“Sister, you did good,” said the young Liberian mother to her American caregiver. With these sentiments, Rebecca Singer, RN, ND, accepted the bittersweet rewards that come with caring for sexual violence survivors in war-weary African countries, such as Liberia.
A gang had raped the woman one night at a bar, leaving her by the side of the road, beaten and in shock. The police brought her to Benson Hospital, where Singer and her colleagues of Médecins Sans Frontiéres (MSF), also known as Doctors Without Borders, started to work with her.
The woman had endured the loss of one of her two children to a foreign adoption she did not understand. And, she was working as a prostitute to support her remaining child.
Singer learned about MSF in 1992. “I was watching a news report with an interview with a midwife working for MSF. I turned to my roommates and I said, ‘If I could do anything else, that would be my job.’ “
On her first mission with MSF, Singer was sent to Liberia, a country that had suffered a brutal civil war from 1989 to 2003, according to Singer. She arrived in 2005.
In Liberia, child soldiers were commonly used. She says more than 200,000 people out of a population of 3 million were killed. “We are dealing with a population that has known nothing but war and deprivation,” she says. “It is a country full of traumatized people. Many people were forced to do very ugly things during the war — either to survive or as combatants. Theft, random violence, rape, and looting became normal for the combatants.”
Singer recounted a conversation she had with a Liberian police officer who said combatants were taught to exploit whatever opening they found. “In his opinion, this behavior has continued the boys see the openings on a woman or girl and they occupy it,” she says.
Singer saw the results of this behavior first hand in her work as a field nurse in charge of sexual violence response at Benson Maternal Child Health Hospital in Paynesville, which is in the greater Monrovia area.Médecins Sans Frontiéres has worked in Benson Hospital (located in Paynesville a neighborhood on the outskirts of Monrovia) since October 2003. The program focuses on improving the health status of women and children including preventing mother to child transmission of HIV/AIDS and treating women and children who are victims of sexual violence.
Singer says the cases of an adult male raping a young girl are the majority of cases there.
“Approximately 87% of our patients are under the age of 19 9% are under 5 years of age,” she says. “Eighty-five percent of the alleged perpetrators are someone who is known to the victim. It is also notable that when the age of the perpetrator is known, 29% are also under the age of 18.”
MSF saw 1,375 patients the year Singer was there.
“Because there is so much news coming out about sexual violence in the Congo and sexual violence in Liberia and now in Kenya, [sexual violence] seems like a very African problem, but I think it is a very human problem,” Singer says. “The stories coming out of the Congo are particularly gruesome inserting objects into the vagina and shooting guns into a women’s vagina,” she says.
Singer also spent six months as a field nurse at Awere Internally Displaced Person camp in Gulu District, Northern Uganda, and six months as a Flying Sexual Violence Technical Advisor, also known as a “flying nurse.”
She returned to Liberia for four months for a special project on sexual violence, which included an analysis of data plus creating an advocacy piece. In her latest project, Singer is working on an evaluation of MSF’s Operational Center Barcelona-Athens in response to sexual violence over the past few years. She is using a database with two years of data she collected on her missions in Africa. Her results will be presented at an MSF research conference. She will continue her work, with visits in the future to Zimbabwe, Congo, or Kenya.
Sexual violence stigmatizes individuals, and when it is as pervasive as it is in countries like Liberia, the cultural effect on the community is profound. “Sexual violence includes more than just rape, of course,” Singer says. “It can include sexual harassment, forced marriage, forced pregnancy, early marriage, female genital cutting, harassment, and molestation.”
MSF offers a basic package of treatment at rape crisis clinics in countries like Liberia. All patients are offered sexually transmitted infection treatment or prophylaxis, according to Singer.
In the first 120 hours, provided the patient menstruates and is not already pregnant, MSF also offers emergency contraception. In the first 72 hours, MSF administers post-exposure prophylaxis for HIV, which are the same medications offered for an accidental exposure. They also administer the hepatitis B vaccine in the first three months and the tetanus vaccine.
Although the work she does is “not easy work,” Singer is motivated by the rewards, like knowing she can make a difference one patient at a time. One patient who remains in her mind is the one with “the saddest eyes.”
“Sister, you did good,” she remembered her patient saying as she approached her home. She was there to follow up on the HIV prophylactic treatment.
“She was smiling and ran down the street and put this big hug on me, and she says, ‘Oh, my God, my sister. Thank you, thank you, thank you!’ ” Singer says.
Touched by the resilience of this woman who had been raped and beaten, and who had lost a child, the nurse was inspired.
“She was just really positive,” Singer says. “She made me feel like [she was saying], ‘This terrible, terrible thing happened to me, but you made it just a little bit better.’ “