Health In Europe

I Believe You

• World Health Organization Regional Office for Europe • Season 8 • Episode 1

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What role does a health system play in protecting women and girls from violence? I Believe You is a new podcast mini-series from WHO's Health In Europe, under the Special Initiative on Violence Against Women and Girls. Throughout the series, we talk with leaders from WHO, UNFPA and UN Women to explore what role health systems play in protecting women and girls from violence and what more can be done to make societies safer.

In this first episode, we sit down with Dr Hans Kluge, WHO Regional Director for Europe, to introduce the Special Initiative and discuss the complex challenges facing healthcare professionals on the front line of this issue.

Show notes/links

David Barrett: You're listening to WHO's Health in Europe. My name is David Barrett 

Violence against women, particularly intimate partner violence and sexual violence, isn't a niche issue. It is a major public health and gender equality problem, and it is a violation of women's human rights. WHO Europe has launched a special initiative on responding to violence against women and girls, and over the next three episodes, a series we're calling I Believe You, we'll hear from the people working to end gender-based violence and what more health systems could and should be doing. 

To start, my colleagues Melanie Hyde and Greg Bianchi sat down with Dr. Hans Kluge, WHO's Regional Director for Europe, to ask him directly what WHO Europe is doing about this issue. Here's that conversation. 

Melanie Hyde: Good morning, Hans. Thank you for joining the show, and we like to start these interviews to get to know a little bit more about our interviewees and where they came from. And so we wondered if you could share with us a little bit about your upbringing and how you started working with the WHO before becoming the regional director for Europe. 

Dr Hans Kluge: Thank you. Thank you so much, Marilie. I mean, it's awesome to be on the, on the show here. So in, in a nutshell, uh, I have a sister two years, uh, older than, than me, and, uh, my father was a, a chief doctor and my mom a, a chief nurse, always working in the local communities in, uh, in Flanders, in, uh, Belgium. And actually, if I look back, they are doing or were doing a lot of stuff that we promote as WHO, but we call it now people-centered and, uh, eh, you know, and, uh, and, and gender equality, but they were practicing this. 

So for me, it was quite natural, let's say, and for my sister. So they always-- To give an example, they also had a private practice, and they would never refuse patients who couldn't afford health services. Their motto was, "People help people." You know, straightforward. So in that sense, I always remind this when making policies that I think which different is this policy going to make at the life of the people in the community, and that became my life mission, let's say. 

Social justice, really. That's where, uh, I get it comes from.  

Greg Bianchi: That's really interesting. It sort of leads us quite nicely into, into our next question, which is particularly about the, the special initiative on- Yes ... on violence against women and girls. And I mean, you launched this, uh, this initiative last year on, on International Women's Day in, in twenty twenty-five and, uh, perhaps at a time when some leaders are starting to back away from, from talking- Yes  about this issue in some ways. And, and that leads me to, to perhaps quite a simple question, but maybe, uh, one you can expand on, which is why are we, uh, or why are you rather talking about this now? And, and also with regards to this special initiative, what role does the health sector have in, in tackling again- uh, violence against women and girls? 

Dr Hans Kluge: Yes. It comes a bit, uh, Greg, from my experience in, uh, Somalia. This was my first overseas mission when I, uh, graduated not only from the Catholic University of, uh, Leuven in Belgium, but also the Institute of Tropical Medicine. I went to, uh, Somalia and, uh- Well, let's say with a, a big theoretical, uh, luggage, but not so much practical. 

And there I was confronted with female circumcision of very young girls, but done in, I mean, honestly horrible circumstances. Definitely not in, uh, in the hospitals. And I had to deal as a very young, fresh graduate with the consequences. I mean, terrible infections, vaginal. And then maybe the thing which still traumatized me a little bit, you try to do well for the girls, but I didn't realize that when they were sent back from the hospital into the communities, that there was quite a backlash from their families, from the community. 

