Mission to Chad Pinpoints Sexual Violence

Their journey was unsettling from the start. First, the 3 women physicians from Boston spent a night in a brothel in central Chad when a nongovernmental organization's compound where they had planned to stay was full. The next day, an armed United Nations (UN) convoy was supposed to lead them safely to a refugee camp in eastern Chad. But the convoy raced ahead after just 15 or 20 minutes on the road, leaving them to drive unprotected in treacherous territory for several hours. Once inside the camp, an atmosphere of intimidation greeted them. Trucks bearing rocket-propelled grenades as well as men and boys carrying AK-47 assault rifles were prominent fixtures of the dry, desolate landscape.

Perhaps even more challenging for the physicians, who traveled nearly 6000 miles to the Farchana Camp last November, were the stories of women living in the camp who have endured beatings, rape, and stigma after fleeing genocide in Darfur at the hands of the Sudanese Army and Janjaweed militiamen. “This was not your usual business trip,” said Sondra Crosby, MD, associate professor medicine at Boston Medical Center and an experienced investigator of torture and abuse cases. “I’ve been to Africa before, but going to Chad was startling.”

Physicians who traveled to the camp with Crosby were Linda Piwowarczyk, MD, PhD, director of the Boston Center for Refugee Health and Human Rights at Boston Medical Center, and Julie VanRooyen, MD, a fellow at the Harvard Humanitarian Initiative (HHI) in Cambridge, Mass. Karen Hirschfeld, MA, former director of Physicians for Human Rights' (PHR) Sudan Program, collaborated with them in conducting fieldwork and in organizing the trip.

Their mission consisted of interviewing Darfuri women in the camp and documenting incidents of sexual assault, sexual violence, and other human rights violations, as well as physical and mental health status. Opened in 2004, a year after the crisis in Darfur erupted, the camp originally was intended to house 2000 refugees but now has a population of some 20 000.

“Talking to us was the first time they’d ever told their stories,” said Crosby. “They’ve been living with the trauma for 5 years and we were the first people they spoke to, which speaks to the underreporting of sexual trauma in the camps.” In May, PHR, in partnership with the HHI, published a report of their findings (http://physiciansforhumanrights.org/sudan/news/nowhere-to-turn.pdf).

Before setting out for Chad, Crosby, Piwowarczyk, VanRooyen, and Hirschfeld were among an expert group who developed a 42-question survey that asked women in the camp about their lives in Darfur, reasons why they left their homes, their experiences in Chad, and how they viewed their health status. An institutional review board at the Harvard School of Public Health approved the survey and an informed consent form that interpreters read to participants. During 3 weeks at the camp, 88 women agreed to interviews that on average lasted 2 hours each.

In their report, Nowhere to Turn: Failure to Protect, Support and Assure Justice for Darfuri Women, the team documented 20 confirmed rapes. Another 12 were considered highly probable, based on the women's behaviors and how they responded to survey questions designed to help verify reports of rape. Crosby, Piwowarczyk, and VanRooyen also conducted physical and psychological examinations of 21 women who said they had been raped. The clinicians carried out those examinations according to international guidelines, known as the Istanbul Protocol, which are used to confirm allegations of torture and abuse. The examinations provided evidence that supported the women's accounts of being raped and abused.

Of the 32 confirmed or probable assaults, 17 occurred in Darfur and 15 in Chad. One woman said she was raped twice in Chad and 2 women reported being raped in Sudan, and again in Chad. Seven of the confirmed assaults were gang rapes; 5 women in the survey group said they had witnessed gang rape in Darfur. Thirty of the women interviewed said they knew of rapes that had occurred in Sudan or Chad. Women reported that rapists often beat women with guns or attacked them with knives before or during assaults. Three of the women who were raped in Darfur became pregnant as a result. Two delivered live infants; the third woman miscarried.

The women also reported deteriorated physical and mental health since fleeing Darfur. When asked to rate their physical health on a scale of 1 to 5, with 1 being very good and 5 being poor, the women's average rating dropped from 2.06 while in Darfur to 3.99 in Chad. Acute symptoms included pain, swelling, bleeding, bruising, lacerations, and difficulty walking.

