Introduction
The media representation of rape during ‘Africa's World War’ (Prunier 2009) led to the Democratic Republic of Congo (DRC) being called ‘hell on earth’ (Kirchner 2007), ‘the worst place in the world to be a woman’ (IRIN 2010), and ‘the rape capital of the world’ (Wallstrom 2009). The use of rape during the conflict has itself been called the ‘war within the war’ (Human Rights Watch 2002) and ‘the greatest silence’ (Jackson 2007). In the light of published estimates (UN Women 2011) of magnitude and consequences of rape, these titles are not necessarily surprising.
The prevalence, or the total number of cases, of gender-based violence in the DRC is however extraordinarily difficult to obtain. This is in part because poor communications and difficult terrain in much of the country impede systematic data collection. There is also ambiguity in laws protecting women which impacts negatively on reporting. For example, the DRC's 2006 Law on the Suppression of Sexual Violence defines statutory rape as sex with persons under 18, while legally one can marry at the age of 15. Thus, whilst Western observers commonly assume that the intention of survivors is to report rape, in reality many societal factors discourage disclosure. Given these difficulties, it is not surprising that estimates of rape vary widely. In 2009 the United Nations reported that 200,000 cases of rape occurred between 1998 and 2009 (United Nations 2010). In 2011 however, the United Nations Educational, Scientific and Cultural Organisation (UNESCO) estimated 130,000 to 260,000 cases in 2009 alone (UNESCO 2011). The most recent and most systematic estimate puts the number of rapes in 2007 somewhere between 407,397 and 433,785 (Peterman et al. 2011). The main differences in these estimates arise from the proportion of wartime rape versus rape within marriage. This is further complicated by the change in the definition of rape introduced in the new 2006 law – exactly the time at which most of the above estimates were made.
Notwithstanding this lack of statistical clarity, the widespread publicity around the ‘rape problem’ in the DRC (Oury 2009) both fuels, and is fuelled by, the attention it has received from both humanitarian agencies and academic researchers. Several important studies contribute to our understanding of rape in the DRC, for example demonstrating the degree of violence seen in many cases, as well as the traumatic outcomes for survivors. This body of research thoughtfully details the devastating effects of rape. This includes the profound impact on both individuals and communities, as survivors are often deserted by their loved ones, subjecting them to what could be described as a double-violence, victimisation, or retraumatisation (Bartels et al. 2010, Birch 2008, 2010, Chu et al. 2008, Harvard Humanitarian Initiative and Oxfam 2010, Human Rights Watch 2009, Johnson et al. 2010, Kelly et al. 2011, Meger 2010, Pham et al. 2010, Steiner et al. 2009, Trenholm et al. 2009).
These studies have arguably drawn international attention to the nature of rape in the DRC in a helpful way. However, more recent scholarship explicitly interrogates the narratives produced and reproduced in the process of documenting rape in the DRC. For example, the Human security report for 2011/12 from Simon Frasier University suggests that the incentive structures that operate within humanitarian agencies focus attention on rape in a way that distorts our understanding of the issue (Human Security Report Project 2012) It has also been suggested that the international attention given to rape has actually increased risk factors for people living in the DRC (Autesserre 2012, p. 15). This is because combatants recognise that if rape is emphasised in international settings above all else it can be an ‘effective bargaining tool’ (Autesserre 2012, p. 16).
It is therefore necessary to question the need for the continued proliferation of international scholarly, humanitarian and media attention on rape in the DRC. If the shared aim of international assistance is to provide optimal benefit to Congolese people, it is clearly necessary to consult the planned recipients and beneficiaries of such assistance. This article thus utilises survey and narrative data on the social determinants of health so as to enable Congolese voices to be heard. In so doing, the article directly engages with the question of whether or not narratives around rape have led to initiatives that benefit Congolese people.
