Pains in silence

For many women in Papua New Guinea (PNG), family and sexual violence is part of their life. A study conducted in the 1980s found that 70%* of women there have been physically abused by their husbands, and in some places that number reached 100%*. The figures have not been updated in a nation-wide study since, but a high level of violence remains, and specialised care is still far from adequate.

Impact of family and sexual violence

This often takes the form of sexual, physical and emotional abuse by a spouse, family members or friends. Most survivors who come to MSF to seek care as a result of family and sexual violence are females over the age of 18. The violence usually occurs in the place where they should feel safest - their own home.

The health consequences of abuses are significant, including serious injuries, unwanted pregnancy, unsafe abortion, sexually transmitted infections such as HIV, infertility and even death. While physical injuries can be easily identified, mental trauma like depression, phobias, suicidal thoughts and attempts can be an invisible but profound scar.

Gaps in care

Although family and sexual violence have long been recognised as serious problems in PNG, the critical medical and psychosocial needs of survivors are almost completely neglected. Very few dedicated services exist in PNG, so survivors will only go to health facilities to treat their serious physical wounds. Their other less visible health needs are overlooked, resulting in very negative consequences. These substantial gaps in care leave thousands of women without the services they so desperately need.

In 2005, Family Support Centres were established by the PNG government in all government hospitals, providing services for survivors of family and sexual violence. However, due to a lack of clear guidance and medical expertise, some centres have not even met minimum standards of care.

MSF's presence in PNG

MSF is the main provider of specialised medical and psychosocial services to survivors of family and sexual violence in PNG. Our experience demonstrates that provision of quality, specialised care is possible. It also shows the levels of need that exist – vary from serious injuries such as broken bones or knife wounds, to the harm caused by daily beatings, slaps, kicks, verbal and emotional abuse.

MSF started working in Lae in 2007, and in 2012 MSF provided free, comprehensive medical and counseling services to 6,500 patients. We have recently successfully handed over the Lae project to PNG government, but will continue to provide support remotely.

Meanwhile, in 2013, MSF opened a new project in the country's capital, Port Moresby, treating patients and training local staff to provide integrated care to survivors of family and sexual violence. Plans are underway to expand this project to more urban health centres so that more survivors can receive care close to home.

MSF has also been running a Family Support Centre in Tari since 2009. As there is an enormous need for emergency medical care – often after assault – the team offers emergency surgery at Tari hospital.

*Figures from the PNG Law Reform Commission

When violence is seen as normal

Dr. Ryan KO is a surgeon from Hong Kong. He completed a 3-month mission in Tari in July 2013. He tells us how the widespread violence leads to many unnecessary sufferings.

“During my stay in Tari, we once conducted as many as 1,900 consultations in a month. I performed 285 surgical procedures when I was there for three months, not including those minor surgeries conducted in emergency room. Most patients were injured because of tribal conflicts or family violence, being attacked by knives and wooden sticks. I was told by local staff that in the past, wives lived separately from their husbands in another house, but with the change of living habits, the whole family live in the same house now. More intimate they are, more frictions will arise. And local people intend to resort to violence to solve problems. Therefore, family violence is so common in the local community.

However, what shocked me most was that local people seemed accustomed to all kinds of violence! How can it be? I felt really sad about this… Though this mindset can hardly be changed overnight, we hope through our local medical programs, we can somehow help people to understand that violence should not occur and we need to step forward.  In our hospital, every patient has to see a counsellor before they can be discharged. Though not everyone is willing to speak, at least we can help some of them to relieve their pressure so that they do not need to bear everything alone.”

Merely the tip of the iceberg

“I am my husband’s second wife. The first wife doesn’t like it that my husband gives me money, so she argued with him and then he came and beat me. He hit me with a stick and broke my arm…When I went home with my arm in a plaster cast, my husband and the first wife were fighting. I went outside. She came with a bush knife and she tried to cut my neck. I put my hand up to protect myself and she cut the cast.”
--- Susan, survivor of family violence and rape

“I don’t know any other service provider that provides post-exposure prophylaxis. The only service provider is MSF. So I knew they had mediation there……Compare 28 days that I need to take treatment and living for the rest of my life on anti-retroviral therapy for HIV, it is just nothing to me. To complete this 28 days is better than fighting HIV for the rest of my life.”
--- Joe, rape survivor

“The last thing anyone wants is for survivors of family and sexual violence around PNG to suffer in silence without essential services they so urgently need.”
--- In November 2012, Dr. Unni KARUNAKARA, the then MSF International President, visited PNG and attended meetings with the government, civil society and other NGOs to discuss the continuing crisis of family and sexual violence in the country

Survivors have both acute and long-lasting medical and psychosocial needs. Medical care is more likely to be effective if it is accessed as soon as possible. The 5 essential services they need are:

Emergency medical care for wounds

Any wounds need immediate medical attention and extreme cases, such as knife wounds, can require surgery.

