INTERNATIONAL CONFERENCE ON PREVENTING VIOLENCE
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RF_MP_11_SUDHA
I
Counselling for Health:
CHETNA ’s Experiences
Jyoti Gade, Vd. Laxmi Bhatt and CHETNA team
Paper presented in International Conference on preventing violence, caring for
survivors. Role of health profession and services in violence held between 28-30,
1998, organised by CEHAT (Research Centre of Anusandhan Trust), Mumbai,
India.
About CHETNA:
CHETNA, which means ‘awareness’ in several Indian languages, is an acronym
for Centre for Health Education, Training and Nutrition Awareness. Its mission is
to contribute towards the empowerment of disadvantaged women and children so
that they become capable of gaining control over their own, their families and
communities health. CHETNA’s activities started in 1980 to improve the impact of
supplementary feeding programmes for women and children, in Gujarat, India. In
1995, CHETNA initiated the Lilavatiben Holistic Health Centre to support
disadvantaged and marginalised women and children from urban slums, in their
efforts to improve their lives through provision of comprehensive primary health
care services, health education, advocacy and guidance, through a holistic woman
centred approach.
The goal of the centre is to assist the women in realising their full potential
enabling them to take control of their own lives and to provide opportunities a
chance for slum children to grow and learn to live healthy lives.
The specific objectives of holistic health centre are to provide health education to
increase awareness, to support adoption of healthy behaviours, to provide an
opportunity to dialogue with men provide models of communication among boys
and girls/women where mutual respect and responsibility co-exist and to provide
basic health care services.
Activities of the centre range from individual counselling to children (
adolescents), women, men and couples to-gether, health education programme are
related to making Children in charge, for adolescent health, women’s health at
community and follow-up of these activities.
Community: Based on late Lilavati Lalbhai’s dream, Lilavati Lalbhai Holistic
Health Centre was started in her residence which is a beautiful heritage banglow
surrounded by medicinal plants and flowers. Nearby this bungalow five urban
slums are located in 1 to 1.5 km radius. The population varies between 2800 to
4000, for 300-500 households. However there is one exception Tol- Naka which
has a population of 140-180 residents and 20 households. Micro survey of the area
revealed that people live in houses without facility of water, toilets or electricity.
Most residents are self-employed as casual labourers and vendors. Due to the large
number of layoffs from the textile mills, women are single-handed supporting their
families by doing work outside the home along with household responsibilities.
2
Counselling for Health: CHETNA’s Experiences
Ms. Jyoti Gade, Vd. Laxmi Bhatt & CHETNA Team.
Somuben lives in the slum community in Shahibag area ofAhmedabad Camp-Godown. Her husband earns Rs.50
as a daily labourer. She has hi o children, one son 5 years old and a daughter who is of age 3. Somuben became
pregnant for the third time, She did not want another child due to her economic conditions. However her husband
who was a drunkard and who beat up his wife regularly was very keen to have a third child. Since CHETNA was
working in this slum, she came in contact with the Lilavati Lalbhai Holistic Health Center and consequently
approached CHETNA team members for advice. She was advised that since she herself did not want the child, she
had a right to abort the foetus. Her selfconfidence received a boost and with support from our team. Rather to this
advice she was referred to the civil hospital for safe abortion and insertion of copper-T. Her husband was not
happy about the abortion and he was even more angry when he came to knov' that his wife had inserted a copper-T.
He heat her up severely. Again she came to the centrefor advice. She was adviced to contact Ahmedabad Women’s
Action Group9 (A WAG) an organisation who legally helps women in distress. It was also suggested to her that for
some time she can go and stay with her parents, so that her husband realizes her importance and that she is not
absolutely under his control and empowered to take a decision on her own. She refused to go to any other
organisation for le^al help, because she did not want to expose her family problems to share people and especially
in the court. Thus she decided to go to her parents home to stay there for afew days.
Meanwhile CHETNA team members started a dialogue with her husband and initiated a process to know the
reasons for heating his wife. He frankly accepted that whatever he was doing is wrong but since he is a habitual
drunkard, he was unable to keep his mental balance, insisted on more frequent sexual intercourse with his wife and
on being refused, beat up his wife severely. He also agreed that he would stop beating his wife.
