Misdirected Messaging in Sexual Violence against Children and Women

A couple of days ago, I read a newspaper headline and couldn't believe what a high ranking government official in one of cosmopolitan states in Africa was quoted to have said. The headline, Pupils urged to resist sexual abuse, once again portrays a basic lack of understanding of this subject by those whose responsibility is it to protect these children from predators. At the said workshop on violence and sexual abuse for secondary school pupils in Alausa, Ikeja, Lagos, Nigeria, a celebrity in attendance  "advised students to be careful of how they dress and the way they react to sex abuse". This is a myth that has been perpetrated by the society. A girl is not raped because of her dressing. She is raped because someone made a conscious decision to abuse his position or power and exert control over her. We are only feeding the beast, a subject of my earlier post, if we keep giving perpetrators excuse for the violation inflicted on the victims.

Meanwhile, we need to ask our government officials and agencies how exactly these pupils are supposed to resist sexual abuse. A director in the ministry of Justice, Clara Ibirogba, who spoke on behalf of the attorney general of the state provided the answer:..."pupils should avoid watching bad films, exposing private parts and reading pornographic materials."
Clearly this is a manifestation of lacking of understanding of basic issues in sexual violence and the need for proper education of policy makers and government agencies in the fight to curb this menace.
Reading through the news report shows the enormous responsibility placed on children in the fight against sexual violence and that invariably implies that they share a major blame for any failure in this regard.
This is bad messaging. It should not happen.
We need to start focusing on the perpetrators and direct attention to appropriate quarters.
Again, victims of sexual do not invite rape upon themselves. No, someone violated them and that person carries the entire responsibility. It is this kind of misdirected message that emboldens perpetrators and essentially puts their victims in the dock of public court. How could we ask children and victims of sexual violence to resist sexual abuse? Placing them on that danger line defeats the message. Society must go after predators and ensure our children are protected.

It is this attitude and poor treatment of victims that made the mother of a girl allegedly raped by a security man, again in Lagos, to cry out in a recent media headline: Police blame me for my daughter’s rape, protect rapist – Mother of eight-year-old girl raped by security man
The link provides a typical example of how deep in the hole we are about solving the problem of sexual violence especially against children and women especially in Africa. A major link in this fight, state agency like the police, is so weak in this regard that it has become part of the problem. The sad story of this woman is replicated all over.
Aggressive training programme for the police, setting up special police unit for sexual violence (often general duty police officers regard sexual violence as "domestic affair" despite the provision in the criminal code), and enlightenment for the general public on sexual violence have become an urgent need in our communities.
The agony of this hapless woman should not be the order as it is presently.

When it Feels Like Giving Up

Dear blog visitor and reader, I apologize for my long absence on blog posts. Too many factors came in the way. I had actually written some materials to post on my link but the sheer volume of occurrences of some of the issues in question and the apparent feeling of helplessness in addressing them was quite overwhelming. One of the issues is sexual violence especially childhood sexual assault. There was hardly a day that would go by (on monitoring media reports), that another gory story of a violation of a child would not turn up. After the usual apparent outrage by the public, the matter naturally dies off and nothing is done to tackle the issue.
The police appear ill equipped to handle these cases because of poor or lack of training in this aspect and lack of requisite equipment, and there are also obstacles occasioned by lack of protocol for collection of credible evidence and attendant technical blockades in the judiciary.
Generally, the issue of management of sexual violence is not a priority for a health sector grappling with budget issues while facing myriads of communicable and non communicable diseases prevalent in our communities.
This and other forensic issues remain an orphan in most of African countries. Everyone talks and pities the situation but there is very little investment in human and material resources, and practically no institutional changes are implemented in tackling the fundamental problems.
I've made presentations before stakeholders, government agencies and NGOs, and I've met with government officials whose offices I reckoned could drive a change. However, the status remains the same and there is a tendency of thinking it is a hopeless situation in our generation to take concrete action in protecting the vulnerable in our community. I've attended to cases of sexual violence in children which reached a dead end even before actual case management began because the kind of multidisciplinary and multi-agency team work required to make any meaningful impact is simply lacking.
So where do we go from here?

2014 ended on a most tragic note. The sudden death of my teacher, senior colleague, a mentor and friend shattered any fragile stability in place. Prof Effiong Essien Udo Akang, an eminent Pathologist and Neuropathologist, was the best friend a colleague could have. He was ever supportive and was a shoulder for younger colleagues to lean on especially when disillusionment beckoned. He was also my Head of Department. The sudden and unexpected nature of the incident made it even more painful. One can only hope for some recovery from this irreparable trauma occasioned by the sudden exist of someone I had interacted with on daily basis for as long as I could recall. He was my family; he was dependable and someone to confide in.

