Mary Ann Hopkins, MDWar Surgery in Ituri, the Democratic Republic of Congo

Since the beginning of the year, tens of thousands of civilians have been displaced by a resumption of fighting between warring factions in the Ituri region of the northeastern part of the Democratic Republic of Congo (DRC). Many of the displaced people have settled in two camps: Tche, which is located in the highlands, and Kakwa, which is on the shores of Lake Albert. Doctors Without Borders/Médecins Sans Frontières (MSF) is running mobile clinics to provide basic medical services to the displaced. Some of the displaced have fled to the city of Bunia, where MSF has run the Bon Marché Hospital since 2003.

Mary Ann Hopkins, MD, a surgeon at New York University Medical Center and Bellevue Hospital, recently returned from Bunia. At the 150-bed Bon Marché Hospital, Dr. Hopkins operated on people, including children, with gunshot, machete, and burn wounds as well as victims of sexual violence, who have been directly targeted by warring factions in Ituri. Dr. Hopkins previously performed surgery with MSF in Sri Lanka and Burundi during those countries' civil wars.

We did between 25 and 40 surgical cases per day. Here in the United States, a busy day is about five cases. The turnover is different—here it can take up to half an hour to clean an operating room. In Bunia, it is three minutes. I remember one day where we did up to 35 cases before 3:30 in the afternoon. – Mary Ann Hopkins, MD

What is the situation in Ituri?

A patient ward inside Bon Marché Hospital. Photo © MSF

I was in the northeastern part of the Congo, which is right on Lake Albert. It's the part of the Democratic Republic of Congo that borders Uganda and is extremely rich in mineral resources like diamonds, gold, and cobalt. MSF responded to two major emergencies during my time in the field. In February, thousands of people began to flee the fighting between warring factions. Most of our patients came from the two major camps in Ituri, Tche and Kakwa, where people have sought refuge from the recent outbreak of violence. During the month I spent in Bunia, Tche grew from 2,000 to 10,000 people. And Kakwa expanded to around 7,000 people from 1,000.

What types of injuries were you treating?

I saw mostly machete and high velocity gunshot wounds, which were often up to a week old. So many of them were children, some as young as five years old. And a lot of children with machete wounds. The majority of my patients had gunshot wounds to the legs and arms. Those people who were shot in other places, like the torso, would have died before they made it to the hospital. It took people so long to get to the camps and then several hours to get from the camps to our hospital, and so the injuries were already very infected. We saw many victims of sexual violence, some of whom I had to operate on, and occasionally, we would see burn victims, women who were deliberately dragged through the fire. Guns, machetes, rape, and fire are the tools of war in Ituri.

What was the most difficult part of the injuries you treated in Bunia?

A child with machete wounds. Photo © MSF

What really got to me were the attacks on children. I see plenty of injuries in my work as a surgeon in New York. I deal with gunshot and stab wounds all the time. And I saw machete wounds in Burundi, but the number of children being affected by the violence in Ituri is incredible. My last day in Bunia, I took care of four children: two 15 year olds—one of whom was a girl who had been raped—as well as a six-year-old, and a seven-year-old. When I first saw them with their bandages on I thought they probably had superficial machete wounds, but once I examined them closer I realized that someone had actually attempted to decapitate these kids. They were deep, deep machete wounds. When I returned home I saw their pictures in the New York Times.

These children were part of about 100 to 150 people that were walking towards Tche during the day, and they were essentially ambushed by a militia group. Only 20 or 30 survived the attack and made it to Tche. I don't know what happened to the rest. Many were killed. Many fled to the surrounding forests. And among the people who made it to the camp were these four kids from four different families.

Then there was a 13-year-old girl who came to the hospital from Tche camp a day or two after I arrived. She had been shot four times. Once in her left leg, twice in her right leg, and once in her right hand. I took care of her every day for the entire length of time that I was in Bunia. Even after the first week, we were still taking out bits of bone from her leg. It was completely shattered. On the third week, as the anesthesiologist was unsuccessfully trying to repeatedly put in yet another IV to give her anesthesia, she just held on to me, put her head on my chest, and sobbed. It was heartbreaking. I have a picture of her—she's the most beautiful girl. It's just so sad to see a beautiful little girl whose life has been destroyed—she can't work, and it is going be difficult for her to have a normal life. There are no prostheses there; there are no artificial limbs.

