One country's plan to solve the world's hidden health crisis
In the crowded emergency ward of a hospital, Dr Prabhat Rijal met a patient covered in bruises.
Her visit was expected. The doctors at Rapti Sub-Regional Hospital in Ghorari, western Nepal see at least one case like this a night. It’s usually shortly after dusk, when abusive men come home from work and start drinking. The patients tend to come in gripping their stomachs or complaining of earaches, but the nurses and doctors look out for bruises or cuts on their bodies that suggest a different story.
女病人的到访并不令人意外。在尼泊尔西部城市格拉希（Ghorari）的拉布提区属医院（Rapti Sub-Regional Hospital），医生们每晚至少会见到一位这样的病人。通常是在黄昏后不久，施暴男性下班回家开始喝酒的时候。病人们一般都紧紧捂着肚子，或者说耳朵痛，但医生和护士会留意她们身上有没有淤青或伤口，有的话就是另一回事了。
Rijal, suspecting something was off, asked the woman what happened. She had run out of her house after her husband beat her, the patient said. Her hair was still slick with sweat.
The dimly lit emergency ward is busy late into the night, with children running around and patients on every gurney, so Rijal and a nurse led the woman into a private room and shut the door. They followed the script they normally employ. Abuse is not normal or inevitable, they told her. She has options.
Moments later, the nurse led her to the one-stop crisis centre, a separate wing of the hospital where patients facing abuse can meet counselors and a female police officer.
Intimate partner violence often leads to long-term health problems. And a doctor’s office is usually the first C if not the only C place where someone might not only notice the problem, but have the expertise and authority to help.
Many governments don't prioritise intervention in healthcare settings. But Nepal, which has some of the highest levels of domestic abuse, is among a growing number of countries embracing a health response C placing support services inside hospitals and training providers to identify and refer abused patients.
‘As common as asthma and diabetes’
Although intimate partner violence can happen to anyone, it disproportionately affects women.
Worldwide, almost one-third of women who have been in a relationship report having experienced physical or sexual violence from their partner. Intimate partner violence is exacerbated in countries experiencing or recovering from conflict, like the Democratic Republic of the Congo and northern Uganda. Although attitudes are changing, studies suggest it is also more accepted in countries across Asia, Africa, and Oceania.
It isn’t only the developing world. A third of women in Denmark and just under 30% in the United Kingdom report having experienced intimate partner violence at least once in their lifetime, for example, with around 5% reporting an occurrence in the last 12 months. In the US, 32% of women have experienced physical partner violence and 16% have experienced sexual violence from a partner, with almost 4% experiencing physical violence and 2% experiencing sexual violence in the last year.
The impact violence has on women’s health is immense.
In the US, intimate partner violence results in 2 million injuries each year, making it a larger health problem than obesity and smoking. It is associated with chronic pain, asthma, difficulty sleeping, irritable bowel syndrome, heart disease, diabetes, stroke and sexually transmitted diseases. Women who have experienced violence from a partner are at higher risk for suicide and more likely to suffer from depression, anxiety, panic attacks and post-traumatic stress disorder.
Medical workers are often the first service responders to come in contact with people experiencing abuse: in the US, for example, women in abusive relationships visit health centres 2.5 times as often as other patients.
Since 40% of female homicide victims are killed by their intimate partners, intervening at this stage can save lives. One study of 139 female homicides that took place over five years in Kansas City found that nearly one-quarter of homicides C 34 C were related to domestic violence. And 15 women had presented to an emergency department C 14 of them with injuries C within the two years before they were killed. A recent survey of 1,554 victims attended to by police after domestic violence calls found that 88% reported having survived a previous strangulation attempt.
But health providers are often unprepared to help patients. In Britain, a 2017 study found that most medical trainings don’t adequately cover intimate partner violence. Although the Affordable Care Act in the United States mandates that more insurance plans cover screening and counselling for patients facing violence, the US government still doesn’t have a national protocol.