Prof Akang died on 31 December, 2014. He left a huge void that may never be filled and I will miss him every day of this life; every day I pass beside his office door almost knocking as usual to exchange ideas or pleasantries. Indeed it is hard to say Goodbye!

The Right to Die and Some Matters Arising

Brittany Maynard, 29, who was diagnosed with a stage 4 glioblastoma, a terminal and aggressive brain tumour, eventually ended her life Saturday, November 1, 2014, in Portland, Oregon, with a fatal dose of barbiturates which was prescribed by a physician.

In a video released a couple of days before her death, she indicated that her greatest fear was losing the capacity to make the choice to take her life. She was diagnosed with an aggressive brain tumour in January 2014 and was told in April 2014 that she would have six (6) months to live. However, at the end of October 2014, she was still alive and functioning. Eventually, she decided November 1, 2014, was the right date to end her life. 

The story brings up several issues which may deserve some closer look in examining the concept of the Right to Die:

1. What should be the role of physicians in this circumstance considering the Oath medical doctors swear to preserving life? 
2. When doctors tell some terminally ill patients that they have a certain period to live, what exactly do they mean by that considering that many patients have defied such “predictions”, sometimes living functional lives weeks, months and years past predicted time? Have we ever correctly predicted the biology of a particular tumour or course of disease in different people at different times and places or even the same disease in a particular person at different times and places? 
3. What is the role of social media in people’s decision to end their lives and when to end it? 
4.  Was Brittany under any form of pressure to end her life in line with the predicted time and expectations of the considerable following garnered on social media taking into account she was reconsidering the early November date she had set because she felt well? Could there have been some pressure to meet certain expectations? 
5. Is there some danger of bandwagon effect and other unintended consequences in streaming such delicate and irreversible decisions on social and conventional media as was the case in Brittany Maynard? 
6. Is the Right to Life the other side of the coin of the Right to Die? If not, why do we choose to treat these two realities of existence differently about our rights therein? 
7. Have we considered all those who are really hurt in such assisted suicide as was the case of Brittany and do such people deserve to be heard dispassionately?
8. Is it possible to step out of the usual sentiments and debate assisted suicide with mutual respect and consideration to all the different positions or views, especially with all the media frenzy that has accompanied the index case? 
9. How do we protect vulnerable people, elderly and disabled people who may suffer irreversible harm should assisted suicide be legalized considering the enormous pressure references like that of Brittany could bring about?
10. Could assisted suicide be used, albeit inadvertently, as a cost-cutting measure in a broken, expensive and ineffective healthcare system? 
11. What will be the death certificate of Brittany Maynard bear as the cause and manner of death?
12. What are other matters arising in your respective jurisdictions?

Meanwhile, my sympathies to the family and friends of Brittany at their loss, and also to all those who wished she had lived even a day longer. We should be encouraged to discuss the circumstances surrounding her death and take a hard look, devoid of sentiments as much as possible, in evaluating what this circumstance presents to the rest of the community in this push for the Right to Die. I invite as many people as are willing to contribute in addressing any of the eleven issues raised above (and more) as I’m personally eager to listen and learn from what others think should be our approach to this very delicate and somewhat controversial and divisive subject.

Eric Duncan is Dead: We Must Stop Ebola!

Initially, Ebola virus disease (EVD) appeared to be a problem of a few West African countries, but not anymore. EVD is now in America and in Europe and perhaps in other yet to be identified locations. Effectively, EVD is now a global disease. However, our response to Ebola has been more of fear filled approaches, mixed messages and poor coordination. Screaming headlines in the press do little to educate than plant more fear, often irrational fear, about the disease thus posing greater danger to efforts at curtailing and containing the disease. Misinformation about the EVD has led to attacks, with some fatal outcomes, on some health workers in West Africa, and even in the more enlightened Western countries, the hysteria (significantly fueled by media hype) that has greeted the initial cases of EVD has been largely borne out of insufficient information and communication about the nature of EVD. The whole world must face the collective challenge Ebola has posed to humanity at this time. This is not a time for apportioning blame. It is a time for doing the right thing right on time.  It is time for collaboration and sharing information about any experience gained in containing the disease in some countries. It is time to provide human and material resources to affected countries and join forces to take down Ebola.