Problematising the rape narrative
Speaking at a US Senate hearing in December 2011, a Congolese scholar argued that Western academics and humanitarians reduce the highly complex problems of the DRC to a simplistic ‘rape–minerals’ narrative (Dizolele 2011). This statement suggests that while the production and maintenance of such a narrative draws positive attention to those persons, institutions and/or agencies which propagate it (by raising money, reinforcing the concept and legitimacy of ‘expert’ knowledge, and so forth), Congolese people do not see any such benefit.
One such example can be drawn from a multimillion-dollar humanitarian intervention currently taking place in eastern DRC, and ongoing until 2015. For this project, a government agency granted more than US$16 million to an US-based non-governmental organisation (NGO). The project was the subject of considerable publicity and high-profile endorsement, even receiving a visit from the under-secretary of state for democracy and global affairs of the United States.
However, the beneficiaries of the project – survivors of rape – were deprived of the post-exposure prophylaxis (PEP) treatment1 they had been promised for nearly a year because US government officials' insistence on sourcing the drugs for the lowest possible cost had the effect of significantly delaying delivery.2 According to the project's annual report, ‘supply of essential medicine for PEP and post-rape treatment for trauma and STIs [sexually transmitted infections] was limited during the first year’ (USAID 2011). During a project evaluation carried out after its first year of operation, a chief Congolese doctor who had agreed to volunteer for the project, when asked to describe the success of the project in his community, replied, ‘What project? To me there is no project. I am not going to publicise this project to my community when I know in my heart there is no medicine to actually treat people with.’3
In public forums, Congolese people have also questioned whether or not they benefit from efforts made towards documenting gender-based violence. At one such event organised by patients in a hospital in Goma in June 2010, one survivor of rape stated, ‘[Researchers] say they can't pay us [for research] because that would be unethical, but they take our dignity for free. They are paid to come here to talk to us but we get nothing!’ Many listeners agreed, with this speaker and a subsequent speaker asked whether or not foreign professors are paid to teach classes based on the knowledge gained from visits to the DRC, and suggested that such payments should be shared with their informants.
Whether or not humanitarians or scholars profit in an unfair way from the use of rape in the DRC in their activities is not the primary focus of this article. Nevertheless, in the light of other research confirming that Congolese people actively challenge the dominant narrative focusing on minerals and rape (Autesserre 2012, p. 14), it is necessary to ask if this focus results in the marginalisation of other health concerns, how this affects the direction of aid dispersal and, ultimately, how it affects the potential of international actors to positively influence health outcomes in the country.4
For example, aid workers complain that they have too much funding to treat survivors of sexual violence and insufficient funds for other health issues (Autesserre 2012, p. 15). This is despite the fact that research shows that the DRC's population suffers from a wide variety of health problems. For example, in examining the causes of the 5.4 million deaths that apparently occurred during the Congo wars, a figure exhaustively cited by humanitarians, scholars, politicians and activists (Coghlan et al. 2007), Mack et al. (2009) suggest that a general breakdown of the DRC's health systems, rather than the war, may be primarily responsible. Mack et al. argue that because reliable pre-war mortality figures were unavailable, the statistic of 5.4 million deaths figure is inherently unreliable and probably an inadvertent inflation of the real figure. The denominator that was used (Coghlan et al. 2007) – the average mortality rate for sub-Saharan Africa – was too low and was not representative of the very high pre-war mortality in the DRC, which was the result of the long-term erosion of the DRC's health system.
These technical details are important when considering (a) what actually causes illness and death in the DRC, and (b) whether the attention given to these determinants by academics and humanitarian actors duly reflects reality. The argument by Mack et al. (2009) demonstrates the need to consider the diversity of concerns when inquiring into health in the DRC. It also raises the question of whether the priorities of international aid agencies are reflective of known drivers of illness and mortality in the DRC.