Meantime his brother died. So Somuben was called back. Her husband promised in not to beat his wife again
however he did not keep his word. CHETNA team members regularly met and counseled him not to beat wife and to
stop his drinking. This process ofcontinuous interaction and counseling had some positive impact on him.
After some days, she came in the centre with her husband requesting the removal of the copper-T. According to
her, relation with her husband had improved so now he wanted a third child though Somu was not keen to have the
third child. She agreedfor her husband's sake due to the change in his behaviour. Our team members talked to her
husband regarding the importance offamily planning. Her husband was convinced not to have a third child and
also agreed not to beat his wife. He was also ready to reduce alcoholism. As per his conviction he reduced his
drinking and they stayed happily for about three months. This process of counseling was continued for about a
year. Meanwhile they shifted a house and went to stay away from the center. Therefore the interaction and regular
visits to the centre gradually manifested a decreasing trend.
Hben we started to work in a new area, this family was a part of this area. When we tried visiting their house they
were not at home. We came to know from her relatives and neighbours that Somuben wanted to stop the drinking
habit of her husband entirely. For this he was not agreeable and again they quarreled and the wife beating started
again. Ultimately she called her parents and went to police department to lodge a FIR. Police askedfor a certificate
from civil hospital to show the evidence of beating and treatment for the same. So they came back from police
station without recording the FIR. Meanwhile her in-laws family suggested to her parents that if they go to police
department it will be a lengthy, complicated & tardy process. Her parents agreed. Though they did not urge FIR
her parent ’s family hired some people to beat him up. Presently, Somuben has gone to her parent's house. We came
to know that wife has lodged a FIR with the Mahila Police. Mahila Police has succeeded in making a compromise
among both of them and within a few days Somu will come to stay with her husband. But how long the present
situation will continue is uncertain.
_____________________
3
I
The second case study is of Madhu who was married 2<2 years hack and whose husband is also a habitual
drunkard who beat his wife regularly and mentally tortured her. Her husband also kept another woman at home
and for obvious, reasons he was not giving money to his wife and children. His elder son who is 19 years old,
worked as a daily labourer was also a drunkard also had acrimonious relations with his mother. Once she
attended a meeting organised by CHETNA in co-llaboration with the Government orgnisation for prohibition of
drug addiction. After this meeting she came to know that her husband can also stop his alcohol habit and if adxice
is provided to such people with patience and love, a medicine may be useful to reduce/stop his habit of alcoholism.
She also realized the harmful effects of drinking on health. She suggested that the CHETNA team talk to her
while
realising.
husband
That he may not leave the other woman but insisted on the reduction of his drinking.
Therefore the CHETNA Team talked to him. Even during the first visit he was very co-operative. After some days
because of regular interpersonal dialogue and counseling he agreed to lea\>e his habit. He also wanted to visit the
drug prevention hospital and get a health check up done. After check up it was evident that he was suffering from
liver problem due to this alcohol addiction. He was admitted in the civil hospital for about a month. Upon his
discharge, he was advised not to drink but he soon resumed the habit. But it was very difficult for him to leave this
habit was for more than 25 years and because more se\fere since the last 10 years. Since he himself is very
conscious that he should leave this habit. The doctor told him that he will give him medicine some which will help
him to reduce his drinking habit. Now he is ready to go to this hospital and he also realized that ifhis alcoholism is
reduced, ultimately wife beating will also stop.
Due to his drinking habit he did not give money to his wife and family members and demanded sex according to
his wish leading to quarrel and wife beating. His wife is well aware that he can not end his relationship with his
mistress therefore she wished that at-least his alcoholism should be stopped and he should stop quarreling and
beating her.
Husband is ready' to stop his practice however he is so heavily addicted and that also for a very long time, that it is
really difficultfor him to give it up altogether, even ifhe is so decided.
Both these case studies are from the Dalit community. However, though violence
is manifested both among the Vaghri and the Dalit communities, it is evident more
among the Dalit, as probably the Vaghri women are more empowered to deal with
the problems of wife beating and domestic acrimony.
4
Impact on Health and Family life due to such violence:
•
•
•
•
•
•
•
•
Physical and mental (emotional) health of women and children gets affected to a great
extent.