Eric Duncan eventually succumbed to this virus in the US. It is quite of concern that while he was battling for his life, his own mother country was preparing to prosecute him for "exporting Ebola knowingly" and the affected State in the US was also considering the possibility of bringing charges against him despite denials from his family that he was not aware of coming into contact with any index EVD patient back in Liberia. He didn't stand a chance to survive if survival depended on goodwill of the authorities. And he didn't survive. We must stop Ebola on fairness and justice. We must stop Ebola on equal treatment and care. We must stop Ebola by valuing the life of every person irrespective of what their circumstance might be. We can stop another Eric Duncan from dying anywhere in the world. The world has always succeeded when we pull together in the face of challenges. Therefore, to successfully stop Ebola, lots of doses of goodwill, expertise, volunteers, money and other resources are required.

Defending Patients' Rights through Proper Documentation

Except in teaching hospitals (which have even seen a significant decline in the practice of this time-tested pillar of medical service), proper documentation is seriously lacking in our hospitals, especially the private ones. It is not unusual to see only a diagnosis written down for the complaint(s) of the patient.  During post-mortem investigations, I have had opportunities to review the medical records of patients who were treated in some private or general hospitals prior to their demise. In some cases, the whole record of some patients who had been seen repeatedly in some health facilities would not be more than a full page. This has made understanding the circumstances of a death or some medical incidents difficult or impossible.

In many parts of Africa, it is possible to exploit the ignorance of patients and the undue paternalistic tendencies in the medical profession to deny patients the right to have complete and appropriate documentation of their medical conditions. The ability to benchmark the care a patient has received from a health facility or hospital has been seriously compromised, and medical records are essentially devoid of any records that could shed light on the amount and quality of care given to a patient. Sometimes, it appears this is a deliberate attempt by practitioners who appear to be in a hurry to move on to the next patient (or "case," as frequently used), which may be akin to processing patients like a factory mass production. However, every patient is unique and brings a distinct dimension to their medical condition, though some features may be similar to that of another patient but not identical. There is, therefore, no excuse for “over-summarized” and "common" documentation as adequate documentation. A contemporaneous account of a patient’s presentation is the standard expected of a medical practitioner or any health professional providing care to patients.

The responsibility, therefore, falls on health professionals to document every aspect of care given to patients, every history that influences the thought processes in arriving at a diagnosis, every finding in the physical examination that directs investigation, and every investigation that confirms diagnosis or excludes some clinical impressions. Proper documentation is good practice, protects patients from medical mistakes, and also makes the transfer of patients to another health facility or caregiver easier for the purpose of continuity of care. It is part of the medical obligation to give a good account of the confidence a patient reposes in a medical practitioner by presenting at a hospital and submitting themselves for the understanding of their peculiar medical conditions.

The rights of patients, especially in the developing world where there is limited supervision by relevant authorities of the quality of care given to patients by medical practitioners, require protection by all concerned. “If it is not documented, it is not done”, should be an applicable dictum in medical practice. Auditing systems in any health care delivery should include the quality of documentation, which should show the thoughts, plans, and steps that give rise to diagnosis, investigation, treatment, and follow-up, where applicable. Autopsy, being an audit process at the back end of healthcare, has often revealed inadequacies in documentation and how it negatively impacts patient outcomes. To prevent such unpleasant consequences, there is a need to place more emphasis on the importance of proper documentation in protecting patients' right to appropriate medical care.

Dignity for the Dead: Lessons from Malaysian Plane Crash over Ukraine

The tragic fallout of the Malaysian flight originating from Amsterdam shocked the entire world. The very circumstance of the crash made the incident even more heart wrenching and an unbearable horror for affected families, friends and nations of the deceased. Almost 300 innocent souls literally dropped off the sky and plummeted to an unimaginable and painful tragedy in a situation devoid of any fighting chance for survival; devoid of any opportunity to send distress calls; and devoid of any preparedness. It was certainly one of the most unwarranted, preventable and painful disasters in recent times. 

The whole world of humanity (unfortunately, we must acknowledge there are relatively few people who believe and live in a world of brutality and savagely, who daily grab media headlines with atrocious acts for whatever reasons or cause) rose up in condemnation, not only of the horrific act itself but also of the treatment of the bodies of the deceased and other evidence at the crash scene. Dead bodies are simply not dead object; these are children, mothers, fathers, uncles, aunties, grandparents, friends, colleagues and nationalities. They do not simply turn to objects by cessation of life. The victims were people who just a while ago, hugged their families and bade farewell to their families, friends and associates. Death only took away their lives but not their personhood; not their dignity; and not their right. The intransigence of the pro-Russian rebels by limiting access to care for the bodies of the victims and secure other evidence was roundly condemned by the humane world. 

