This is about fistulas—and rape, which in Congo has become the continuation of war by other means. Fistulas are a kind of damage that is seldom seen in the developed world. Many obstetricians have encountered the condition only in their medical texts, as a rare complication associated with difficult or abnormal childbirths: a rupture of the walls that separate the vagina and bladder or rectum. Where health care is poor, particularly where trained doctors or midwives are not available, fistulas are more of a risk. They are a major health concern in many parts of Africa.
In eastern Congo, however, the problem is practically an epidemic. When a truce was declared in the war there in 2003, so many cases began showing up that Western medical experts at first called it impossible—especially when local doctors declared that most of the fistulas they were seeing were the consequence of rapes. "No one wanted to believe it at first," says Lyn Lusi, manager of the HEAL Africa hospital (formerly called the Docs Hospital) in the eastern Congo city of Goma. "When our doctors first published their results, in 2003, this was unheard of."
It had been no secret that nearly all sides in the Congo's complex civil war resorted to systematic rape among civilian populations, and estimates were as high as a quarter million victims of sexual assault during the four-year-long conflict. But once fighting died down, victims began coming out of the jungles and forests and their condition was worse than anyone had imagined. Thousands of women had been raped so brutally that they had fistulas. They wandered into hospitals soaked in their own urine and feces, rendered incontinent by their injuries. "Pastors would say to me, 'Jo, I can't preach because the church is too smelly," says Dr. Jo Lusi, a gynecologist and medical director at HEAL. (He and Lyn Lusi are husband and wife.) "No one wanted to be around them. These women were outcasts even more than rape victims usually are. They would say to me, 'Dr. Jo, am I just a thing to throw away when I smell bad?' "
The rapes—and new reports of fistula damage—have not stopped. Even now, "It is still happening, even today," says HEAL's medical director, Doctor Lusi. "Every space we have in the hospital is very, very busy with people." Most of the dozen or so militias in the country have signed on to peace terms, and their battles with each other and with the Congolese Army have mostly stopped since the arrival of United Nations peacekeepers. But many of the armed groups—even those that have made peace—continue to attack civilians, especially in rural areas. "They won't go ahead and fight each other, [but] they attack that village that supports the other group," says Lyn Lusi. "This is a horrible perpetual movement of militias. They join after their families are killed, sometimes right in front of them. They see their women raped, and then they go and do the same thing. It's a cycle of violence."
Ordinary rapes, even violent ones, do not usually cause fistulas, although it's not medically impossible. Doctors in eastern Congo say they have seen cases that resulted from gang rapes where large numbers of militiamen repeatedly forced themselves on the victim. But more often the damage is caused by the deliberate introduction of objects into the victim's vagina when the rape itself is over. The objects might be sticks or pipes. Or gun barrels. In many cases the attackers shoot the victim in the vagina at point-blank range after they have finished raping her. "Often they'll do this carefully to make sure the woman does not die," says Dr. Denis Mukwege, medical director of Panzi Hospital. "The perpetrators are trying to make the damage as bad as they can, to use it as a kind of weapon of war, a kind of terrorism." Instead of just killing the woman, she goes back to her village permanently and obviously marked. "I think it's a strategy put in place by these groups to disrupt society, to make husbands flee, to terrorize."
The worst perpetrators call themselves the Federation for the Liberation of Rwanda. They were the Hutu militiamen—also known as the Interhamwe—who carried out the 1994 Rwandan genocide. That bloodbath ended when the Interhamwe were forced to retreat across Rwanda's western border into Congo, where they remain to this day, deep in the forests, armed, deadly and with nowhere else they can go. But the tactic of violent rape is used by many of the other armed factions in the area, including the Congolese Army, according to relief workers and United Nations officials. "It has been used as a weapon of war for so long it's become almost a habit," says Ross Mountain, the U.N.'s humanitarian coordinator for the Congo. "All sides are doing it, and the national army is by no means immune from that." "All the armed men rape," says Doctor Mukwege. "When we see a lesion, we can tell who the perpetrator is; there are special methods of each group, types of injuries. The Interahamwe after the rape will introduce objects; a group in Kombo sets fire to the women's buttocks afterwards, or makes them sit on the coals of a fire. There's another group that specializes in raping 11-, 12-, 13-,
14-year-old girls, one that gets them pregnant and aborts them." The youngest victim of fistula from rape his hospital has seen was 12 months old; the oldest, 71.