So very quickly, I realized that we had to be much more smarter. Actually, what we call now gender and cultural appropriate, so that whatever we try to help the girls, it wouldn't be turned against them once they were getting back to their communities. I mean, to give one example, uh, it was almost impossible for me to do a medical consultation with, uh, a girl or a woman without the f-father standing next to them. 
And of course, then they were not free to, uh, speak, uh, about this. So, uh, in that sense, this kind of, uh, injustice I saw really from the very beginning that we had to do something. And this, honestly, Greg, was before I knew about the terrible figures, which I did not anticipate in the WHO European region. I mean, to give an example, almost one in three women and girls in our region experiences sexual or intimate partner violence in their lifetime. 

Six hundred thousand women and girls in our region are subjected to female genital mutilation. And actually, what I see the moment that I start to speak about this also with governments country after country, the more data and experiences show up. We had a meeting this morning, the weekly meeting with our WHO country representatives. 

They were thanking me for the message I sent out in the context of International Women Day on this subject and wrote the WHO representative one particular country who was telling, "Well, actually, Hans, we just had a very-- another tragic, uh, uh, incident of femicide in the country." So we are doing worse than twenty years ago, uh, Greg, so this is a big issue. 

On the question why the health sector, actually, I remember that even some close colleagues were telling, "Well, why you're stepping into this field, uh, Hans? This is a, a police issue. This is nothing t-to do." But the more we are doing on that one with, uh, our wonderful colleagues, uh, like we have with the, the Venice, uh, office and, uh, uh, Melanie and, uh, Natasha and Mil, I see that the health sector has such an important role because it's often the first and only contact point for survivors. 

So if we don't catch the survivors there, those women and girls may never have the opportunity to heal. And most of the protocols, guidelines are there, but it's about the awareness of the healthcare workers. So it's not necessarily that it has to cost a lot of money, but we need to, like we say, if you see it, say it. 

Melanie Hyde: Thanks, Hans. I think that's really an important point in terms of linking the health response to, to gender equality, um, and in terms of the limited amount of power that, that many of the women that come into our clinics will have and, a-and I'm reflecting on your experience of, of really, you know, not being able to provide that care without the father or the husband being there, and we still unfortunately see that, uh, in, in many countries. 

I'm also wondering in terms of Recognizing your role as a man working in this space and seeing gender inequality around us and, and unfortunately some positive actions, but a lot of regression also in, in terms of the pushback that we're facing. How do you as a man enter into these difficult discussions in your day-to-day work? 

'Cause I remember when we started this, you saying to me, "Well, Melanie, nobody raises this. They're not saying that it's an issue." Right. And so how, how do you confront that and then, and, um, in your discussions, uh, from day to day?  

Dr Hans Kluge: May- maybe two points, uh, come to mind, uh, Melanie, and you remember very, very well indeed. 

So number one is I'm very fortunate. I'm surrounded by women in my family, right? With, uh, Katrina, my spouse, Anastasia, and Sophia. And then I'm thinking, one out of three, right? If, uh, women and girls experiencing this violence and actually even, you know, Melanie, at universities, you know, where, where you, uh, maybe would not, uh, expect. 

So it is ingrained in society, and as you say, it's regressing. It's not getting better. So I feel both as a spouse, as a father, a moral duty. And then a second point is at one time One colleague who is dealing with this was telling me, "Hans, it are the men that we need to get on board, right? So speak about it, that the men start talking and appreciating that something needs to be done." 

And maybe going back to my own roots and my parents, actually, we talk about something, Melody, which for me is almost something that should be so logically. I mean, if a society does not appreciate, support, protect women, and then I'm speaking often about, uh, families which are not in the most vulnerable situations, right? 

And then what we saw on the, during the COVID-19, during the lockdowns, that my respected colleagues from UNFPA, Florence and Belen from UN Women were telling, "Hans, imagine that you are locked up at home in the lockdown with a perpetrator." I mean, this blew my mind. I mean, this is so, so sad. So we have to be proactive and be much more smarter, right? 

If the usual social protection mechanisms are not there, what can be done? And it's possible with, uh, in Belgium... Actually, in Belgium, my own country, there was a article that the last five years, partner violence has increased with twenty percent. And most women, again, don't go to seek for help. But there are apps. 

Then in an African context, a colleague was telling me that there were, uh, women were using, uh, to tick on the, the pans and the pots if they're going to be attacked at home. So signals, right? To, to mobilize community. So there is always, even in the most difficult circumstances, something which can be done to protect women and girls. 