Using the same 1 to 5 scale, the women reported an average mental health rating of 4.9 while in Chad. They reported feeling hypervigilant, easily startled, sad, dysphoric, anhedonic, and weak. Sleep disturbances were common. Many of the women said they had recurrent flashbacks of attacks and relatives being murdered in Darfur.

Results from the interviews cannot be generalized, but Piwowarczyk said the findings offer a glimpse into the struggles of women refugees. “Even after fleeing war or persecution in their countries of origin, finding themselves in another environment may not mean safety,” she said. Many of the women told not only of being beaten or raped themselves, but of watching militia attack or murder their families.

She recalled a woman, pregnant as a result of being raped in Chad and close to giving birth, who asked Piwowarczyk to take the baby back to the United States with her if the infant was born during their stay. “My eyes teared up just hearing that,” she said. More than 6 months after returning to Boston, she added, “These women and their stories have stayed with me.”

Documentation of violent acts and rights abuses such as those committed against the women in Chad is possible only with meticulous planning and the flexibility needed to jump unforeseen logistical hurdles. “A lot of prep work had been done to open this doorway,” said Piwowarczyk.

“The security situation is Chad is so unstable that the trip was changed many times,” Crosby recalled. Initial plans to leave in June 2008 were called off amid reports that rebels may cross the border from Sudan into Chad and that a military coup was being planned in the Chadian capital of N’Djamena.

The rainy season intervened, too. In the meantime, Crosby juggled an ever-changing clinic schedule. “So many things were out of our control,” she noted. Finally, the group left last November.

Through PHR, they received training in security measures, techniques in interviewing survivors of sexual violence, and collecting forensic evidence. But once they arrived, additional issues and obstacles arose.

“There were concerns [about] interviewing women with a history of sexual violence because of such extraordinary social stigma related to sexual trauma,” said Piwowarczyk. “There was fear that women who could be seen being interviewed could subsequently be targeted.”

Rape survivors in war-torn regions often are ostracized from communities, divorced by husbands, or harmed by their own family members. Asking women who had endured sexual violence to step up for interviews would put them and possibly the interviewers in great jeopardy.

In fact, a 2007 World Health Organization report, WHO Ethical and Safety Recommendations for Researching, Documenting, and Monitoring Sexual Violence in Emergencies, warns of “life-threatening implications” in some settings for participants and researchers involved in collecting data on sexual violence (http://www.who.int/hac/network/interagency/news/ethical_and_safety_recommendations/en/index.html).

To ensure the women's safety, Crosby said the group emphasized to men and women leaders in the camp that the survey was intended to help improve the women's health and well-being. “We worked very hard at making sure that we were accepted,” said Crosby. She noted that the researchers asked permission from men in the camp to conduct the survey and refrained from raising the issue of domestic or interpersonal violence in the camps. “We thought that would be too dangerous to discuss,” Crosby added.

Talk of sexual violence in the region strikes raw nerves. VanRooyen, a urogynecologist who also is a well-traveled human rights researcher, recalled a threatening encounter with a local official at a second camp the group considered visiting. Crosby and Piwowarczyk stayed at Farchana Camp while VanRooyen, Hirschfeld, and 2 translators went ahead to scout the site. The official ordered that they be held at gunpoint. “We were not free to leave until he decided that we could go,” she said. “When he heard that we were discussing rape, he became livid.”

They were not released until a translator, speaking in Arabic, insisted that the group must leave. The incident is just 1 example of the peril in which human rights researchers may find themselves. The UN Office for the Coordination of Humanitarian Affairs reported than in 2007, 50 humanitarian personnel were arrested or detained, 105 were kidnapped, 66 were sexually assaulted, and 5 were killed.

VanRooyen said the experience of being detained “was unsettling enough that we chose not to go to any other camp.” As a result, they were not able to obtain as many interviews as they had planned. But VanRooyen said the experience “made me realize that if I was scared and I was threatened . . . how completely helpless the women there are.”

After 3 intensive weeks in Chad, returning to Boston also had its challenges. “It was hard,” said Crosby. “Coming back at the end of November, right before the holidays, all I could think of was these women who were eating sorghum and oil for every single meal 365 days a year.”

Added Piwowarczyk, “It's always sobering to come home to relative opulence when you know you're leaving behind people who can't leave their circumstances so easily.”