More Vicious Than Rape

Warning: do not read this story if you are easily disturbed by graphic information, or are under age, or are easily upset by accounts of gruesome sexual violence.

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."