It is an alarming figure: In Salamabila, in the province of Maniema in central-eastern Democratic Republic of Congo (DRC), at least seven people on average are raped every day, according to data collected by Doctors Without Borders/Médecins Sans Frontières (MSF) since the start of its intervention in 2018.
In this province, sexual and gender-based violence is a persistent crisis. Armed men, who remain responsible for three-quarters of the attacks, are still present. Since 2019, MSF has treated 16,436 survivors in Salamabila, and between 2019 and 2024, the number of women MSF treated increased by a factor of 11.
Despite these advances in reaching survivors, and a positive track record, particularly in terms of community-based care, the fate of these women is now uncertain. At the end of October, MSF will conclude activities in Salamabila. Health workers are sounding the alarm to ensure that this care is continued.
Respectful and compassionate care must be prioritized
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*, who was raped by members of an armed group on her way back from the market, shares her story: “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.”
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 emergency contraception. Women also received psychological support if they wanted it. Our team also distributed hundreds of emergency kits to those who had been expelled from their homes by their husbands following their rape.
Former survivors as 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 occurs at the peripheral level, providing survivors with confidential and rapid access to care within 72 hours.
MSF trained reproductive health agents within the communities themselves. Working closely with the community, 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.”
“For me, it's sometimes painful to hear their stories because I feel like I'm reliving their trauma with them,” says Baati, a reproductive health agent. “I have a lot of empathy and I also consider my work to be very important. I draw on my personal history so they can identify with me and trust me. Without the medication I received, I might not be alive today."
Avoiding 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 neighbor 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, which is intended for all men in a household, 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 resources on medical and humanitarian emergencies amid growing needs and sharply decreased international humanitarian funding, and the 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 Dr. Jean Claude Alfani Selemani, who works at Kayembe Health Center: “If there are no more medicines, the survivors will hardly come anymore, attendance will drop, and I am very worried.”
The Ministry of Health and international actors must take action
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 reproductive health workers has been proven. The model in place in Salamabila is replicable and vital from a humanitarian perspective.
Despite the progress made, however, the response has been far from adequate and stable. This is 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.
*Names have been changed