This little girl (shown here playing with the anesthesiologist's cell phone) required an amputation. Photo © MSF

There was another girl who was paralyzed below her waist. No sensation, nothing. We took her into the operating room every day to clean her wounds. But her wounds kept getting worse and worse until her bone was exposed—this was her leg bone, right where it went into her hip. I had to amputate her leg from the hip down. It's called a forequarter amputation. She had arrived at the Bon Marché Hospital severely malnourished. Her hair had turned blonde from malnutrition. But she was so cute and always smiling and asking for passion fruit. When we took her into the operating room, she was singing songs with the anesthesiologists during the amputation. The hospital has become her life. It's all she has now.

Can you describe a typical day at the Bunia hospital?

Dr. Hopkins performing surgery. Photo © MSF

We did between 25 and 40 surgical cases per day. Here in the United States, a busy day is about five cases. The turnover is different here in the US, where it can take up to half an hour to clean an operating room. In Bunia, it is three minutes. I remember one day where we did up to 35 cases before 3:30 in the afternoon. You have to be fast and organized-a lot of these surgeries involve trying to get people's wounds clean so it's not like you're doing major surgery. Most of the time I was performing surgery in order to save a person's arm or leg from infection. The people whose lives were really threatened didn't make it to the hospital in the first place because it's too difficult to get there. One of the real problems that always occur in this type of situation is that people cannot move at night. And so when I would go back and forth between the hospital, the road was deserted after dark. Even at seven in the evening, it's completely empty. Women could not walk at night due to the real threat of rape. So the insecurity definitely added to the delay of people getting to the hospital.

Did you treat many victims of sexual violence?

Dr. Hopkins making rounds in Bunia with Congolese nurses at the MSF women's health center. Photo © MSF

There is a tremendous amount of stigma associated with rape. One of the incredible things that MSF has done has been to diminish this stigma. We would get upwards of 20 women per day coming to the women's health center to receive treatment for the dreadful consequences of sexual violence. (Between June 2003 and January 2005 at Bon Marché Hospital, MSF has treated more than 2,500 victims of sexual violence.) Not all of them were recent; many of the women had been raped over a year ago. But as the word got out that MSF had started a support program for victims of sexual violence, people would just come because they realized that they would get the support and the treatment they desperately needed. Obviously, there is still stigma and emotionally there's nothing that's going to take the horror away, but now there's help and recognition of the serious impact of sexual violence on the victim. Besides the immediate treatment for their injuries, rape victims who come to the MSF hospital receive post-exposure prophylaxis to help prevent transmission of HIV and other sexually transmitted diseases and psychological support.

Each and every story of sexual violence I heard would have been front page news here: a 13-year-old girl held for one month by four guys who raped her every day; a girl, only 7 years old, the same age as my niece, who was raped.

In between surgeries, I would see patients at the women's health center. My very first morning in the health center, I saw four women who had been raped. And I started to cry. And I'm not a crier. I'm relatively tough. I've seen people with their limbs blown off. I've seen trauma. And that first morning, I saw the 13-year-old girl who was held captive for a month by those four guys and a 70-year-old woman who had been raped and beaten by two men. And there are not that many 70-year-old women there.

Dr. Mary Ann Hopkins with nurses at the MSF women's health center. Photo © MSF

The Congolese nurses who work with MSF in the women's health center took me aside the next day. They said, "Look we know you are having a hard time, let us try to help you through this." They said you know we don't have to tell you the entire story, maybe we can just tell you a little bit of the story, and then you can examine her. They were able to get me to a point where I could listen to the story.

And I would also go see the midwives in the maternity ward to see if there were any c-sections. There was the seven-year-old who was raped. The nurses in the gynecological department said that they couldn't treat the girl's injuries. She needed surgery. And I don't mean suturing up a tear, I mean inside her abdomen. The nurses were so emotionally devastated that they couldn't help heal the girl's internal injuries.

I was overwhelmed by the stories of sexual violence after only one day. So I think it's an incredible tribute to these women—the local Congolese nurses that work in the health center—that they are able to listen, to examine, to help, and to do it day in and day out. The Congolese nurses would go out in the mobile clinics to tell women about the opportunity for treatment and counseling. I think it is probably mostly due to them and their work that people are coming to the women's health center. People recognize that it's not their fault that they were raped and so now they are beginning to come to get help.