The fistula wards at HEAL Hospital are overflowing, with two women to a bed and patients tucked into every possible corner in the 150-bed center. Doctors there say two-thirds of their hospital's fistula cases are the result of sexual violence. Since 2003, when the hospital had to be completely rebuilt after a volcanic eruption buried the town in lava, HEAL's doctors have seen 4,800 rape victims requiring medical treatment; last year alone, surgeons there performed 242 fistula-repair operations. Panzi Hospital, in the town of Bukavu, some 70 miles southwest of Goma, is an even bigger medical center specializing in fistula surgery and treating rape
victims. Its surgeons did 540 fistula repairs last year; its two fistula wards, 25 beds each, are usually full. Doctor Mukwege estimates that 80 percent of his hospital's fistula cases are the result of sexual violence, either directly from sexual assault or from rape-induced pregnancies that were forcibly aborted in the bush; the rest were normal obstetric complications. "It's an epidemic," he says.
Panzi is running at capacity, with 250 to 300 admissions a month due to rapes, most of them new cases. Other hospitals run by aid groups in eastern Congo report similar statistics; the Medecins Sans Frontieres Bon Marche Hospital in Bunia, in war-torn Ituri province, northeastern Congo, normally admits between 10 and 20 rape victims daily—a minimum of 300 a month—again, mostly new cases, according to MSF officials there. "IRC and its partners in South and North Kivu provinces registered 40,000 cases of gender-based violence [since 2003], and we're not even counting everyone," says Brian Sage, a coordinator for the International Rescue Committee, which helps support both Panzi and HEAL hospitals. "This is just the tip of the iceberg." Many more cases take place in the interior where aid workers still haven't reached. When Doctor Mukwege sent a mobile team under U.N. protection to the village of Nzingu, the group was prepared to treat 200 rape victims. Instead, 1,400 women came forward asking for medical help.
The only hope for these women is a difficult operation. It usually takes several hours, followed by a recovery period of two or three months. Even then, the doctors may have to try again. Sometimes the surgeons never manage to restore the patient's continence. "We've had a hundred fistula cases where there's no hope of recovery," says Doctor Mukwege. "We tried and tried but were unsuccessful. Psychologically, it's difficult to bear these cases. They come in here with great hope, it's very difficult for them but also for me, they come full of hope, it's so difficult to bear." Last April, he says, a 5-year-old girl was brought to him. Her tormentors had raped her and then fired a pistol into her vagina. She was operated on twice at Panzi Hospital without success before being sent to a hospital in the United States where surgeons tried twice more to repair the damage. They failed, too. She'll spend the rest of her life with a colostomy bag.
The doctors have a hard time coping with the anguish they see every day. "I no longer question the women about what happened," says Doctor Mukwege. "It's hard to listen, it's very hard to see them—children without vaginas, without rectums, their bladders destroyed. The questions they ask. The girls say, 'Is it not possible for me to have children?' 'Why don't I have menses?' These are questions to which you cannot answer."
But those questions are relatively easy. The really difficult question is posed again and again by fistula patients like 20-year-old Bahati: Why? When she arrives to be interviewed in an examination room off the main fistula ward at Panzi, she is carrying a basin; which she keeps at her feet as she talks. Her fistula has left her incontinent. She and the other patients interviewed here were chosen to speak by a counselor who believed they could benefit from telling their stories.
Late one evening a group of Interhamwe gunmen raided her village in South Kivu, killed 10 of the men, and abducted 10 women and girls. She says she and the other captives were kept chained except when they were unbound to be gang-raped. She became pregnant after five months, and her captors gave her a crude abortion by shoving something into her—she says she doesn't know what they used. Her doctors say the abortion probably caused the fistula. Eventually she escaped and found her way back to her home village after three days. At the Interhamwe camp, sometimes as many as 30 men would rape her, she recalls. Whenever she resisted, she was beaten. "I'll never understand why they could do that to me," she says.
Benga, 16, and Masoro, 17, ask themselves the same thing. The two friends were abducted along with their mothers from the remote South Kivu village of Nzingu. Their captors dragged them to an Interhamwe camp. "When we got there," Masoro recalls, "they said, 'This is a horrible place where girls and women suffer, and you will suffer also'." They were kept tied to trees except when they were doing domestic chores or being raped. Their mothers were raped in front of the girls. Benga bursts into tears recalling the experience. "Their purpose is simply to ruin people, to rape people," she says. "I don't know why."
No one can say why. The answer is almost too awful to consider, and impossible to understand.