This article does not intend to suggest that exposure to rape should be dismissed as trivial, nor that the consequences of rape are not deeply damaging, life altering or profound. Instead, this article broadens the discussion of health and illness in the DRC by including empirical data from Congolese respondents. In so doing, this article also showcases the ways in which Congolese people have been organising to address these issues for decades. This highlights the extent to which narratives created by international organisations, but deemed inadequate or distorting by Congolese people themselves, might remove the latter's agency to define their own vulnerabilities, while simultaneously diverting aid and other resources from the determinants of health seen as most urgent and important by those who actually suffer from these problems.
Methods
This ongoing study began in April 2009 as a collaborative project between researchers at the University of Florida and Congolese social scientists. A team of researchers systematically collects annual data during a four- to five-month period in order to document Congolese perceptions of the determinants and barriers to health over time. Respondents are specifically asked what they believe determines health and illness, and are encouraged to discuss personal experiences to elucidate responses. The narrative data reported in this article were collected during the period between April 2009 and August 2011. In this article, we consider 121 semi-structured interviews from 16 total locations, with male and female respondents ranging in age from 19 to 81.
| Province | Town or Village | No. of Interviews | No. of Focus Groups |
|---|---|---|---|
| Maniema | Ferekeni | 10 | 1 |
| Lubutu | 7 | ||
| Punia | 11 | ||
| North Kivu | Birambizo | 12 | 1 |
| Bweremana | 9 | ||
| Goma | 14 | 2 | |
| Kayna | 10 | 1 | |
| Kirotsche | 9 | ||
| Sake | 9 | ||
| Orientale | Bunia | 8 | |
| Kisangani | 11 | ||
| Komanda | 8 | ||
| South Kivu | Bukavu | 13 | |
| Idjwi | 11 | ||
| Kitutu | 7 | 1 | |
| Shabunda | 12 | ||
| Total | 161 | 6 |
Data were collected in all four eastern provinces of the DRC (Maniema, North Kivu, Orientale and South Kivu). Part of this study (April 2009 to June 2009, and May 2010 to July 2010) was conducted in conjunction with HEAL Africa, a Congolese NGO that runs a hospital in North Kivu's capital city of Goma. Access to many of the locations and displaced populations (which have been and in some cases still are affected by conflict) would have been impossible without this partnership, given the lack of roads, reliable maps or transportation in the region. Interviews varied greatly in duration according to the safety of the location (e.g. a health centre versus a forest), but the median time was approximately 50 minutes.
During the first round of data collection for this study (April to August 2009), the research team's initial analysis of data revealed the many ways in which Congolese people were organising (both formally and informally) to fill in the gaps left by their health-care system, via their own community-based health-care provision. This forced the investigators to broaden the research agenda beyond the documentation of determinants of and barriers to health. The research team focused on a second question: are these local providers of health care better placed to identify and address the determinants of illness than international agencies, and, if so, would it be preferable to direct donor funds directly to them?
During analysis, specific attention was paid to the use of metaphor by respondents, as well as to indigenous categories of suffering (Bernard and Ryan 2010). Using a structured codebook of identified themes, presence and absence of themes were analysed (MacQueen et al. 1998). The following findings arise from line-by-line coding of all narrative data and analysis based on both the presence and absence of themes in the codebook. Therefore, the quotes provided in the next section represent overarching themes in the data. Details are also given about which code(s) were applied to quotes displayed below.
Findings
This study has three major findings, each of which is analysed in turn in this section:
- 1.
Congolese people report that the determinants of health most urgently needing redress are structural in nature.
- 2.
Women believe their vulnerability is caused by a variety of barriers to health, of which rape is just one among many.
- 3.
For decades, women and men have organised community-led health-care provision.
