Auckland general practitioner Dr Karen Chung recently spent a year in Swaziland, where she was Médecins Sans Frontières’ focus person for survivors of sexual violence.
“A young girl sits silently, eyes downcast. Her jersey is tied tight around her waist. Her clothes are torn. Her skin bruised and scraped. She is so slender a slight breeze might blow her over. She is so quiet and still that she seems an extension of the chair on which she sits. Three hours ago, this was a normal day. She and her classmate were walking to school when a man jumped out from the bushes. He had a knife. The day then became a nightmare. He caught her friend first and threatened to hurt her if either of them ran. He made her lie on the ground on her belly, and lay her friend on top of her. He raped her friend while she lay underneath and made them swap positions and then raped her. Now she sits like a shadow; her parents hovering around her protectively. She is a survivor.
In Manzini, we are working on improving access to medical care for survivors of sexual and gender based violence (SGBV). We are providing care at our comprehensive clinic in Matsapha and supporting Mankayane Hospital to provide SGBV care. In Matsapha, survivors arrive and are immediately seen by psychosocial staff. Then they see the nurse and doctor who perform examinations and give the appropriate medications and vaccinations. They are seen again by our psychosocial team who provide a ‘dignity pack’ (a small bag of toiletries), and arrange follow up. There is a 24 hour phone line for SGBV advice outside working hours. In Mankayane we are supporting SGBV care through staff training and community education activities.
“You want to protect, to undo, to smite… We want to do everything but we can only do so much.”
We can only do so much
SGBV care is complex and emotive. Survivors and their families have many needs. They have medical needs certainly; care of wounds and injuries, prevention and/or management of pregnancy, sexually transmitted infections, HIV, hepatitis B and tetanus. But they also have psychosocial and medico-legal needs. We interact with other organisations to address these multi-faceted needs. Their stories are so sad, so terrible, so infuriating that, as health professionals, we may find we have our own needs to be met. A staff nurse said in a training session, “you go home from this so upset, so angry, especially when you think of your own children, that you just cannot function.” You want to protect, to undo, to smite. We are reminded sharply of our limits and vulnerabilities. We want to do everything but we can only do so much.
Resilience and Hope
Providing SGBV care is both a devastating and a beautiful thing. In the deepest darkness, there can be rays of light. Our frozen girl sitting silently; at some stage, she has to get up from that chair. When her tightly tied jersey falls away, we see her skirt is caked with dried brown blood. She looks so bewildered, so ashamed. I get her some new underwear from the children’s drawer. As they unfold themselves I must look genuinely dismayed to find they are roughly the size of the girl’s torso. A short burst of laughter erupts from our survivor which turns into a stream of merriment when I look into her eyes. Somehow, the thaw has begun. A week later, she is seen by our psychosocial team. She draws a picture of a beautiful smiling lady with gorgeous long hair and stunning high heels, labelled with the word ‘love’. When asked who this person is, she says it’s our counsellor. This little girl is nothing like the frozen creature of a week before. She radiates warmth. What a beautiful thing the human spirit can be, filled with resilience and hope and love.
Like HIV and tuberculosis, which comprise our core work in Swaziland, SGBV is fraught with issues like ignorance, fear and stigma. These are huge barriers to access. According to a UNICEF survey in 2007 of 1,244 females aged 13–24, only 2.1 per cent of survivors sought medical help. SGBV work cannot be done in the clinic alone. As such, we have embarked on ‘sensitisation’, or community engagement. SGBV was the focus of our activities at Umhlanga, the annual Swazi reed dance ceremony. In partnership with One Stop Centre, a new care facility providing integrated SGBV services, we shared our message of getting medical care for SGBV within 72 hours. More than 100 girls with bright young faces danced, chanting ‘72 hours’, laughing and giggling, full of life. More than 100 girls raised eager hands to answer questions about SGBV. When an opportunity came to speak, over a dozen girls were seen to move forwards then step hastily back; eyes downcast, shy, afraid. One brave girl came forward and shared her story. It was unexpected, that movement, that desire to share then and there. They were too many. Too much. It broke your heart.
With the community engagement activities, more and more survivors are presenting to us. But we cannot do our work in isolation. We are forming and strengthening our relationships with the police, public prosecutors and other clinics and NGOs. This year we have also embarked on multiple onsite training sessions for all our medical and psychosocial staff. We have been fortunate to have had staff complete international SGBV training. They have taken leading roles in training other staff and in improving the services we offer.
Sometimes it is the most immeasurable things that reflect the highest quality; the softest smile, the gentlest touch, the knowledge that good and kind people were there when they were needed. In our training sessions, people were asked what the needs of survivors were. Every person wrote something about support, love and care. As SGBV care evolves, we will continue to strive for quality in providing this support, love and care for our patients.”