Greg Bianchi: Thanks, Hans. I think that's, it's really interesting and, and actually a really important point you make there about that sort of... And it came up a lot in, actually, in our conversation with, uh, Elisa from, um, UN Women about this sort of multi-sectoral- Yes ... uh, and, and we kind of summarized it almost as it's, it's everyone's business in that sense, that, uh, it's, it's, yeah, from the top down, sort of keeping it and being vigilant for these, these signs and, and various things. 

Um, I want to turn to one question. It's, it's slightly personal based on your experience that you've already mentioned. Uh, so I know you worked on the, the front lines with, uh, Medecins Sans Frontieres. So, uh, for our English listeners, that's, uh, Doctors Without Borders. And reflecting on that experience, did you feel prepared to, to respond to women who, who had experienced violence? 

And, uh, and how did you respond as a doctor when, when you might see this, these signs of violence, but they may not directly disclose it? How did you, how did you approach that?  

Dr Hans Kluge: I mean, listen, Greg, I can be very straightforward here. I, uh, I was not prepared, and I have made some, uh, mistakes also. I was prepared to treat, let's say, the physical wounds. 

Greg Bianchi: Mm.  
 

Dr Hans Kluge: But looking back, this was the, the sh-- I mean, was very important, right? The bleeding and, and the infection, but this was the, the, the s- the start only. I mean, the whole social psychological healing. I mean, some of those girls were then, uh, uh, expelled from their society, or they couldn't find then the... or, or were not allowed to, uh, uh, to, to find the, the husband-  

Greg Bianchi: Mm ... 
 

Dr Hans Kluge: or, or were, uh, forced to, to have a husband then who was sometimes the perpetrator. 

So no, absolutely not, and that's why it's so important that we are working to provide our healthcare workers the, the tools and the coaching how to deal with a very, uh, complex issue and situation, but which ultimately touches us, all of us, and should touch all of us in the heart. I mean, if we don't tackle that one, honestly, what the hell we are doing otherwise, right? 

I mean, then we're turning a blind eye to, to do, I mean, to do something at the sideline And actually, when I came down here in the elevator, so many people came to me to tell, "Hans, thank you so much for also naming some of the, uh, victims who are in the media in your message for International Women Day. 

Thank you because we congratulate women at International Women Day, but we dance around the elephant in the room-  

Melanie Hyde: Mm. ...  
 

Dr Hans Kluge: and you didn't do this." And I really have to thank all the people, uh, around me to, to work on the, on that one, uh, Greg, because every day I'm learning from my colleagues like, uh, Melanie and, uh, you know, and, and many, many people. 

So we have to do better on the... You know that I'm a, a born optimist uh, Greg, so I must say whenever I talk to ministers, prime ministers, I was just in Greece with, uh, Prime Minister Mitsotakis, with Minister Adonis Georgiadis. Until today, I can tell you there is no any prime minister, no any president or minister of health who was not joining the movement. 

Okay. West to East, you know, be it in Central Asia or in the EU. Honestly, I'm overwhelmed. So we have now to think smart how to capitalize on that enthusiasm to make a difference, again, not for Kluge, but for the, the, the women and the girls in the most vulnerable situations.  

Melanie Hyde: Thanks, Hans, and I think that, I think takes us to what's next. 

I mean, last year in Madrid, you stood side by side with, uh, Minister Garcia of, of Spain launching the report, the shocking figures, um, the fact that less than forty percent of our countries actually have policies aligned with WHO guidance to, to guarantee the provision of these services. So what's, what's the priority now? 

Dr Hans Kluge: Very, very important question, uh, Melanie, because now we have, we, we have the, the, we started the movement. There is enthusiasm, but it should not wane, and we should be practical. And, and, and you know me by now, uh, Melanie, I'm, uh, I join you in, uh, pragmatism. I think first to abolish mandatory reporting of violence by medical professionals. 

So we have the data now, right? We have the report. Let's say X countries will abolish this in the next one or two years Number two, I was shocked to know that only 4 out of 10 of our member states have actual clinical guidelines post-rape, which I thought, I mean, is quite basic. So this, I mean, desperately has to be improved. 