(1) Structural barriers
Theme 1: health services as a structural determinant of health
When asked what causes sickness and what leads to health in their communities, respondents in both rural and urban locations placed a strong emphasis on hospitals and health centres: the condition of physical structures, the location of services, the quality of services and the cost of services. The physical decline of hospitals and health centres that respondents describe is occurring in both rural and urban settings. However the situation is reported as being worse outside of the main cities.
| Interview, female, rural | Interview, male, rural | Interview, female, urban | ||
| Theme 1: health services as a structural determinant | Code: condition of physical structures | ‘Sometimes there are holes in the roof and you get rained on while you are delivering your baby. There are cracks in the walls of the room where you sleep. Mosquitoes and sometimes snakes come through these cracks.’ | ‘I would like to answer that question with a picture. Can I take you outside quickly?’ [Interviewer is brought to a wooden latrine lacking a door] ‘My wife had to wash herself right there after she gave birth. That is where a sick man goes to vomit. My wife used that exact latrine [pointing] to wash herself, next to faeces and vomit. Please take a picture to bring to your big meeting at the White House and say this is why women die in Congo. It is not because of rape but because there is faeces where they bathe.’ | ‘Why are we dying? Because our hospitals have been cracking and without medicine since Mobutu's time [1965–1997] and government officials do not care because they can leave the country to get care in South Africa.’ |
Access to hospitals and health centres varies greatly, according to the setting. Rural respondents report that they are frequently unable to visit hospital because of a lack of transportation. Urban respondents did not report travelling long distances. This is unsurprising, given that 80% of Congolese people live in rural locations whereas 80% of services available are in urban locations (Esanga et al. 2010).
| Interview, female, rural | Interview, female, rural | Interview, male, urban | ||
| Theme 1: health services as a structural determinant | Code: location of services | ‘After a two or three hours of walking, we arrive so tired at the health centre. It even happens that we give birth on the way to the health centre. Those who reach the health centre are so weak that they need care. Maybe a woman has not eaten for all the day.’ | ‘I am pregnant with this baby now but I will have to sit right here in the forest when the baby comes…. I won't take the risk of making that long trip.’ | ‘Yes, we have hospitals and they are not far. Maybe you don't like what you find inside them but we do have them and you can walk five minutes, six minutes. There is also a bus.’ |
For urban respondents however, access to health services depends on their ability to pay high fees. Rural respondents report the same high fees, which frequently prevented access to services, but they reported greater acceptability of payment in kind for health services. Urban respondents reported that when cash is unavailable to pay for services, it is common for the patient to be detained in hospitals until family members could locate sufficient funds. Some respondents linked this detention to increased exposure to pathogens.
| Interview, male, urban | Interview, female, urban | Interview, female, rural | ||
| Theme 1: health services as a structural determinant | Code: payment for health services | ‘It is money. Without money, there is no way you can get care at the hospital. When someone is sick and doesn't have money, you will be kept in the hospital until the day you will pay. And they will not give you food.’ | ‘I had to have a caesarean section even though I knew I could not pay for it. After the operation I waited in the hospital for three weeks while my husband searched for money. My baby got many fevers during this time because she was surrounded by sickness.’ | ‘I still have a debt to the doctor who delivered my first child. For this pregnancy I will have to visit a traditional birth attendant because she will accept a chicken instead of money.’ |
A common opinion among respondents from both rural and urban locations was that the variable quality of care provided is a determinant of health. Such variation included the absence of staff members at health-care facilities, which was a particular problem in rural locations. Both rural and urban respondents identified the training and attitude of health practitioners as a determinant of health.
