished children and has now established a primary health care program for the refugees.  MSF and Action contre la Faim (Action against Hunger) are the only international NGOs working at the makeshift camp.⁵The treatment the Rohingya face in Bangladesh and elsewhere isn’t much better than in Myanmar.  The Bangladeshi government has been accused of blocking food aid, conducting arbitrary arrests, beating and harassing the unrecognized refugees.^3,4  Reports have come in of the Thai military conducting “pushbacks” – rounding up Rohingya, putting them on a boat, and pushing them out to sea.¹  But the truth is that no one wants them.  Bangladeshi officials, denying allegations of abuse, insist that “[w]e are the victims. The Burmese people have been kicked out of their country and we gave them shelter.”⁴ 

More information on the Rohingya and refugee health
Rohingya in Bangladesh: Unrecognized, Unprotected, and Unassisted (MSF slideshow)
The United Nations High Commissioner for Refugees
Forced Migration Review – published three times a year in English, Arabic, Spanish, and French by the Refugee Studies Centre of the Department of International Development, University of Oxford. 

Spotlight on Maryam Bibi, an extraordinary woman, on International Women’s Day

The twittersphere is abuzz today with tweets from people, government agencies, and NGOs celebrating International Women’s Day.  The call to continue working to improve health and human rights for women across the globe is loud, clear, and multi-voiced.  And although much still remains to be done for women in developed and developing countries alike, the voices of high-profile women and the tireless work of individuals and organizations committed to bettering the lives of women are making great strides.

But while governments and large aid machines attract most of the attention given to work in women’s health, it is often the work of individuals that is the most moving.  Amid all of the “#internationalwomensday” tweets over the course of the day, the one that caught my eye was the Acumen Fund calling attention to Maryam Bibi, an extraordinary woman who has worked for women’s health and education in Waziristan since 1993.

Image courtesy of the Times Online.

Ms. Bibi set up Khwendo Kor (a phrase in Pashto meanings “Sisters’ Home”), an agency in Peshawar that works with women in Pakistan’s Northwest Frontier Province to improve their education, health, and economic well-being.  The organization began in one village with four staff members; now it works in more than 300 cities and has over 340 staffers.^1,2,3  Khwendo Kor focuses primarily on social organization, community-based education for women, microcredit, primary health care, and advocacy, and it collaborates with men and local leaders to accomplish its goals.¹  It has trained 180 young women as village-based teachers and established 170 community schools, and over 200 women have been given opportunities to begin small businesses through microcredit.^2,3  Through her schools, approximately 6,500 girls have been educated, and 3,500 are currently enrolled.³  She has received multiple awards for her work, including the Fatima Jinah Medal (2003) for outstanding women in the social sector and the Star of Excellence National Civil Award (2001) in Pakistan, the UN’s Recognition of Services award (2000), and the ILO’s Human Rights Award (2001).^1,2,3

Despite international honor and recognition for her work, Ms. Bibi still faces considerable opposition and danger close to home.  While she enjoys walking to work, she says that “the office vehicle often collects me.”⁴  Radical religious organizations slander Khwendo Kor through mosques and local media.  Children’s learning centers established by the organization have been blown up.  Their vehicles have been stolen, staffers have been shot at, and fatwas have been issued against them.  Ms. Bibi can no longer stay late in her office because of death threats.  Still, she is not deterred.  “Some people say that I am an elderly lady and that I should be ashamed of myself doing this work: that I should be sat at home and saying my prayers. But as an elderly woman I would like other elderly women to join me because this work is a matter of our children and our future generations and we have to do something to bring about change.” ²

February 6: International No Tolerance Day to Female Genital Mutilation

February 6 has been designated by the UN as “International Day against Female Genital Mutilation,” a day to raise awareness about the dangers and health consequences of this traditional practice in sub-Saharan Africa and the Middle East.¹ Female genital mutilation (FGM) refers to the partial or total removal of the external female genitalia for cultural, religious, or other non-therapeutic reasons.² It has no health benefits and frequently causes both immediate and long-term problems for women and girls: in addition to severe bleeding, infection, and problems urinating, it can cause infertility and complications with childbirth.^1,3 An estimated 130 million women alive today are currently living with the consequences of FGM.

