ABUJA, Nigeria — Nigeria's public health officials are preparing medical support for the 276 kidnapped girls being held by Boko Haram to treat them for the effects of rape, sexually transmitted infections, and the possibility that some will need abortions, which are all but illegal.
"What is happening to the girls is an open secret: sexual abuse. We are preparing based on this assumption, which is almost a given," Dr. Ratidzai Ndhlovu, the country representative of the United Nations Population Fund (UNFPA), told BuzzFeed.
It is a reality many people would rather not discuss, but in recent weeks, Nigeria's health community has come together to craft a plan for dealing with the psychological and physical consequences that rape could have on these girls, their families, and their communities.
"The first thing those men [Boko Haram] will be thinking of is sexual violence," said Dr. Valerie Obote, the national president of the Medical Women's Association of Nigeria (MWAN). "There's no way those men are using protection; we don't know how many will get HIV [or other sexually transmitted infections]. It's a crisis on our hands."
Nigerian doctors acknowledge that it took a few weeks for the medical community to recognize that crisis, but representatives from the state and federal health ministries have met with NGOs, U.N. agencies, and funders like the U.S. Agency for International Development, and DFID, the British government's development arm, twice in the last two weeks to determine which services the Chibok girls — should they be rescued or released — may need.
The girls were kidnapped from their school dormitory nearly six weeks ago by the extremist Islamist militant group Boko Haram.
Rape requires a panoply of follow-up care, from post-exposure prophylaxis to help prevent HIV transmission to physical care for any injuries or sexually transmitted diseases to psychological care to abortions.
The latter is perhaps the most delicate part of health planning. Rape, real or presumed, brings stigma to families in Nigeria, especially in the rural north, which tends to be more conservative and less educated than the country's urban areas. Pregnancy can compound that stigma, and some health workers worry that those social stresses could leave girls and their families at risk, even once the kidnapping is behind them.
"What's the aftereffect of rape? How will the family understand what to do if the girls are pregnant?" asked Dr. Nihinlola Mabogunje, the country director of Ipas, an international health NGO. "If I don't talk to them now and tell them there's a way out, when the girls are pregnant they could take it a different way."
These "different ways" could include unskilled or "traditional" abortions, or even suicide, Mabogunje said. Doctors and others in Abuja have already had reports from colleagues, friends in the Chibok area, and mothers of some girls who escaped their captors, that some of the kidnapped girls who escaped have taken "concoctions" to end possible pregnancies.
Mabogunje has determined to make sure families understand that their daughters will have a choice to end any pregnancy that may have been inflicted on them.
"Let's bridge the gap, meanwhile. Let the family be counseled on traumatic counseling for them to understand that the girls will be helped when they get out" she said. "These are the possible consequences of rape … but there are ways to deal with it."
She hopes those conversations will help parents cope better with the fate of their abducted children. Mabogunje has pledged to make medical abortions available to any girls who want them, and she's courted and won support, if unofficial, from other medical leaders in Nigeria. This is a stunning achievement given that in Nigeria, abortion is illegal except to save the life of the mother, unlike 26 other African countries, whose laws allow for abortions in the case of rape.
"Be that as it may, a child in Nigeria who has been raped needs the option to terminate," said Obote, president of MWAN. "It's not going to be done officially but we will talk with parents, with the mothers of the girls and the girls, and see if they would like to accept … It still has to be the patient coming to you, willingly accepting."
Because of Nigeria's law, not all health providers can speak frankly about their support for the matter. Several top officials have attended two coordinating meetings in Abuja and discussed advocating a broad interpretation of "life saving" to include saving the Chibok girls from the trauma and social stigma of bringing a child of rape to term. Suicide by raped teenagers is considered a very real possibility in these communities, and the stress of the Chibok abductions — the uncertainty of what's happening to the girls day by day, the near-certainty of their rapes — has already caused the deaths of at least three parents, according to Dr. Salma Kolo, the Borno state health commissioner.
Psychological and physical care for rape survivors is just one part of a comprehensive strategy that federal and state health officials, United Nations agencies and international organizations have been brainstorming over the last several weeks. On Wednesday, Kolo began a training in trauma support counseling for 11 community health workers, and a health committee began mapping the crisis area Tuesday.
The kidnapped girls were boarders at their public school, which means they had come to Chibok from dozens of different nearby villages the night they were taken in mid-April.
There is still no comprehensive record of exactly which girls were kidnapped and exactly where their families are located; mapping will help determine where the families are, which health facilities are closest to them, and how to lay out a referral network for specialized care, Kolo said.
The collaborative plan was drawn up at a five-hour meeting Monday between Kolo and the families and community leaders of Chibok.
"They were very happy," Kolo said of the community's reaction to the plan. "They said this is the first time the government has called them to talk about psycho-social support."
As Kolo begins her work, the ad hoc coordinating team in Abuja is looking for donor commitments for the estimated $1.5 million the comprehensive health outreach will cost.
Abortion provision is likely to be a difficult area to fund, despite the clear negative psychological impacts of pregnancy as a consequence of rape. U.S. government funding is restricted by the 1973 Helms Amendment, which prohibits the use of federal funding for the provision of abortion.
That hasn't stopped U.S. money from funding organizations that may offer abortion. "USAID works with a range of organizations that provide a host of family planning and reproductive health services, and a few do provide abortions. However, organizations use non-U.S. government funds for this purpose," USAID spokesperson Karl Duckworth told BuzzFeed in an email about the Helms Amendment in February.
But Nigerian health workers fear that avoiding issues around rape and pregnancy will compound trauma, not only for the Chibok girls and their families but for communities generally in Borno State, where every remote village is vulnerable to attack by Boko Haram.
Human rights workers say the stigma about sexual assault is one reason the pattern of kidnappings of women and girls in Borno state, which they document going back as far as 2011, has gone unacknowledged.
"It was hidden," said Dr. Salma Kolo, the health commissioner of Borno state. "[The families] don't report it... It's always a hearsay."
That's partly because stigma, like all vulnerability in the rural north, doesn't affect only the girl who has been assaulted.
"The north is a collective society. If you touch one person, you touch a network of persons," said Dr. Robert Chiegil, deputy director of FHI360, an international family health organization. "If you hold Esther, you also hold Esther's parents, siblings, cousins, aunties."
Chiegil says that means the health response has to be collective too.
"Once they hear Esther is in trouble, they will all come out," he said. "If I had resources, I would not wait for Esther. I would start now by managing the tension for Esther's family members, which right now could be even more than Esther has."