BUKAVU , 5 March 2009 (IRIN) - In Bukavu, the main town in South Kivu Province of eastern Democratic Republic of Congo (DRC), the Panzi referral hospital receives six to eight women daily who have experienced sexual violence.

"At least 60 percent of the women have been sexually violated, probably as sex slaves, through gang rape or through domestic violence," Maria Bard, manager of the hospital's Victims of Sexual Violence Project, said.

Despite the high rates of sexual abuse, poor local health systems and inadequate psycho-social support have made it difficult to treat the women.

According to the International Committee of the Red Cross, specific healthcare needs of women are often ignored or insufficiently taken into account in war situations. "People wounded in fighting are given priority for medical treatment, but women, even pregnant mothers, are often given scant attention despite their special needs," said Nadine Puechguirbal, ICRC's adviser on women and war issues.

Training issues

The hospital also receives women with severe gynaecological problems, including childbirth-related fistula and prolapse, said Bard.

Fistula is a severe medical condition caused when a hole develops either between the rectum and vagina or between the bladder and vagina and can be caused by rape and prolonged obstructed labour. In 2008, the hospital performed 40 fistula operations.

A uterine prolapse occurs when the uterus protrudes into the vagina.

"Preferably, we would like the women to be treated as close to home as possible," Bard told IRIN. However, this is not often the case because of a lack of training, competence and resources at the local level.

Most cases at the hospital are from Bukavu, Kalehe and Uvira territories in the province. "The needs are largest in FDLR [Forces Démocratiques pour la Libération du Rwanda] and Mai-Mai areas," she said.

The FDLR are a Rwandan militia blamed for the 1994 genocide while the Mai-Mai comprises various pro-government factions. Human rights activists have criticised the FDLR for abuses against civilians.

Lack of access

Overcrowding in communes such as Bagira, Ibanda and Kadutu was also to blame for some rape cases, local residents said.

"Rape cases are not just carried out by the armed groups," Winner Nishuli, a resident of Bagira, told IRIN. "The other day a domestic worker defiled a five-year-old not far from here."

In 2006, the UN reported 27,000 cases of sexual assault in the province. Even then, poor roads and insecurity make it difficult for the women to access healthcare, especially in remote areas such as Bunyakiri Ombo, north of Shabunda territory.

"It costs a lot to fly the women from there," said Bard. "We know that the women are there but we cannot access them."

Some of the women are stigmatised. "People talk badly. The women [who have been raped] are said to have been the wives of the enemy. They come to the hospital in privacy," she said.

Harsh reality

A recently concluded joint army operation by the DRC and Rwandan governments to oust the FDLR in neighbouring North Kivu also saw more cases of abused women coming to South Kivu.

"Sexual violence has invaded our lives ... the abnormal has become normalised. We come to accept that this is the reality for girls," Morag Hill of the local NGO Fondation Solidarité des hommes, told IRIN. "There is a lack of punishment and this reinforces the mentality."

Jean de Dieu, a Bukavu resident, said most rapists fled to avoid arrest. "Those who are arrested pay a small fine or bribe and get out yet they ruin women's lives," he said.

A new constitution adopted in 2006 introduced a 20-year minimum sentence for those found guilty. But even when cases come to court, it is difficult to ferry witnesses and perpetrators from remote areas.

Hill said it was necessary to provide the rest of the war-traumatised population with care as well. "I can't start to imagine a durable peace without dealing with the trauma," she said. "To be required to do so much while everyone's mental health is suffering ... we just won't be able to step up to the plate."

In 2008, an estimated 9,829 people in the province received psycho-social support. "But what kind of service did they receive?" Hill asked. "Many people in need are not accessing quality service."

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