| Interview, male, urban | Interview, female, rural | Interview, male, rural | ||
| Theme 1: health services as a structural determinant | Code: quality of care | ‘Many times a doctor tells you something and you cannot believe that he is right. The medicine he gives does not work. And then you talk to another doctor and he says something different, but you have already been given medicine by the first doctor and you are weak from a long illness.’ | ‘Here you are lucky if there is someone at the centre when you arrive. If there is someone there who has not fled the danger, you are lucky if there is a bed that has not been looted. If there is a bed, you are lucky if there is medicine.’ | ‘[A doctor] is working in order to get US$50 at the end of the month. At the end of the month, he will not get that entire amount of money; he will receive US$10, maybe US$20 … that is same thing for nurses too. When you come as a patient, he will not hurry, because he is not motivated.’ |
(2) A variety of barriers to health
Theme 2: rape as a determinant of illness
As expected, exposure to rape as a barrier to health did emerge as a theme among women and men. However, Congolese respondents commonly viewed rape within the context of structural determinants. For example, the inability to obtain a legal abortion was often cited as a barrier to health, as carrying to term a pregnancy that was conceived in rape is viewed as strongly detrimental to psychosocial health. The ability of women to safely terminate a pregnancy was seen as a protective factor, though the risks involved with black-market abortions were also reported for their severity, which respondents explicitly viewed as a structural issue.
| Interview, female, rural | Interview, female, urban | Interview, female, rural | ||
| Theme 2: rape as a determinant of illness | Code: quality of care | ‘Rape is a problem here and it can cause women to be very, very sick if they cannot get to the hospital to be treated.’ | ‘Rape is very dangerous to women when they get pregnant because it is illegal in this country to abort a pregnancy. So they look for a doctor who will do this abortion and they will find someone but this person is hiding [because the procedure is illegal] so he does not have clean tools, or the medicine necessary. Very many women die because they tried to get an abortion like this. This is a problem with our medical system.’ | ‘Would you get a surgery in a house made of mud? My sister died from bleeding after she got her abortion. If she had been in a hospital being cared for this would not have happened!’ |
There were other ways in which respondents explicitly referred to the structural problems that influence health-care delivery for survivors of rape. Women and men were well-informed about the risk of contracting a sexually transmitted infection during rape, but viewed this as a consequence exacerbated by a paralysed official health-care sector. The emphasis was placed on the lack of structural capacity and resources to treat the consequences of rape such as human immunodeficiency virus (HIV) and other sexually transmitted infections, which are viewed as highly threatening in the context of poor health-care delivery. In addition, the question of whether or not exposure to rape is itself a by-product of structural factors, such as travelling long distances, was explicitly raised.
| Interview, female, rural | Interview, male, rural | Interview, female, urban | ||
| Theme 2: rape as a determinant of illness | Codes: rape exposure + structural determinant | ‘We all know that there are soldiers who try to make us sick with their viruses. They wouldn't be able to do that if we had hospitals here that had doctors and medicine.’ | ‘If another man has sex with my wife and gives her his sickness, the only way we could continue to live together is if she is treated for this sickness and then no longer has it. Otherwise it is not possible.’ | ‘Rape is a problem because there are people who try to benefit from the circumstances here in the Congo. People know they can profit. For example, a man sees a woman walking to the hospital 92 kilometres away. He sees that he can profit if he just follows her until no one is around, he can grab her and take advantage of her once she reaches the forest. There is a simple solution for this problem. If we had public transportation and hospitals close by, no one could profit in this way. Many people think rape is unique to Congo but I think it is simply an issue that our conditions allow for profiting and so people profit. That man wouldn't rape if he had a job to keep him busy. That woman wouldn't be raped if she didn't have to walk half the day to get somewhere. Do you see?’ |
Theme 3: food insecurity as a determinant of illness
Lastly, when asked what was the single most significant factor influencing poor health, the majority of female respondents (82%) stated that food insecurity, past experiences with food insecurity, and fear of future food insecurity determine health and illness. This finding was found among respondents in both urban and rural locations and was true even in locations with continuing armed conflict and high rates of sexual violence (such as Shabunda in South Kivu). Respondents emphasised the root causes of food insecurity in describing the negative health consequences that have obvious nutritional causes. Direct references were made to the DRC's unsophisticated agricultural technologies (relative to other countries), lack of both fertilisers and high-yielding seeds, and lack of basic infrastructure needed for the transport of food products to markets.