但医护人员往往并没有做好帮助患者的准备。英国2017年的一项研究发现，大多数的医疗培训并未充分涵盖亲密伴侣暴力的相关内容。虽然美国的《平价医疗法案》（Affordable Care Act）规定，要有更多的保险覆盖到受家暴人群的筛查和咨询服务，但政府现在仍未推出全国统一的规范。
Training medical workers to identify and refer abused patients depends on how a country funds its healthcare, says Kelsey Hegarty, a family physician and researcher who helps develop health interventions in Australia. Governments can’t require privately funded institutions train their staff on responding to intimate-partner violence and many governments don’t fund protocols and trainings. As a result, civil society groups often take on the task of developing interventions and in-hospital services.
“For something that is as common as asthma and diabetes and causes ill health, it’s very disturbing,” says Hegarty.
Not sensitising health providers has consequences. One recent study suggested that some health providers in Lebanon feel violence is justified if women exhibit aggressive behavior.
Unsurprisingly, patients often don’t feel comfortable disclosing abuse. In Nepal C where nearly half of women have experienced some form of abuse C patients worry that health providers will laugh at them or accuse them of not being “good” wives.
“The police didn’t even care when I told them what happened to me before, so why would doctors care?” says Neha, who had been in an abusive marriage before she visited a one-stop crisis centre in Nepal. (To protect the safety of the women interviewed, we have not used real names.)
There is debate over how health providers should identify patients like Neha. Some advocates recommend screenings which require that health providers ask patients if they’ve faced abuse. But there’s little evidence to suggest it helps. A review of 11 studies in the British Medical Journal found that screenings helped identify patients facing abuse, but did not necessarily help them access support services. The World Health Organization advises against screenings in its guidelines on gender-based violence for health providers.
医护人员应该如何发现倪娅这样受到家暴的病人，对此仍然存在分歧。有的人认为，应该让医护人员询问病人是否受到虐待来进行筛查，但没有证据证明此举有用。《英国医学杂志》（British Medical Journal）上一篇对11项研究的综述发现，筛查能够帮助发现遭受家暴的病人，但未必能帮助他们获得所需的帮助。世界卫生组织在其给医护人员关于性别暴力方面的指导中也建议不要进行筛查。
Instead, many experts suggest approaches like the one Nepal has embraced.
Inside the one-stop crisis centre at the hospital in Ghorahi, Maya was curled up on a teal-covered cot. She had visited the emergency ward a day before. Now, she was back to meet with counsellor Radha Paudel, who sat crouched near her bed, inspecting a string of bruises running up her arm. On a pillow nearby was a sheet of paper listing her other symptoms C a headache, hematoma in her right hand, swelling on her head, pain in her chest and on her upper and lower back.
“You came in earlier with your husband, too,” Radha said in a near-whisper.
“My husband refused to come today,” Maya said. He was at her house watching her children.
Months earlier, Maya had lodged a complaint against her husband, who was briefly arrested, and filed for divorce with the help of Sabita Thapa, the police officer who works at the crisis centre full-time. Radha connected Maya with a local women’s group to help her establish an independent source of income. Her situation reflects an imperfect, but evolving health response. Although Maya still faced abuse, the one-stop crisis centre has linked her to multiple services. Her husband has moved out and their divorce is pending in court.
Nepal opened its first one-stop crisis centre in 2011 in its central and far-western regions and continues to place them in hospitals around the country. In 2015, the government developed a protocol to help health providers identify and refer more patients to the crisis centres, which received technical support from Jhpiego and the UN Population Fund and is now funded by the government.
尼泊尔于2011年在中部及西部偏远地区开设了首家一站式危机处理中心，随后在全国的医院中继续推广落实。2015年，政府制定了一项政策方针，帮助医护人员鉴别受暴者，并把病人转介至危机处理中心。这些中心从附属于美国约翰・霍普金斯大学的国际性非营利健康组织Jhpiego，以及联合国人口基金（UN Population Fund）处获得技术支持，现由尼泊尔政府资助。
Hundreds of health providers have been trained so far, ranging from gynaecologists to family physicians at small health posts high in the Himalayas.
At the hospital in Ghorahi, experts believe this multi-faceted approach has helped increase the number of women reporting abuse and receiving counselling and legal advice. In 2013, only 74 women reported abuse to the hospital. By 2017 that figure jumped to 493 women. Although most women visited the hospital to report abuse on their own, each year the number of nurses or doctors referring patients to counsellors increases.
“Health workers were scared handling these types of cases,” says Saroja Pande, one of the physicians who helped design the protocol. “They would refer them to services, but the survivors were traumatised and would drop out of follow-ups, stay at home and develop depression. Some killed themselves.”
