Mental Health Care Must Be a Priority in the Global Fight Against Gender-Based Violence

Congo. It’s a name that evokes the deepest realm of the imagination—one that conjures up mystery and intrigue as well as a sense of fear and “darkness.” This source of sensationalized sentiment has influenced literary minds for generations—from Conrad’s “Heart of Darkness” to Coppola’s “Apocalypse Now” to Crichton’s “Congo”—yet none have even scratched the proverbial surface when it comes to actually describing the systematic suffering and dehumanization of the second largest nation in Africa.

According to a recent study in the region, 39.7 percent of women and 23.6 percent of men report having experienced sexual and gender-based violence (SGBV). While these statistics are shocking in numbers alone, personal narratives bring to light the true depths of these atrocities.

“The soldiers came in,” one woman told researchers. “They were Tutsis. They…wanted to kill my husband. They had machetes…they butchered him, like a slaughterhouse. They took out his intestines and his heart. I had to pick up all the pieces. I had to lie down on his body parts. I wept and they started raping me. There were 12 of them. And then my two daughters in the next room. After six months…my daughters were pregnant. They said it was my fault that my husband is dead. When my grandchildren ask me now about that scar, I can’t tell them. It was their fathers who did it.”

Women and girls in the DRC at a ceremony organized by the Ministry of Gender, Children and Family in partnership with UN agencies, Private Sector Partners, Multilateral and Bilateral Agencies and other NGOs and National Networks to launch the UN’s 16 days of activism against violence against women and girls campaign. (UN Women)

The Democratic Republic of Congo (DRC) has been torn apart by wars since 1996. The neighboring Rwandan genocide garnered worldwide attention, but when the conflict between the Tutsis and Hutus ended in Rwanda, it spilled immediately into the DRC, and even involved nine African nations at one point. This conflict, aptly referred to as the “First African World War” and often described as the deadliest conflict since World War II, continues today. Reports vary, but it is estimated that as many as 6 million people have been killed since 1988. Such widespread humanitarian complexities have precipitated the largest and most expensive UN peacekeeping operation in history. 

In a society of lawlessness, poor infrastructure and destructive leadership, all fueled by the greed created by one of the largest mining industries in the world, men and boys are insidiously drawn into conflict to seek identity, respect and purpose. Respect for human life, widely known to have been stripped of value starting with the oppressive colonization of King Leopold II, is further eviscerated within these caustic environments, thereby legitimizing murder and desensitizing rape. Rapes are often used by militarized groups as an instrument of terror; gang rapes are reported by 33.4 percent of women.

Yet little of the world is aware of this epidemic. In a contemporary era now acutely aware of gender-based discrimination, how are these women forgotten? 

Such pervasive acts infect communities and provoke a constant state of fear and an internalized sense of weakness and hopelessness. This culture of violence bleeds into a feeling of collective inadequacy and humiliation among men, exacerbated by a lack of economic security and leading to a drive to procure a sense of power and domination. Such inner turmoil and rage precipitate a familial destructive environment which often includes SGBV. One recent study reported that 41.6 percent of women reported interpersonal violence (IPV), but it is not just women who are affected. 30.7 percent of men also reported IPV, an occurrence that is often overlooked. 

This culture of violence clearly causes a wide cascade of adverse effects on health—and in particular, on mental health. According to the same study, 40.5 and 50.1 percent of adults met criteria for major depressive disorder (MDD) and post-traumatic stress disorder (PTSD), respectively. Even worse, 16 percent attempted suicide.

While the traumatic effects in the DRC are certainly not representative of the global South, mental health is generally not prioritized by global health and development organizations. In fact, countries in sub-Saharan Africa (SSA), on average, spend less than 1 percent of their total health expenditures on mental health, compared to approximately 20 percent on HIV/AIDS. Even the World Health Organization (WHO) does not specifically address mental health in their Millennium Development Goals, recommending an expenditure of  less than $0.25/person annually in low-income nations. 

African primary care physicians (PCPs) are not well trained to detect or manage mental health, and specialists are a relative rarity—for example, there are only four in South Kivu, a province with a population of more than 6 million. Consequently, most mild and moderate mental health conditions are overlooked, and more severe conditions are dismissed as “foolish” or even “witchcraft.”

Public health and sociopolitical environments are closely related. Countless examples demonstrate the efficacy of community empowerment to resist the caustic forces of corrupt and inept governments. If communities are ravaged by unresolved state-sponsored trauma, they will continue to remain victims in a complex web of social injustice. 

The tools needed to build resilience are necessary to empower communities. Such tools are a basic provision of care built into robust systems that support mental health care. SSA, particularly the DRC, is wholly lacking such systems, and it is time this changes. It is within the scope of care of Congolese PCPs to manage mental health. Until they do, the health care system will continue to remain saturated by the more topical physical conditions with underlying mental health correlates, and a nation of such vibrance and strength will never reach its full potential. 


Tyler B. Evans, MD, MS, MPH, AAHIVS, DTM&H, is the acting Chief Medical Officer for the County of Santa Cruz (California) Health Services Agency; Associate Professor at the Leonard Davis School of Gerontology at the University of Southern California and Assistant Professor at the Charles R. Drew University of Medicine and Science; and Founder of the New York City Refugee and Asylee Health Coalition.