“I would be dead today if it wasn’t for the counselling,” says Constance Phiri.
Phiri, not her real name, lives in Bapong, near Rustenburg in South Africa’s platinum belt. Here, one in four women between the ages of 18 and 49 has been raped, according to a survey released in 2016 by international humanitarian organisation Doctors Without Borders (MSF).
Phiri was gang-raped by three men in her home on May 26 2015. In pain and suffering from shock, she reported her rape to the police and was taken to the nearest community health centre. The clinic had no rape kits and no forensic nurses or health workers trained to collect medical evidence for crimes such as sexual assaults or domestic violence.
In South Africa, 265 public health facilities are designated to provide the kind of care rape survivors need to start to heal physically and mentally, and to ensure that police have the forensic evidence they require to bring rapists to justice.
But new research released by MSF on Tuesday found that only one in four of these facilities provides "essential comprehensive care".
We believe this is the first telephonic mapping of all forensic health facilities in the country. Of the 167 facilities that participated in the mapping, almost 60% said they did not provide all medical examination services and treatments. Factoring in facilities that did not give information about whether abortions were offered, this figure rises to 70%.
In fact, almost one in 13 said they provided no services at all.
Phiri eventually found help after being driven almost an hour east to Brits District Hospital.
“A forensic nurse tested me and gave me treatment — PEP [post-exposure prophylaxis] to prevent HIV infection. She took all the evidence, including my clothes, which she put inside a plastic bag. I went back to test three times [for HIV] until they confirmed that I was still negative.”
MSF has worked with the North West department of health to provide healthcare and clinical forensic services to survivors of sexual violence in the Rustenburg area since 2015. We know that most survivors, unlike Phiri, do not report their assault.
Designated forensic facilities should provide services such as medication or vaccination to protect survivors who do come forward from contracting sexually transmitted infections such as HIV or hepatitis B. Female survivors should also be offered medication for preventing pregnancy, or the choice to terminate a pregnancy upon referral.
Meanwhile, less than one in three facilities assessed had access to a psychologist and almost a quarter lacked social workers, the MSF research revealed.
When services such as these are unavailable, or located at faraway hospitals, rape victims risk having to confront a host of long-lasting mental and physical repercussions that could be mitigated.
In Brits, Phiri was also able to get the follow-up counselling she credits with saving her life. She explains: “I returned for counselling three times, until I found I was strong.”
“A lot of women do not go to a properly equipped facility after being raped because they don’t see any mark on their body, but I would be dead today if it wasn’t for the counselling I received. I would’ve killed myself.”
By the end of the year, about 11 000 women in Rustenburg alone will have been raped, reveals our 2016 survey. On the platinum belt and nationally, survivors need life-saving post-rape care and forensic services close to home, at their local clinics.
Without access to "comprehensive services" after rape, more people will be at risk of a severe health consequences.
More people are infected with HIV and other sexually transmitted infections without PEP and preventive treatment, or prophylaxis, for these conditions. And, without access to information about terminations of pregnancy, an increasing number of women may risk their health in backstreet abortion clinics.
If there aren't mental health services for rape survivors, women like Phiri may not be with us today.
Most designated facilities offer only forensic examination by a doctor — to extend services further, we need more specially-trained health workers, including forensic nurses.
Currently, only Free State University offers a one-year post-graduate diploma in forensic nursing. But provinces such as Gauteng and the North West have begun pairing on-the-job mentoring for nurses with a two-week training course developed by the national health department and Medical Research Council with some success.
South Africa should urgently think about further training professional nurses to manage forensic examination and care for rape survivors. A similar “task shifting” approach in HIV care, from doctor to nurse-provided care, has helped more people start treatment in South Africa and more broadly throughout Africa, a 2010 review published in the journal Human Resources for Health found.
But we can’t begin to fix what we don’t yet fully understand. That’s why MSF is recommending that the departments of social development, health and justice undertake a detailed assessment of forensic services for rape survivors and develop an interdepartmental plan to address crucial gaps.
Health consequences of rape can be reduced but we need them to be prioritised: services need to extend beyond current constraints and closer to communities. This includes better access to PEP, antibiotics, vaccinations and psychological support.
Amir Shroufi is the medical co-ordinator for MSF in South Africa.
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