| Interview, male, urban | Interview, female, rural | Interview, female, rural | ||
| Theme 3: food insecurity as a determinant of illness | Code: food insecurity (past, present or future) | ‘We have the most fertile land [in Africa] with the least amount of tools to farm [the land]! Do you see why we are sick and dying? We are hungry! You would not see a thirty-year-old man so weak that he looks like he is seventy, in a country that has the ability to feed its own people.’ | ‘I gave birth to seven babies in my life and each time I looked at the baby and thought to myself, that baby was starving inside of me and it will starve now that it is in the world. Three of my babies died because of starvation. I hope I don't have another pregnancy because that baby will starve too.’ | ‘I think I am sick so often not because I am hungry. My body is habituated to hunger. I think I get sick because I am so scared that I will be hungry tomorrow, and then again tomorrow, and then again tomorrow. This is illness of the mind.’ |
(3) Community provision of health services
The unexpected finding of this study is perhaps the most noteworthy. In theory, poverty is pernicious to society because it drains people of the time needed for activities superfluous to individual survival (Maslow 1968), such as organising for social good. However, empirical evidence collected during this study paints a picture that strongly challenges this theoretical paradigm.
Among respondents, an abundance of human resources outweighed their shortage of economic resources, with the result that Congolese people are organising both formally and informally to mitigate their own suffering. This is true at every level, from rural and urban communities of less than 200 persons, to the national level, where large organisations have been established by small groups of people whose work is recognised as effective by their peers. Two well-known examples of such organisations are Children's Voice in North Kivu and the Programme de Promotion des Soins de Santé Primaires (the Programme for Promotion of Primary Health Care – PPSSP) in Orientale. Others include Promotion et Appui aux Initiatives Féminines (Support and Promotion of Women's Initiatives – PAIF), Concert d'Actions pour les Jeunes et Enfants Défavorisés – Collective Action for Disadvantaged and Children and Youth – CAJED) and Synergie pour la Lutte Anti Mine (Synergy in the Fight Against Mines – SYLAM).
At a more local level, respondents reported the existence of networks of doctors who are known to provide safe and hygienic abortions,5 as well as of networks of women who are knowledgeable about abortion and willing to care for women who have abortions.6 These networks are often led by midwives and traditional birth attendants, who train family members to recognise risk factors that commonly occur after abortions. Respondents made reference to networks such as these in 10 out of the 16 locations. Although the authors were unable to verify this finding in every instance, it is still significant to report respondents' knowledge of community-led health-care provision outside the formal system.
In terms of food insecurity, in North Kivu there are several examples of women within one community organising around a single farm to plant, plough, weed and harvest crops.7 Typically, half of the harvest is kept and distributed among themselves for their own food, while the other half is sold in the marketplace. Profits earned are then channelled back into the community, to pay for costs such as health care. This finding was cross-checked with the hospital administrator at a large hospital in North Kivu, who confirmed that health-care costs are often paid using this collective system.8 These women prioritise seed-saving practices, to allow for future plantings and harvests. Respondents also reported that money is occasionally made available as microfinance for women wishing to start their own small businesses.9
Communities also have their own mechanisms for dealing with the trauma of rape. In all 16 of the locations in this study, there exist purification rituals for survivors of gender-based violence.10 Amicable agreements are used as a means of seeking justice between the family of the perpetrator and the family of the survivor.11 Networks of women willing to support and counsel rape survivors are open in their activities and do not experience the kind of stigmatisation often experienced by individual survivors.12 Women survivors of gender-based violence have at times decided to leave their communities and have received support in host communities in the form of housing, food, even legal assistance.13
In addition, respondents reported the existence of groups of women who gather to talk about their legal rights,14 women who have formal systems of providing nutritional support to vulnerable community members who are pregnant,15 and communities who use traditional mechanisms for assembling courts and levying penalties for crimes such as looting the hospital and perpetrating gender-based violence.16
Community-led initiatives for mitigating or removing the risk of exposure to rape also exist. For example, women often assemble in groups when travelling to their farms, reporting that this decreases the likelihood of violence against them.17 Communities in areas most susceptible to attacks have night-watch systems in place, where armed delegates use cellular telephone networks and code systems to enable the timely alerting of the community to violent occurrences or potential threats.18 In Kitutu, a rural community located next to a forest used as a base by soldiers of the Forces Démocratiques de Libération du Rwanda (Democratic Forces for the Liberation of Rwanda – FDLR) who have inflicted numerous acts of rape and violence on community members for nearly a decade, residents have lobbied United Nations' officials to escort them to FDLR camps so they can invite the soldiers to come and live among them. They have also offered to build houses for the soldiers.19 According to respondents, integrating the soldiers into community life is the only way to resolve the violence. They believe the community plays a more important role in this process than international agencies, since they are genuinely willing to invite soldiers to live with them, with the prerequisite that they lay down their weapons.
