MSF in Salamabila: “What will become of the thousands of rape survivors?”

Despite these advances in reaching survivors, and a very positive track record, particularly in terms of community-based care, the fate of these women is now very uncertain. At the end of October, MSF will end its activities in Salamabila. Health workers are sounding the alarm to ensure that this care is continued.

In a discreet wing of Salamabila Hospital, within the walls of a small, dark room where a thick curtain protects her from prying eyes, Fabienne tells her story to Alice, an MSF social worker: “There were five of them. First, they hit me very hard in the stomach. They ripped off my clothes and abused me. When they left, they even took my underwear, where I had hidden some money.”

While returning from the market, Fabienne was raped by members of an armed group. A month after the attack, the trauma is still raw, and Fabienne tries to hold back her tears with her apron: “When I think back on it all, it hurts me deeply, right here in my heart,” she confides.

Fabienne is one of more than 16,400 rape victims treated by MSF in Salamabila since 2018. Like her, all of them received emergency treatment for sexually transmitted diseases and pregnancy. Women also received psychological support if they wanted it. The organization also distributed hundreds of emergency kits to those who had been expelled from their homes by their husbands. Between 2019 and 2024, the number of women MSF treated increased by a factor of 11.

Former survivors become pillars of community care

This success is based on the implementation of a decentralized model of care for victims of sexual violence since 2019. The community-based strategy offers care at the peripheral level, providing survivors with rapid access within 72 hours and confidentiality.

MSF trained Reproductive Health Agents (RHAs) within the communities themselves. Working closely with the population, these 13 “mothers,” often survivors of rape themselves, welcome women into their own homes, listen to them, and provide treatment. In total, over a period of six years, they have cared for two-thirds of survivors. “This is our greatest victory here; they have become indispensable,” says Elodie Françoise, MSF medical coordinator. "Going to these agents is much more discreet than going to the hospital, where they would be exposed to questions from residents and risk arousing the suspicions of a husband who could expel them from the home at any moment.”

In Salamabila, Baati is one of these Reproductive Health Agents. She took in eight more victims last week. "For me, it's sometimes painful to hear their stories because I feel like I'm reliving their trauma with them,” she says. “I have a lot of empathy. But I also consider my work to be very important. I draw on my personal history so that they can identify with me and trust me. Without the medication I received, I might not be alive today."

Working with men to limit the double punishment of stigmatization

When Fabienne returned home, her husband, in a state of panic, informed the entire village of the assault. He kicked her out of the house and then asked a neighbour sheltering her to kick her out as well. “At that point, I couldn't sleep at night,” Fabienne explains. “I was afraid of ending up with nothing. My husband had already taken all our possessions, and I was at risk of ending up on the street.”

This double punishment is linked to preconceived notions and other stigmas surrounding rape. MSF is working to change these attitudes by creating a “husbands' school.” In this structure, intended for “all the men of the house,” health promotion teams have raised awareness among at least 1,520 men about a crucial message: rape is neither infidelity nor shameful; it is violence that no woman has provoked. This long-term effort has borne fruit. “Little by little, we saw husbands change, encouraging their wives to seek treatment and even accompanying them, which was unimaginable before,” explains Kalume Kalumwendo, health promotion supervisor.

Drug shortages are a growing concern

After seven years of intervention, MSF is ending its medical activities in Salamabila at the end of October. This withdrawal was planned but has been slightly accelerated to allow MSF to focus its resources on medical and humanitarian emergencies, in a broader context of growing needs, sharply declining funding, and ongoing crisis in eastern DRC.

Maniema province is one of the most isolated in the country. Insecurity, the remoteness of health facilities, and the high cost of transportation severely limit access to care. Since the armed conflict worsened and Bukavu airport closed, transporting medicines and staff to Salamabila has become longer, more complex, and more expensive, although it is still possible by air.

In the five health centers supported by MSF and among several Reproductive Health Agents, there is immense concern that the medicines provided by MSF will run out once the donations have been used up. Emmanuel, a nurse at the health center in the village of Sous-Marin, makes a bitter observation: “When I see a rape survivor arrive, I feel tears welling up because I know I won't have any more drugs to protect her. I feel powerless.” This pain and concern are shared by Jean Claude Alfani Selemani, a doctor at the Kayembe Health Center: “If there are no more medicines, the survivors will hardly come anymore, attendance will drop, and I am very worried.”

Call for action by the Ministry of Health and international actors

Faced with this situation and the persistent shortcomings of the health system in Maniema, MSF and the health authorities in Salamabila have appealed to Ministry of Health, donors, and humanitarian partners to mobilize all the necessary resources to resume activities.

Charles Bamavu, chief medical officer for the area, fears a return to square one. “I fear that the armed men who commit these rapes will once again intimidate the victims and that the code of silence will return. So I am appealing to the Ministry of Health and all partners who can help us to take over MSF's activities. It is vital for all these women.”

The effectiveness of the community-based approach led by women from the community trained as Reproductive health workers has been proven; moreover, the model in place in Salamabila is replicable and vitally important from a humanitarian perspective. Despite the progress made, however, an adequate and stable response is far from being in place, because a public health problem such as sexual violence on this scale requires a holistic approach, including medical care, psychological support, socio-economic assistance, and protection and legal services.