Psychological first aid

Survivors may arrive in a state of shock. Initial counseling helps to stabilise their symptoms and prepare them for medical consultations. Timely counseling can prevent the development of more serious mental disorders like depression and post-traumatic stress disorder.

Prevention of HIV infection and other sexually transmitted infections (STIs)

Post-exposure prophylaxis with antiretrovirals (ARVs) can prevent HIV infection, but it only works if started within 72 hours of the rape. It must be taken for 28 consecutive days. If a patient arrives later than 72 hours after the rape, it is too late to prevent HIV infection.

Other STIs like syphilis and gonorrhea can be prevented and treated with antibiotics. Without treatment some STIs can result in infertility.

Emergency contraception

If a rape survivor seeks medical care within 5 days of the assault, it is possible to prevent an unwanted pregnancy with emergency contraception. The pill stops ovulation and inhibits implantation of a fertilised egg in the womb.

Vaccinations for hepatitis B and tetanus

Hepatitis B virus can be transmitted through sexual intercourse and is more contagious than HIV. Vaccines are effective in preventing infection if the first dose is given within 3 months of the rape.

Depending on the wounds inflicted, the survivor may be at risk of contracting tetanus. If a survivor has not been previously immunised or when the immunisation status is unknown, they should receive a tetanus vaccination.

Attack on MSF members in South Sudan

On 5 August, a group of armed men attacked a car belonging to MSF on a main road outside Juba. Two MSF staff members were seriously injured, one of them died from his injuries two days later. MSF is outraged by the attack.

Migrant project closed in South Africa

MSF’s project in Johannesburg for Zimbabwean migrants closed at the end of March, 2013, as the access to healthcare for migrants has considerably improved since the project opened 5 years ago. MSF continues to provide HIV/TB care in the country.

MSF’s new clinic in Kenya

The centre in Kibera South in Nairobi was inaugurated in May 2013. It offers comprehensive primary healthcare and maternity services integrated with the management of chronic diseases like HIV. MSF is the only provider of free healthcare in Kibera.

Treating Kaposi’s sarcoma in Maputo, Mozambique

In Maputo, MSF is working with the Ministry of Health to treat patients suffering from Kaposi’s sarcoma, a type of cancer that causes painful and disfiguring lesions on the skin that is linked to HIV. As of early July 2013, 400 patients are receiving treatment at MSF’s facility.

Supporting treatment of patients suffering neurotoxic symptoms in Syria

Three hospitals in Damascus governorate that are supported by MSF reported that they received about 3,600 patients displaying neurotoxic symptoms on the morning of 21 August 2013. Of those patients, 355 reportedly died. Treatment of neurotoxic patients is fully integrated into MSF’s medical strategies in its programmes in Syria.

Two aid workers freed in Somalia

Montserrat SERRA and Blanca THIEBAUT, who were abducted from the Dadaab refugee camp in Kenya in October 2011, have been released in mid July 2013 after 21 months in captivity. Both are safe and healthy. They have already returned home.

After working continuously in Somalia since 1991, MSF has made one of the most painful decisions in its history and announced the closure of all its programs in Somalia from mid-August. It is the result of extreme attacks on its staff in an environment where armed groups and civilian leaders increasingly support, tolerate, or condone the killing, assaulting, and abducting of humanitarian aid workers.

“We have reached our limit in Somalia with the sequence of murders and abductions over the past five years,” said Dr. Unni Karunakara, the then MSF International President. “But security is not the reason we left. What dashed our last bit of hope of working in the country was that the very parties with whom we had been negotiating minimum levels of security tolerated and accepted attacks against humanitarian workers.”

MSF remains committed to addressing the tremendous needs in Somalia through medical humanitarian assistance. But all actors there must demonstrate through their actions a willingness and ability to facilitate the provision of humanitarian assistance to the Somali people and respect for the safety of the humanitarian aid workers.