Then looking to our mandate, because we always look at our core mandate, we are working with doctors, with nurses. We have a lot of supporters like FIGO, right? The International, uh, Association of Gynecologists, but also WONCA of primary healthcare doctors to work together on online awareness courses so that all healthcare workers are aware and equipped. 

Like, for example, I was not when Médecins Sans Frontières sent me to Somalia, but also in our own countries. Ultimately, I mean, we want to move towards Zero violence. We know that this is an ambitious goal, but sometimes it's good and it's a matter of moving towards. So we need to see less violence. But of course, how do we know it? 

First, women and girls have to be encouraged to report because we all know that there is an underreporting. So that's a bit, I think, what, uh, uh, comes to, to mind. And as was mentioned yesterday at the, uh, amazing webinar from the Division of Health Systems, that we cannot underestimate the importance to stratify data by gender and by age, because otherwise we're making policies and shooting our bullets in the dark, right? 

We, we need, uh, data so that we can further improve. But congratulations to, to you, Melanie, and to, to the whole, uh, team, right? To have the first report. We have a report. It's a baseline. Now we can improve. But again, I see a lot of awareness also in the media, by the way. But we need to, uh, uh, keep it... And let's not forget maybe a final point. 

We cannot ignore this. I mean, we're living in, uh, in an era-- In our region itself now we have, uh, three wars, so that women and girls are the first victims in conflicts, in wars. Very, very sad always that rape and sexual violence is being used as a, a weapon also, right? So, so that we're doing a lot of work and we need to continue to do this because I really strongly believe, I was telling my, uh, personal mission is social justice. 

It means to leave no one behind. I strongly believe in, uh, in that one. And we can never compare human suffering, whether it is one woman or thousand woman, every human suffering is one too much because that woman, that girl has to go to sleep at night, cannot sleep, often has no voice. So I mean, we have to be the voice of the voiceless. 

Melanie Hyde: Thanks, Hans. I think a, a strong reminder too of how deeply stigmatized conflict-related, uh, sexual violence is, and certainly we see that coming out often the true scale many years later. Thank you so much for, for sharing with us, uh, Hans.  

Dr Hans Kluge: It was my pleasure. Great pleasure. Great job. Thank you. 

Greg Bianchi: So, Melanie, I think that was, uh, a really interesting discussion. It was kind of also really interesting to hear a bit more from Hans on his, uh, motivation around the initiative, and that when he brings up this topic, which, uh, I know we sort of challenged him once, one of the questions, but it's interesting to hear that whenever he brings up the topic with, uh, member states, that they're very receptive to, to his messages on, on the special initiative. 

I think the thing that really stuck out to me from that, that whole interview was, uh, and I was quite struck by his answer on when he said he faced cases of, of gender-based violence as a young doctor. Um, and he simply didn't know how to respond, and I think he was quite upfront about that as well, beyond providing treatment for physical wounds and not, maybe not understanding the psychological impact, too. 

I don't know, I don't know f- what you thought about that as well.  

Melanie Hyde: Yeah, I think that's really common. I mean, when I've trained health workers across our region, I find the clinical stuff they get really quickly, of course, but it's the soft skills that are really the hardest because often this wasn't covered in their medical training. 

Um, like, how do you respond when you see those signs of violence in your patient, but the patient is not disclosing that violence was the cause? Which of course is really, really common. Um, and it's really an absolute joy to watch doctors then practice role plays, um, with these kinds of scenarios and then be like, "Wow, now I feel much better prepared to handle these situations. 

Like, I know what my role is, and I have a framework to respond that is evidence-based." So it's, um, no, it's, it's really interesting to hear that from him as well.  

Greg Bianchi: Yeah, being confronted with those scenes, it must be, it must be really, really hard to deal with, and especially, as you say, if you don't have that training as well. 

So it's, uh, yeah, I guess that's one of the things that the initiative's really looking towards. I think we'll cover some of this in, in a bit more in our next interview with, uh, Florence Bauer from UNFPA, uh, the regional director for Eastern Europe and Central Asia. So, um, yeah, looking forward to hearing more in the next episode. 

Melanie Hyde: Absolutely.