Mental health: Guilt and insulting feeling leads to depression- (feel like crying, tension,
anger, do not feel like talking & eating, can not sleep well & does not take interest in ife),
sexual dysfunction, fear, can not concentrate in any work and do not take interest in life, self
injurious behaviour.
Physical health: Lose of appetite and weight, gynecological problem such as disturbance in
menstrual cycle, leading some times to irregular menstrual cycles and heavy bleeding.
Mobility: She can not go out of house because deep sense of guilt and insult.
Low self esteem: Since her husband does not respect her, other family members also neglect
her and are not at all co-operative especially the in-laws.
Impact on boys: Male children starts drinking from a very young age and they are
encourage to behave in similar way as their fathers with there own wife and even with their
mothers.
Impact on girls: Girl children feel bad and they are emotionally hurt due the beating of their
mother. If in case they try to stop their father, girls are also beaten up.
Vicious circle: Due to alcoholism half of the money earned goes in this habit and one third
goes to maintain the mistress. Therefore due to economic constraints, not enough food to eat
leading to bitter fights and wife battering and the vicious circle continues.
Due to mental and physical health symptoms and problems leading to inter related conditions of
improper overall health & development of women and family members, ultimately the
community.
Uderstanding Violence Against Women And Health:
While taking a public health approach to address the question of violence the mental, emotional
and health development problems should be taken in account. The working definition of violence
defines it as “intentional use of physical force of power, threatened or actual, against oneself,
another person or against a group or community, that eithers. Violence against women has been
defined as, “any act of gender based violence that results in or is likely to result in, physical,
sexual or psychological harm or suffering to women, including threats of such acts, coercion or
arbitrary deprivation of liberty, whether occuring in public or private life.” (as in the Declaration
on the Elimination of violence Against Women-1993 by the UN General Assembly).
CHETNA understands: “Health is a personal and social state of balance and well-being in
which a woman feels strong, active creative, wise and worthwhile, where her body's vital power
offunctioning and healing is intact, where her diverse capacities and rhythms are valued, where
she may decide and choose express herself and move aboutfreely. ”
It is being realized that health cannot be viewed only in terms of an individual but also in the
context of the social, cultural, political and economic reality which is based on the power
relations between men and women those are unequal due to patriarchal society. Violence against
women within the family runs along this line of power.
5
Services provided by Holistic Health Care Centre:
Institute based primary health care services: When this service was initiated it was realized
that most women who came to the centre are emotionally disturbed due to violence by husband
or in-laws in the family. This emotional disturbance is responsible for their physical and mental
ill health. Therefore to deal with emotional disturbance is a key factor to improve women’s
health. When a close rapport was established with them, whenever women are victims of such
violence they come to the centre to talk about their inner feelings and sometimes even just to cry
and to get sympathy from Vd. Laxmi and Ms Bhanu (field worker) or whenever they go the
slum victims, women call them at their home to talk of their feelings and lighten their minds.
It was also experienced that they are not ready to go to the Government hospital due to the fear
of police case. CHETNA also felt that there is no need to go at the initial stage to the police,
rather through counseling, understanding, trust, respect and love bond among couples should
be enhanced. We have seen positive responses due to this approach. In cases of extreme
violence, since we do not provide legal help, we enable linkages with other organization which
works on legal aspect for violence against women to ensure that proper legal help is provided
to these needy women.
Counseling: Women who are victims of domestic violence, efforts to stop such violence, to
prevent violence and ultimately to empower women to tackle domestic violence. Counseling
brings changes in mind-set, behaviour, attitude, practices which provokes to take the appropriate
decisions. It was also realized that counseling with significant people in her lives who are
responsible for violence as well as who can support her to avoid violence such as husband,
mother-in-law, neighbour, relatives is essential because approach is to work with change that can
enhance all members in relationship.
Support system: Whenever they need to go to the hospital, drug prevention centre or NGOs
and GOs for legal advice, economic empowerment activites, CHETNA provides complete
support through its linkages.