Today’s trainings are comprehensive. They include a mix of theory, games and role-play scenarios, including a courtroom simulation to prepare health providers for what will happen if they are called to present evidence.
Another goal is to expand empathy. Medical workers are encouraged to recognise and question biases they may hold about abuse. During one session, the trainers ask them if they believe a woman wearing a short skirt is assaulted because of her clothing choice. They take the opportunity to debunk myths about what motivates abusers.
Ishwor Prasad Upadhyaya, the training coordinator, says they want health providers to think of this work as more than a job. “We tell them, if you can’t serve a survivor from the bottom of your heart, then don’t touch their case,” he says.
培训协调专员乌帕迪亚（Ishwor Prasad Upadhyaya）表示，他们希望医疗人员不要觉得这只是一份工作。“我们告诉他们，如果无法发自内心地帮助家暴幸存者，那从一开始就不要接手。”
“If you can’t serve them, send them to another health worker.”
Other countries have similar approaches. One-stop crisis models and their variants exist at health centres in Rwanda, Guatemala, India, England, Malaysia, South Africa and Colombia, among others. Jordan’s government has a protocol for health providers and reproductive health clinics, like Profamilia in the Dominican Republic, screen patients for gender-based violence.
But these approaches still face serious challenges. Experts agree that merely training health providers is not enough unless a country has strong support services in place, including shelters. But in Nepal, as in many countries, shelters are underfunded, only let domestic abuse survivors stay for a brief period of time, and can be rare in rural areas.
At the hospital in Ghorahi, there can be delays in following up with patients, which may make them less likely to seek support services. Many women also opt for family counselling instead of filing police complaints against their husbands, owing to a lack of family and financial support. Police officers in Nepal often urge mediation as an alternative to prosecution, but research in the United States suggests it can increase risk.
Worldwide, the burnout rate for health providers engaged in this work is also high, says Upala Devi, the gender-based violence coordinator of UNFPA.
“I think what we’re seeing right now in terms of momentum is very positive and welcome,” she says. “But at the same time much more remains to be done.”
How untrained health providers can help
Experts agree that health providers who haven’t been trained can still help identify and refer abused patients.
Hegarty has only one piece of advice: read the World Health Organization’s guidelines on responding to gender-based violence, which outline evidence-based suggestions.
Most importantly, the guidelines list the things a health provider should consider before asking a patient if they face abuse C such as make sure you are in a private setting, ensure confidentiality, follow a protocol, and refer him or her to resources, including legal and other support services.
Ideally, health providers should be trained on how to sensitively ask about abuse. But in situations where this isn’t possible, the guidelines explain how to listen, enquire about needs, and validate the patient’s experiences.
In Nepal, health providers keep an eye out for patients who come in with vague symptoms or symptoms that don’t correspond with an examination’s physical findings. They also observe their behaviour and that of those accompanying them. If a patient seems depressed or answers questions erratically, a health provider should consider asking them about their relationships or refer them to a qualified counselor, says Pande. If the family member or spouse accompanying the patient refuses to leave her alone with a health provider, this might also signal abuse.
Jinan Usta, a physician who has designed training for health providers in Lebanon, says it’s important to develop safety plans with patients if they choose to stay with their abusers. First, medical providers should ask the patient whether the violence has increased over time or in severity, and if there are firearms or other sharp instruments around. If there are, she recommends patients leave the house immediately when their abuser starts acting violently.
There are a number of other safety measures: avoid hiding in enclosed spaces, have a number on your mobile phone of someone you can call immediately, hide sharp instruments, and keep the front door of your home unlocked so that you can quickly exit.
Usta believes that listening to domestic abuse survivors holds its own power. “It’s enough to listen to the women and make them feel like they are not alone in this,” she says.
Sabita agrees. On a recent afternoon, she walked into the crisis centre in Ghorahi during a burst of monsoon rain and sat in a corner, watching the staff shuffle papers.
Three years ago, she reported abuse here. Now she stops by for follow-up counselling. She has moved back in with her husband, but says the abuse stopped shortly after the crisis centre staff helped organise his treatment for depression. She regularly refers other women to the crisis centre.
“They treat us better than our mothers and fathers,” she says.