End Fistula: Our Experience in Post-conflict Liberia

I was leaking urine all the time. I could not go to school” Mary, on life with fistula

In 2008, five years after the conflict in Liberia, Dr Bernice T Dahn, then Deputy Minister of Health and Social Welfare (MoHSW), described a “dilapidated health system struggling to meet the needs of survivors of sexual violence.” The burden of communicable diseases was high as was the maternal mortality rate. She spoke of urgently needed drugs, equipment and trained health workers as well as the conflict’s effects on women, their relationships with family, the community and their ability to reproduce or live productive lives.

Today, 13 years since the end of civil war and 8 years since Dr Dahn spoke of a strained post-conflict health system unable to fully support sexual violence survivors, Liberia faces similar challenges. In a bid to recover from the overwhelming effects of the Ebola crisis on an already weakened health system, post-crisis recovery is focused on revitalizing basic health services. As WOMSUD’s Grace Yeanay explains, “Ebola was another war that caused a lot of shock to Liberia. For instance, a lot of sick people who did not have Ebola died because the health system was overstretched.”

While less visible, the need to ensure access to sexual and reproductive health services for women and girls like Mary is particularly pressing, especially following conflict or crisis.

Speaking to women war survivors in Lofa, Bong, Maryland and GrandKru counties, the Isis-WICCE team discovered that 62.5% had suffered a sexual violation- women shared tales of rape, gang rape, attempted rape, sexual slavery, forced incest and forceful insertion of objects in vaginas. A medical assessment then found that 69% of the women had at least one gynecological complaint (61.4% of which required surgery) and 43% had significant psychological problems with 12% psychologically dependent on alcohol (IsisWICCE 2009).

Five years since the armed violence ended, these women’s physical and psychological wounds had not healed and still needed critical surgery because they had not received timely medical attention during or after the war. With 1158 survivors screened, Isis-WICCE partnered with the MoHSW, Ministry of Gender, WANEP and WIPNET, to run an emergency medical camp targeting women in remote locations with more under-developed health infrastructure and a lack of access to sexual and reproductive health services.

Some survivors had more than one surgical condition, several had mental health disorders and needed sustained psychosocial support. Women especially needed surgery for vesico-vaginal fistulae, genital prolapses, pelvic inflammatory diseases and infertility issues in order to resume their lives without stigma.

In present day Liberia, rape is the most frequently reported crime, and accounts for a third of sexual violence cases- including gang rape and sexual assaults. While sexual violence is often under-reported, the prolonged Ebola epidemic is said to have increased cases of rape and forced sex for food among young girls, particular during curfews and school closures and with families facing the biting economic and social effects of the outbreak. In 2014, of 626 rapes reported, 605 were girls under 18 years (UN, 2015) who are more prone to suffer vaginal fistula and other sexual and reproductive health complications during child birth particularly in the current context of limited access to quality sexual and reproductive health services.

As such, this International Day to End Fistula, our call is for a stronger focus and more human and financial resources allotted to increasing women and girls’ access to quality sexual and reproductive health especially in post-conflict or post-crisis settings. Reconstruction is incomplete without the complete recovery of women and girls.