Strategy & process of Counseling :
It is experienced that counseling is a crucial aspect in violence. A health worker plays an
important role of counselor, guide and educator. It is realized that moral/emotional support is
needed from the health functionaries to overcome their fears, inhibitions and take appropriate
decisions.
Wife/ Women: Interpersonal relations and rapport were built with woman and her family. We
discuss lot with them, which helps women to think critically about their interpersonal relations,
need of communication with husband, cultural and social belief system upholds about their roles
and responsibilities at family. Counseling process helps them to enhance their self-confidence,
self image and esteem and aware about women’s rights.
6
Husbands/men: Interpersonal communication developed with husbands. They talk respectfully
with CHETNA team and also agrees that what they are doing are wrong. However to put the
advice into practice is a difficult task for them.
Neighboring women: It was discussed with them, they should interfere during wife beating,
since this is not a family problem but the issue of women’s rights and health. However some
time they do not get the support from the battered wife herself. (In some cases, the wife
considers this to be a totally private family matter).
Wife/Husband together: After establishing rapport with husband and wife separately, together
they are ready to listen. Also discussed the violence due to unequal power relations among both
of them So the efforts are made to improve their relationship towards equality through
enhancing dialogue among them.
Mother-in law: In some families she is the decision-maker. Therefore she is also taken into
confidence and she is explained, diet during pregnancy and other ways health care. But some
mother- in- laws are not co-operative.
Community Meeting: Twice in a week the community meetings are held for women. In this
meeting gender equality, women’s rights and health aspect including preventive and promotive
issues are discussed frequently and repeatedly.
CHETNA’s approach to Counseling?
• CHETNA team is an active member of this community. The women do not consider us as
outsider. Such a rapport has been built up with the community.
• We eat and sit with them as their family members.
• Listen to them as much as they speak and their concerns.
• Work towards an integrated approach including provision of primary health care, prevention
and promotive aspects. Also try to understand the problems as complex and related to wider
structural norms, values, practices and beliefs.
• Try to make the linkages to improve economic and living conditions and status of women.
• Patiently explain to the women and wait for the changes to the manifested.
• Do not fight with men nor do we say they that they are their enemy or bad but try to take
them into confidence and develop trust with them. Therefore men have started respecting us
and also reveal their inner feelings. They are ready to accept the messages given by our team
members.
• Try to understand both sides. Rather than favouring only one side.
• Process of emotional involvement interspersed sometimes with hard words and compul sions.
• Regular visits and interpersonal communication helped to enhance the process of couns eling.
7
Principles learnt from counseling process:
•
Role of health worker as a counselor: Should keep confidentiality, patience, should provide
encouragement, accurate information, faith and trust, sensitivity, judgmental, seriousness,
effective communication, regular and continues dialogue. Friendly behaviour, there should
be no imposition (direct decisions) but suggestions (alternatives).
Involvement of men: Since most men are the head of the family and unequal power
relations among husband and wife are responsible for violence, therefore men should be
involved in the counseling process from the beginning itself.
•
Environment and privacy: Should be such where women and men and couples can speak
frankly and with their inner feelings.
•
Adequate time: Should be provided to listen and talk to husband and wife to-gether and
separately.
•
Follow-up: Regular and continuous follow-up with women, men and community for the
expected results.
Constraints:
•
Timings: During daytime, community men are not available in home. So especially to meet
them we have started going on Sundays or at a time when they are available. To work at a
convenient time with the community, sometimes disturbs the health worker family life. In the
process the health worker tends to get mentally exhausted and emotionally disturbed.
•
LLHHC provides health care for women and children: Some men are not ready to come
to the Holistic Health Centre, because of shyness and feeling of guilt. Other reasons may be
because the center presenting provides primary health care services only to women and
children.
•
Behaviour changes needs time: Sometimes while they are very different in front of us and
seem that they are convinced that their wife should not be beaten. However to put this in to
practice is a constraint for them many a times due to deep rooted patriarchal ideology.
Lack of legal information: At present health workers are not equipped with appropriate
legal information and procedures .
•
8
Learning:
•
•
•
•
•
•
•
•
•
•
One needs patience and time for counseling.
Success depends on the skill of the counselor to convince men/women and couples to-gether.
In respect of women most of her emotional health issues are related to violence therefore to
treat violence is an important step to empower her to improve overall health status of the
women and her family.
