The pediatric ward at the Rutshuru hospital is so full that a temporary shelter has been set up to accomodate the overflow. Photo © Spencer Platt/Getty Images

A rutted track winds through the mountainous terrain of the far east of the vast Democratic Republic of Congo (DRC). Snaking for more than 1,200 kilometers (750 miles), this jolting road is the main artery linking the towns of Goma and Kisangani.

Today, even more than three years after the conclusion of the war, much of the road is impassable due to insecurity. Armed groups with diverse backgrounds and aims still plague this strategically and economically important region, making any journey treacherous and bringing misery to the lives of the population.

In the health zones of Rutshuru and Kayna, located along the road to the north of the provincial capital Goma, Doctors Without Borders/Médecins Sans Frontières (MSF) supports secondary health care in two general hospitals, which also act as referral centers for more than 20 outlying health facilities linked by regular ambulance services. The medical needs for this estimated population of 330,000 are staggering.

Combined, the two hospitals treat in excess of 1,200 inpatients per month. More than a quarter of these admissions are children and the pediatric ward in Rutshuru hospital is so full that a temporary shelter has been set up to deal with the overflow.

Simultaneous epidemics

"It's almost inconceivable to see so many epidemics occurring simultaneously. The war has weakened the people and destroyed the health system in this area and these are the consequences." – MSF medical coordinator Dominique Bernard

During May and June, there were 52 admissions for measles in Rutshuru. To contain the outbreak and to treat the patients, MSF teams erected a large isolation tent in the center of the grounds. In nearby Rubare, MSF intervened after a cholera outbreak overwhelmed the local health facility. Eighty-five people were treated in the first three weeks of July. In addition, cases of meningitis and tetanus have been recorded and malaria continues to wreak havoc, accounting for more than 40 percent of all admissions in Rutshuru.

The link between violence and malnutrition is striking. The children often come from recently displaced families or from an area where an armed group has pillaged the food stocks. Photo © Spencer Platt/Getty Images

"It's almost inconceivable to see so many epidemics occurring simultaneously," says MSF medical coordinator Dominique Bernard. "The war has weakened the people and destroyed the health system in this area and these are the consequences."

Malnutrition also abounds, but the cause is not a shortage of food. The MSF therapeutic feeding center (TFC) in Kayna admits more than 150 severely malnourished children per month.

"The link between violence and malnutrition is striking," says Bernard, a nurse. "These children often come from recently displaced families or from an area where one armed group or another has pillaged the food stocks. For a small child, such a sharp shock can bring about severe malnutrition within just a few weeks."

Every Thursday, an ambulance arrives at the Kayna TFC bringing malnourished children from the area south of Kibirizi. Arriving late afternoon, it spills out a human cargo of color and noise. On this particular day only seven children arrive, most manifesting the swollen features that are the trademark of the Kwashiokor form of malnutrition (symptomatic of diet low in protein and accompanied by swelling of the belly and limbs). "This is a good day," says Julie, the MSF doctor, "last week there were 16 of them."

For Fred Demalvoisine, the MSF head of mission, it is an imperfect system. "Our pick-up point with the ambulance is in Kibirizi, because at the moment this is as far as we can go due to security constraints. But most of the cases come from the zone to the south which is particularly insecure. This means the mothers have to walk to get to us, which can be dangerous. The result is most likely that many don't take the risk, so the children we treat are probably only the tip of the iceberg."

This is not just the case for malnutrition. The amount of children that have succumbed to diseases such as malaria and measles due to the lack of access to health care can only be guessed at.

High levels of sexual violence

The direct effects of the continuing violence are no less alarming. In sexual violence clinics integrated into the MSF programs in Rutshuru, Kanyabayonga, and Kayna, MSF treats an average of 160 new cases of sexual violence every month.

"We deal with up to 25 cases [of sexual violence] per week. We treat men, children and women, everybody, and of all ages." —Esperance, an MSF nurse in the Rutshuru victims of sexual violence clinic

"We deal with up to 25 cases per week," says Esperance, a nurse in the Rutshuru victims of sexual violence clinic. "We treat men, children and women, everybody, and of all ages. Most come from villages away from the towns. They get attacked by any one of the armed groups and even by civilians. Most of the time we see women who have been raped while working in their fields."

In Kanyabayonga, a similar situation prevails. Sitting next to nurse Elysee in the MSF clinic, a woman in her mid thirties tells her story as she cradles her nine-month-old child on her lap.

Among patients at the Rutshuru victims of sexual violence clinic, many women were raped while working in their fields. Some return to work despite the danger of attack in order to provide for their families. Photo © Spencer Platt/Getty Images

"I was in my field when a man in uniform came up to me," she explains. "He said, 'you are poor and you have nothing to give me so I am going to sleep with you.' He was armed and I had no choice. He raped me there in the field."

This was the second time she had been raped, the first incident had happened three years previously.

"This is not unusual," says Elysee, "one woman who came recently had been raped on five separate occasions. But they have to feed their families so there is no choice but to go back to the fields to cultivate."

For MSF, it is vital that the patients come to the clinics as quickly as possible after a sexual assault. "If they arrive within 72 hours we can begin a post-exposure prophylaxis (PEP) which can avoid transmission of HIV," says Elysee. "If not we treat for any physical injuries they have, start antibiotic prophylaxis for sexually transmitted infections such as chlamydia and vaccinate against tetanus and hepatitis B. If they arrive within five days, the patient also has the possibility to get drugs to prevent unwanted pregnancy."

For the PEP, an ongoing public awareness campaign around Rutshuru has ensured that by June, 80 percent of cases were arriving within 72 hours, up from 54 percent in April.

Lifesaving surgery

In addition to treating cases of sexual violence, MSF surgery teams also deal with conflict-related injuries. Between July 17 and July 23, 10 patients were treated for gunshot wounds in the Rutshuru hospital, including a five-year-old child whose left leg had to be amputated below the knee.

In Rutshuru, more than 100 operations are carried out every month. Photo © Spencer Platt/Getty Images

Surgery is an important component in both the Kayna and Rutshuru programs. In Rutshuru, more than 100 operations are carried out every month, 80 percent of which are for emergency cases such as cesarean sections. With basic medical treatment a luxury in most of North Kivu, aside from the limited capacity of MSF, life-saving secondary health care such as surgery is totally out of reach for all but the very wealthy.

"The elections currently taking place are a source of hope for the people of this area," says Demalvoisine. "But even if they are a success, an end to the violence which is responsible for so much suffering is a distant light in the tunnel."

And like the infamous road passing through the mountains of North Kivu, hope for the future is fraught with insecurity.