Image courtesy of afrol News

FGM is entrenched in the cultural and religious beliefs in many communities.⁴ In many parts of West Africa, this cutting is presented as a religious obligation to Muslim women.⁵ It is internationally recognized as a violation of the human rights of girls and women: it is nearly always performed on minors,² and it is sometimes used to facilitate sexual relations with child brides.⁵ Additionally, FGM is just one component of cultures in which women have no voice in decisions that affect their everyday health and well-being. For example, Amnesty International recently called attention to the high rate of maternal deaths in Burkina Faso, which it ascribes to gender discrimination: many women are unable to access sexual and reproductive health services due to discriminatory attitudes and illegal demands for payments by corrupt medical staff.  Burkinabe women have little to no say in when they can seek medical care or the timing and spacing of their pregnancies, and they are still being subjected to early marriages and FGM.⁶

There has been recent progress by governments, human rights groups, and NGOs in persuading communities to abandon the practice.  In Mauritania, 34 imams and Muslim scholars recently signed a fatwa, or religious ruling, against the practice.^7,8 Authorities in Niger recently took steps to enforce a ban enacted in 2003 by administering fines and jail sentences to 45 mothers who allowed their daughters to be cut.⁷  Tostan, an NGO that works primarily in Sénégal, has worked with thousands of villages that have made the decision to abandon FGM: the group educates villagers and then allows them to make their own conclusions.  Because the practice is often tied to marriage opportunities, intramarrying groups must make a collective decision to abandon the practice in order for efforts to be effective.⁴ Since 1997, 4,580 communities working with Tostan have declared their decision to end the practice.

The UN and other international health and human rights groups have campaigned aggressively to end FGM, and more countries are passing laws against the practice.  Recent indications that communities in West Africa are moving away from it are encouraging.  However, two million girls are still at risk every year.² As the international community observes this day of awareness, we should be attuned to the need for culturally sensitive approaches to end FGM in order to protect the rights of women and girls.

The “Angel of Bukavu”: A light in the heart of darkness

Blog contributor: Jessica M. Keralis

To most, the Rwandan genocide that began in 1994 is a page in the history books, and the resulting instability in the Kivu region of eastern DRC is old news.  But for Dr. Denis Mukwege, a surgeon who specializes in the repair of vaginal fistulas, the atrocities of Congo’s “second war” are a harsh, every-day reality.  Vagina fistula, a condition in which the tissue wall between the vagina and the bladder and/or colon is torn, is a common result of the systematic rape to which the women of this region of the Congo are subjected.

During Rwanda’s civil war and genocide in 1994, thousands of refugees and armed militant groups fled to the eastern region of the Congo, generating a climate of political instability and local anarchy.  A “second war” began in 1998, in which Rwanda and Uganda organized and fostered armed bands to terrorize the local people and maintain the insecurity to justify militarization that enables them to plunder the resource-rich region.  This conflict has been the deadliest since World War II, and more people have died than in Iraq, Afghanistan, and Darfur combined.  Intermingled with the high death toll is the widespread calculated rape of women of all ages.  It is used to physically and psychologically terrorize: the women are raped or gang-raped in broad daylight and in plain view of their families and neighbors.  As a result, social networks are destroyed and family ties are fragmented.    The widespread sexual violence has taken its toll on public health both physically and socially. Sexually assaulted victims outnumber wounded soldiers 4 or 5 to one and civilians with gunshot wounds 2 or 3 to one.  Medical sources estimate that between 19 and 30 percent of the victims test positive for HIV.  Half of them have syphilis.  The women are virtually destroyed, often abandoned by their husbands, and their children are traumatized.  Those that survive become outcasts.

In the midst of such atrocities, Dr. Mukwege has been called the “angel of Bukavu.”  He typically performs ten surgeries per day, often working 14 hours or more.  To the women he heals, he is more than just their doctor: he is their brother, their counselor, their confidant.  He has been featured by CNN, the New York Times, and Glamour magazine, and has been given numerous awards, including the Olof Palme Prize and the UN Human Rights prize.  But while Mukwege is grateful for the attention drawn to the conflict and money for the hospital, what is truly needed, he says, is a political response to the violence.  “Visitors come from the international community.  They eat sandwiches and cry, but they do not come back with help. Even President Kabila has never put his foot here. His wife was here. She wept, but she has done nothing.”

Interview with Cécile Mulolo Kamwanya, psychologist at Panzi hospital: