In a report released today at the 1st South African National Conference on Violence, Doctors Without Borders (MSF) outlined startling levels of sexual violence in Rustenburg Municipality, low numbers of women reporting to health care services after rape, and numerous barriers to accessing post-rape care, including low levels of knowledge among women about the benefits of receiving timely medical attention.
MSF called on the South African government to urgently roll out a comprehensive and widely accessible medical and psychosocial response that addresses and removes the barriers to accessing a basic package of health care services for victims of sexual violence, both in the Platinum Mining Belt around Rustenburg and across the country.
Untreated Violence: The Need for Patient-centred Care for Survivors of Sexual Violence in the Platinum Mining Belt, which discusses the findings of an in-depth survey of over 800 women aged 18-49 years, revealed that one in four women has been raped in her lifetime, with approximately half of women reporting experiences of sexual violence or physical intimate partner violence..
Extrapolating these figures to the municipality as a whole, around 11,000 women and girls in Rustenburg are raped each year. Yet 95% of rape survivors had never told a health professional of the incident, and only half of those surveyed knew that HIV could be prevented after being raped.
According to MSF Epidemiologist Sarah-Jane Steele, the findings show that rape is not only highly prevalent in Rustenburg Municipality, but that opportunities to reduce the more serious health impacts of rape are being missed.
“Treatment and psychosocial counselling for rape survivors reporting within 72 hours can prevent HIV infection and unwanted pregnancy, and help to mitigate long-term psychological suffering,” said Steele, “but the majority of women we interviewed don’t know such treatment exists, services close to where they live are sorely lacking and lack of financial independence may make access difficult even when services are present.”
Limited Access to Services
Rustenburg sits within the Bojanala Health District where MSF, in partnership with the North West Province Department of Health, is piloting the expansion of a patient-centred response to sexual violence, including a clinical mentorship programme for professional nurses on the care and management of sexual violence. The district has a population of approximately 1.3 million people.
According to the North West Province Department of Health, out of 783 total health facilities in the district, only 11 designated public health facilities — including the MSF/DOH Kgomotso Care Centre in Boitekong— provide post-exposure prophylaxis (PEP) to prevent HIV, and support forensic examination for rape survivors.
Most of the dedicated facilities for rape survivors are at district hospital or community health centre (CHC) level. The capacity of each of these designated public health facilities varies, dependent upon the number of trained staff available that can conduct the examinations.
Expanding the patient-centred approach
According to MSF Medical Co-ordinator Amir Shroufi, what’s urgently required is a patient-centred approach to rape and sexual violence that prioritises the medical and psychosocial needs of survivors.
For this to happen more trained staff and more widely available comprehensive services are needed.
“All rape survivors should receive access to comprehensive medical and psychosocial services to reduce the risk of contracting HIV and other infectious diseases, preventing unwanted pregnancy, addressing psychological distress and linking the patient to appropriate social support," says Dr Amir Shroufi, MSF Medical Coordinator in South Africa, “but that doesn’t diminish the importance for all survivors to also be given the option to undergo forensic examination and to pursue a legal response to rape”.
The basic package of care that MSF offers in Bojanala includes:
- Medical first aid to treat injuries
- Comprehensive medical assessment, including forensic examination
- Post-exposure prophylaxis to prevent HIV infection, and treatment for other sexually transmitted infections
- Vaccinations to prevent hepatitis B and tetanus
- Emergency contraception to prevent unwanted pregnancies
- Counselling as well as linkage to appropriate social support measures
The 1st SA National Conference on Violence is aimed at mobilising science, communities and policy for the prevention of all forms of violence in South Africa.
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MSF Activities in Rustenburg, Bojanala Platinum District
Since July 2015, and in cooperation with the North West Province Department of Health (DOH), MSF has worked in the Rustenburg Local Municipality of Bojanala Platinum District, providing patient-centred medical and psychosocial care to survivors of sexual violence. This project started in response to perceived high rates of sexual violence and difficulties faced by survivors in accessing care in the platinum mining belt.
MSF supports the DOH in running the Kgomotso Care Centre (KCC) in Boitekong, which provides patient-centred care for survivors of sexual violence (SV), including for rape, intimate partner violence (IPV) and other forms of domestic violence. The model of care offered at KCC emphasizes the importance of addressing the survivor’s medical and psychosocial needs first. A forensic examination is always conducted to ensure that if a survivor would like to pursue the judicial process at a later stage, they have the option to do so. KCC staff includes a dedicated forensic nurse, counsellor and social worker to ensure that survivors have timely access to comprehensive care.
Starting in August 2016, MSF will extend its support to Bapong and Letlhabile community health centres in Madibeng Local Municipality, to increase the capacity of these facilities to provide comprehensive patient-centred care for survivors of sexual and intimate partner violence. As part of this strategy, which will increase access to quality care, clinical mentorship will be provided to professional nurses working in these facilities as part of a broader pilot mentoring programme.
MSF has observed a gap in the number of health care professionals who are trained in providing care for survivors of rape and other forms of sexual violence. This gap is due in part to a lack of forensic nurse training facilities, or alternatives that allow for rapid training of professional nurses to deliver high-quality care. MSF has therefore embarked on piloting a clinical mentorship programme for professional nurses in the care and management of survivors of sexual and domestic violence in Bojanala Health District.
Professional nurses in the programme are provided with two weeks’ training in a DOH-accredited course called: Caring for Survivors of Sexual Assault and Rape: a Training Programme for Health Care Providers in South Africa.
Once professional nurses have completed the course, a six-month clinical mentorship follows. The system offers practical training and consultation to foster professional development of mentees to deliver high-quality care for survivors. Furthermore, the programme identifies mentored staff that can be trained as trainers themselves, to promote sustainability and support further scale-up of the model by DOH in the future.
MSF and the DOH depend on close partnerships with the Thuthuzela Care Centre (TCC); Family Violence, Child Protection and Sexual Offences Unit (FCS); South African Police Service (SAPS); Department of Social Development (DSD); National Prosecuting Authority (NPA); and the Victim Empowerment Forum (VEP). Together with active health promotion activities in the district and regular engagement with the community, these partnerships are intended to ensure as many survivors as possible receive medical attention following incidents of sexual violence, and are appropriately referred to other social or legal services.
Living and Working in Rustenburg
The local economy around Rustenburg is fuelled by the extraction of platinum-group metals from the world’s largest repository, the Bushveld Igneous Complex. Accounting for 68% of Rustenburg’s economy, around 50% of people living in the area rely on the mines for their direct employment. The potential of finding work in and around the mines has contributed to exponential growth of the population of Rustenburg, which increased by 78% between 1996 and 2011, from 308 903 to 549 575 people. Health care coverage in Rustenburg is low compared to the high concentration of people who live and work in the area.
Unlike in the rest of South Africa, the bulk (55%) of people living in Rustenburg are men. This is due in part to men making up the overwhelming majority (~89 %) of mineworkers, many of whom come from rural areas of South Africa and surrounding countries.vi, vii However, Rustenburg also attracts many women from across South Africa and abroad who hope to benefit from the local mining economy in the platinum belt. Unemployment is particularly high for migrant women, creating conditions that promote dependency on men who are more readily employed by mines in the area.
The presence of mines creates economic growth for some, but - at the same time - many who migrate to the mining areas in hopes of finding work are unsuccessful, or receive low levels of remuneration. Consequently, a large number of informal settlements have developed around the mines in recent years, many of which are characterised by “grim poverty, the absence of government services, limited basic infrastructure, no running water and poor sanitation”. As a result, the communities that live alongside one of South Africa’s biggest industries are particularly vulnerable to violence, financial dependence on others and disease.
Regards Ryan and Angela