Discussion
Like many anthropological studies of human health, this study sought to identify the determinants of health in the DRC from the perspective of those living in the communities directly affected. The results of the study were (and still are) expected to inform international agencies of ways in which their funding and activities can most effectively influence positive health outcomes. However, as noted above, it became clear that this research question was limited in its ability to paint a complete picture of the needs relating to health and illness in the DRC. The current situation in the DRC, far from being one of destitution and helpless victims in need of outside intervention, is one in which communities are creatively organising on a small scale with success. Though it is difficult to know what the outcome would be, these efforts do indicate real potential for greater impact if they were funded on a large scale. This finding presents a profound challenge to the typical development model in the DRC in which programme targets are not empirically driven (Autesserre 2012). If international aid funding were directly channelled to Congolese communities, would this prove more effective than the current system at achieving the collective goal of positively influencing health outcomes in the country?
Participants in this study clearly state that structural factors are the ultimate cause of poor health in the DRC. Some respondents went as far as to suggest that the ‘rape problem’ exists because of the absence of adequate services to provide health care, employment and transportation. However, without economic resources, the informal networks of Congolese people who are working to mitigate these circumstances are limited in their ability to produce large-scale changes. Roads need to be paved, hospitals need to be built, and health-care professionals need to be better trained to staff them adequately. The astronomically high rates of unemployment in the country suggest that there are millions of people who could be doing this work (Trefon 2011).
Many international organisations working in the DRC understandably prioritise humanitarian intervention. For example, in 2009, of the US$329,560,000 in foreign assistance appropriations given to the DRC by USAID and the US Department of State, 43.9% was ‘humanitarian assistance’ which encompasses ‘protection, assistance and solutions’. Only 4.4% of these funds were earmarked for ‘economic growth’, which covers ‘infrastructure, agriculture, economic opportunity and the environment’. Most of this 4.4% went to agriculture, and infrastructure received no funding whatsoever (USAID 2010).
It is important to acknowledge that humanitarian intervention in the current situation in the DRC is a well-meant response to urgent problems. However, its efficacy must be challenged in the light of what we already know about the capacity of indigenous communities to address their own health problems. For example, anthropological scholarship on AIDS in Uganda suggests that potentially hundreds of thousands of lives could have been saved if Western donors had favoured African solutions over their own opinions (Green 2011).
Data presented in this article show that the priorities of many Congolese people are different than Western donors, encapsulated in the phrase of one respondent: ‘You say rape, I say hospitals, but whose voice is louder?’ More specifically, the article finds that if funds were reallocated towards Congolese-led and Congolese-inspired solutions such as improving the overall health-care system by building health-care structures, strengthening the capacity of health professionals, and reducing barriers to access health services, funding would be more effective in helping victims of rape, for which gender-based violence is just one manifestation affecting women's health. Furthermore, supporting community-led initiatives, such as those targeted directly at soldiers, could potentially address one of the root causes of rape perpetration.