The contrast, which is a standard for treatment of the dead, could be seen in the manner in which the bodies of the dead were prepared and transported to Netherlands for forensic investigation. Each body was placed in a separate coffin and carried into transport aircraft with solemn air and decorum. On arrival at destination, there was a formal procession to welcome the dead bodies. They were treated with the dignity they deserved even in death. Each coffin was carried by a separate hearse and accorded utmost respect. It would have been “convenient” and “cheaper” for just one cargo plane to have carried all the bodies/bodies parts bundled together, but a decent world would not do that. Two or more bodies could have fitted into a coffin; after all they were just being transported to a facility for further investigation. And that would have been very 
inappropriate. The way any society treats the dead is a reflection of level of civilization of such society.  

Africa has a lot to learn from the crash over Ukraine. Most governments in Africa do not reckon with expending resources to manage the dead. Once a disaster occurs and after some feeble rescue and recovery operations, the next move is usually to quickly dispense with the dead to “avoid epidemic”. Such unfounded assertion and unchallenged myth has been promoted even by government officials.  Any attempt to advocate for proper management of the bodies of the dead and disaster victim identification (DVI) is usually met with the cold attitude of the dead not being in any priority for “scarce resources”. The next action is usually mass a burial of largely unidentified and unclaimed bodies, and the penchant to “move on”. To nowhere! Families, friends and communities are left permanently in a pit of devastation without any opportunity to achieve closure. The resultant deep resentment, suppressed anger and lack of closure fuel a vicious cycle of violence in Africa with attendant destruction of more lives and property. It therefore makes no socioeconomic sense to “save cost”, ignore the dead and “move on”.  Society never recovers in the true sense from such disasters and it is almost impossible to make any human progress where people are still stuck in a pit of despondency and unresolved cases.  

The lack of disaster preparedness especially with management of dead bodies in mass disasters is lacking in most of Africa. The use of refrigerated train coaches by the government of Ukraine to store and transport the dead underscored the essence of innovation, creativity and flexibility in disasters.  

And the dead never die as the pain, loss and reality of the sad incident still reverberates through affected families, friends, communities and nations. Only a process of closure which includes proper treatment of dead bodies with respect and dignity, appropriate investigation and justice for the dead and their families and loved ones, is a definitive step in soothing the pain of the affected community. Indeed, the dead cannot be forgotten because their families, friends and loved ones bear the scars in their heart. Dignity for the dead is at the heart of our individual personhood. Anyone could be a victim of disaster at anytime. Management of bodies of victims following disasters is therefore as important to the dead and their families and friends as rescue operation is to the living. This subject was the theme of the 2014 pan-African conference of the African Society of Forensic Medicine (ASFM) in Abuja Nigeria. It is a message that government and agencies in Africa desperately need to embrace especially through difficult times on the continent where a trail of bloody conflicts and man-made disasters leave numerous dead victims.

Terrorism in Nigeria: Victims Support Fund

It is a good development that the government of Nigeria has established a Victims Support Fund for victims of ongoing terrorism and other conflicts in the country. Terrorism is not a familiar terrain in Nigeria and members of the Victims Support Fund Committee will need to work with a technical committee that will ensure that the Victims Support programme achieves the intended purpose. The need for accountability and objectivity in the disbursement of the funds and other support facilities for the victims should be a core aspect of this intervention if the objectives are to be realized. I'll needs to focus on forensic medical management of victims and their families and reiterate that trampling upon  fundamental human rights are at the core of the tragic incidents going on in parts of Nigeria. The victims of the terrorism and other conflicts in Nigeria are not only those who are alive, the survivors, but also the dead and their families.

The Victims Support Fund should therefore articulate a broader approach in ensuring that funds are also made available for appropriate disaster victim identification (DVI). The current disaster management in the country especially with regards to terrorism and armed conflicts apparently excludes DVI. Mass burials, chaotic and indiscriminate claim of bodies by families and relations have further complicated the picture. The  prevailing sociocultural mindset, often laced with religious interpretations negate the principles and essence of disaster victim identification,  and government officials often do not see reasons why resources should be deployed in death investigation and DVI "after all the dead is dead and nothing can bring them back to life" being the usual justification for this sorry state. However, this unfortunate disposition has failed to appreciate that treating the dead in that manner means how much we devalue life itself, and counters the right of victims to dignity and justice. The Victims Support Fund should cater for the dead in facilitating DVI, proper storage, handover of bodies to families and relations and decent burial. Families, relations and dependents of dead victims should also receive adequate financial support. Living victims in addition to adequate medical intervention to restore their health following injuries sustained, also deserve appropriate forensic medical management for injury interpretation, psychosocial care and compensation for trauma, disabilities and lost property. It is therefore imperative that a technical committee comprising of relevant expertise be put in place for expert and objective assessment. Transparency, accountability and probity must be the key words.