I'm not a doctor, not a nurse nor a midwife. But I can still contribute my effort. Whether one can bring changes to lives only depends on how deep and how far one takes the first steps.

Sierra Leone, located in western Africa, is one of the world's poorest countries. The civil war ceased fire in 2002, but people are still traumatised. They only want to live peacefully with their family members.

My humanitarian mission starts at the southern city of Bo. The hospital here, built more than a decade ago, has obstetrical and paediatric departments. To address the substantial needs for obstetric and paediatric services there, we planned its renovation and expansion and kick-started the work early this year.

Hands-on work on the frontline

My duties here are more hands-on than those I had in Hong Kong. I want to be involved in formwork, steelwork, concreting, concrete curing and building brick walls. Not only do I hope to exchange ideas with the local staff, my involvement can also motivate them to work.

There are nine local staff members in my logistical team. All of them are great working partners, but they don't really understand the reasons and importance of every single working procedure. Even if they have done the same task for 10 times, they could still make mistake in their 11th trial. So I try to explain to them the reason behind every command I make. I am really glad to see them doing better and better.

This month, we conducted three rounds of recruitment interviews. I was overwhelmed; I felt sorry but was also moved. I was overwhelmed to know how much a job can change people's lives. I felt sorry for so many of them losing the opportunity to learn due to the civil war. Looking through their eyes, though, I was so moved to know that they have never given up amid all the hardship.

Only knowledge can change their lives. They are all treasures on the construction site. With limitations in machinery and materials, they can adapt far better than they are aware of, but they just didn't realise that they have actually grown the fruit of knowledge in their work.

Simple happiness

Recently, I started to give the team a construction lesson every Friday after the team lunch. In the first lesson conducted last week, I taught them the composition of concrete. They all know that adding iron bars into concrete can strengthen the structure, but they don't understand why. I looked at them trying to exchange opinions, paying attention to the class, and enjoying the learning process. My happiness can be as simple as that, as simple as hearing, “Thank you, I've learned much from you.”

I'm not a doctor, not a nurse nor a midwife. I'm just a humble engineer, but I can contribute to MSF humanitarian work. The project scale here is not comparable to those I worked on in Hong Kong, but my work here can save more lives. The small steps I've taken can hopefully bring more changes in others' lives.

Every day, over 30,000 MSF staff from all over the world work and provide assistance to people in need, of which 86 percent are recruited locally. Pan Yuan, a Yunnan born logistician, was himself recruited as a Chinese national staff member and has now become a veteran international fieldworker. He shares his view of the importance of national staff and the ways for the internationals to work more effectively with them.

I started working for MSF as a translator and logistician for the Changjiang flood disaster relief project in the mainland China in 1998 .Our team consisted of two Chinese and three international field workers. I remember that when we went to local counties and villages to conduct assessments, local governments did not know our organisation, while our international staff lacked knowledge of local culture. So my role was to bridge the culture difference, improve the understanding and communication between the two sides. I realized at that time that field workers from overseas could bring resources and skills, but still nothing could be done without the support of local staff.

Understanding and respect

The biggest challenge of working with national staff is how to think from a local’s perspective. So before I myself went on any overseas mission, I would read as much background information about the place and the project as possible. When I first arrived at the project, I would observe closely how local people worked and why they worked like this. I would also take advice from local colleagues before making any decision or change.

It is also important to respect the local culture. In Myanmar, local colleagues usually do not respond directly if they are aggrieved or think you did wrong, simply because Myanmar people are not good at expressing themselves in this way. They even regard speaking aloud as disrespectful. So I preferred talking to them in informal occasions and gatherings.

Teach him how to fish and you feed him for a lifetime

I placed great emphasis on training national staff instead of only pushing them to work since I regard this as the biggest added value to bring to locals

In Myanmar, one day my two assistants came to me with a problem. Instead of giving them my answer I encouraged them to suggest solutions and to discuss their feasibility. Gradually they gained more confidence, able to work more independently and develop long-term views.

I also listened to their future plans and gave them advice. It made me feel proud to see their growth and improvement. I once recruited a young assistant in Bangladesh, and a few years later he has become the person in charge of logistics in a project in Uzbekistan.

PAN Yuan was the first international MSF field worker from mainland China. He started with MSF in 1998 and has been to Sudan, Bangladesh, Sierra Leone, Uzbekistan and Myanmar as a logistician and later a logistic coordinator. He has been a board member of MSF-Hong Kong since 2008.