Some newer international initiatives demonstrate that this is already being tried in the DRC. Organisations such as IMA World Health, the International Medical Corps and Eastern Congo Initiative now employ almost entirely Congolese staff in their projects, which aim to provide capacity and trained personnel, while other projects are training paralegals (to improve the judicial system) and psychosocial counsellors (to support the health-care system). These kinds of projects are also noteworthy for involving Congolese people in project design and implementation. However, even these projects are receiving funding based on their role in addressing the donor community's priority, i.e. mitigating gender-based violence. The current model, in which Western donors decide on areas of intervention and then solicit projects in these areas, means that they predetermine where funding is directed. Instead, ways could be found to enable community members to come together to decide what types of projects they would favour.
Conclusion
This article, having analysed the social determinants of health in the DRC from the perspective of Congolese people, argues that decision-making about aid dispersal must be empirically driven. In building upon other scholarly work about the ways in which Congolese people have provided new services to fill the gaps left by an absent government in eastern DRC (Kabamba 2008), it challenges the conventional dynamics of development and suggests that Congolese community-based networks are better positioned to determine the most effective use of funding aimed at improving women's health. Furthermore, this article adds to the debate around the potential harm in maintaining standard narratives about rape in the DRC.
While no one would deny that incidences of rape in the DRC are very high, two important points could also be highlighted. First, there is a rape problem in many societies worldwide, not just in the DRC. This includes countries within which organisations are tasked with creating projects around the mitigation of sexual violence in the DRC. For example, a recent report from the Centers for Disease Control and Prevention in the United States shows that one in five women in the United States are exposed to rape in their lifetimes (Black et al. 2011); an older report found that one in three female soldiers in the US Army experience rape whilst in the military (Sadler et al. 2003). It is important to recognise that high rates of rape are found in places such as the US military, as well as in the DRC.
Second, anthropological inquiry into the socio-cultural context of rape divides studied societies into two groups: ‘rape-prone’ and ‘rape-free’. According to this analysis, the United States falls into the category of a rape-prone society and one of the rare examples of a rape-free society is the Mbuti ethnic group in the DRC (Sanday 1981, Turnbull 1965). Although this finding could be outdated, it suggests both that (1) Africans already possess some of the tools to redress the problems they face; and that (2) Westerners look at the DRC as a society of victimhood, and therefore that is what they see.
Wider structural change is of course urgently required in the DRC alongside basic infrastructural improvements. A large number of Congolese organisations are currently at work to improve their country. In some cases, international organisations have recognised their work, and even partnered directly with them. This is true of many of the aforementioned groups, including HEAL Africa, CAJED, Children's Voice, PSSP and SYLAM. However, the direction of the activities of these local organisations has been shaped by the requirements of funding or the terms of partnerships with international agencies that often have different priorities (whether explicitly or implicitly) to those of Congolese people themselves.
Scepticism about the capacity of aid recipients to organise their own development activities in a country facing grave challenges is understandable, particularly if large sums of money are involved. But if this scepticism stifles the potential of Congolese organisations to control the direction of aid money in their own country, there is a risk of choosing the wrong targets and registering poor results. This study has unearthed a variety of creative ways in which Congolese people have made gains towards meeting their own needs, at times unbeknownst to anyone except themselves. If international agencies entrusted local groups and organisations to define their own needs and then provided funding accordingly, this article suggests that improving the overall access to and quality of the wider Congolese infrastructure of health would be the highest priority.
Notes on contributors
Nicole D'Errico is a doctoral candidate at the University of Florida and a visiting scholar at the New York University's Gallatin School of Individualized Study; Tshibangu Kalala is a PhD student at the University of South Carolina; Louise Bashige Nzigire is a Gender Specialist for IMA World Health; Felicien Maisha is a monitoring and evaluation specialist at HEAL Africa hospital; Luc Malemo Kalisya is a physician at HEAL Africa hospital and professor of medicine at the University of Goma.