When the confidence of the woman is enhanced and she is empowered to talk with her
husband they can counsel to their husbands regarding alcoholism and it was observed that
when women are empowered, the incidences of violence decreases.
To prevent violence, economic empowerment of women plays an important role.
To provide support services in severe violence cases is an important aspect.
Even though few men are gender sensitized they are very helpful to convince & counsel
other men. Such men also bring their own wives during the health education session and to
treat their health problems.
To fulfill economic aspects and other basic facilities, linkages with other NGO and GO are
very much needed.
In the beginning building the rapport and trust with wife and husband takes a lot of time and
sometimes the counselor may not be successful initially and has to keep trying repeatedly.
Some families are not co-operative especially in the beginning but when they see the positive
responses and results in the other family, then they are also ready to- co-operate.
Future strategy to strengthen the program:
From our rich experiences & learnings during these three years, in future we would like to
strengthen the program in a following way:
Men’s involvement and participation: Since most of the violence cases are due to
husband/men, their active involvement in curative care and counseling is absolutely essential.
Also men are decision-makers in the context of sexuality and health care services. Therefore
their participation will play an important role to stop violence and we plan more intensive
dialogues with them in a balanced perspective.
Awareness Program for Adolescent Boys and Giris: Adolescent is the key group of future
society builder, therefore work has been started with both boys and girls who will be future
partners in family life. Education is provided to raise their consciousness on health, sex
education and gender equality, and empowerment. Their understanding on these issues may play
an important role to prevent violence at family level as well as in the public places.
Overall Empowerment of Women including Economic Empowerment: For the sustainability
of this programme, active women and men who have leadership qualities and are accepted by the
community will be chosen Peer Educators and Community Volunteers, who will be then trained
by the CHETNA team and through their help, we can explore other new areas and extend our
activities in these new areas.
9
<
,1
CMET»
Centre for Health Education, Training and Nutrition Awareness
Lil^vatiben Lalbhai’s Bungalow, Civil Camp Road, Shahibaug, Ahmedabad-380 004, Gujarat,
India. Phone : 2868856, 2866695, 2865636 Fax :91-79-2866513 and 91-79-6420242
Gram ; CHETNESS
Email : Indu.CapoorfG?Lwahm.Net (OR) chotnaadinot.ornol.in
f1 -
Outline of paper to be delivered at CEHAT meeting
I
Rehabilitation of survivors of violence from politics to practice
Dr V Nathanson
In all countries where centres are being established, or are already in place, to help torture survivors,
and survivors of domestic and other violence, a key issue is navigating the hostile political and social
environment, to ensure the safe establishment and survival of the help centre.
Repression by states may be directed at political and social leaders, heads of lobbying and other
bodies. Where these were predominantly male die pattern of violence reflected the societal position.
But die involvement by women in politics has increasingly led to dieir involvement as victims. This
type of violence is likely to also encompass torture and other systematic abuses within prisons or other
institutions.
•J
Societal violence patterns vary from country to country. But in most it is true that men, especially
young men, have the highest risk of injury or death from casual violence. This pattern is associated
with cultural factors: western patterns of social behaviour accompanied by drug or alcohol ingestion,
associates violence witii the influence of diese drugs. There is also often a linkage to criminal activity,
albeit often of a relatively minor nature. Women are more often victims of random acts of violence;
because they are in the wrong place at the wrong time, rather then putting themselves knowingly at
risk.
Domestic violence is portrayed in the developed world as a predominandy male on female issue; diat
is males are aggressors, women victims. The reality is that this is the commonest presenting pattern,
but tiiat women can also be violent in domestic and otiier settings. The apparent underemphasis [on
men as victims is now leading to a backlash which is undermining the “Women’s Aid ” movement.
Interestingly although there is little good evidence about the frequency of female:male violence,
there is no doubt that courts treat it differently. If an abused woman kills her male partner/abuser
the courts usually treat her leniently, the inverse is not the case. This further fuels the “male as
victim” argument. Further the concept that women may be victims of domestic violence and
eventually react with overwhelming violence against their abuser has now been used so extensively
in court cases that it is treated with considerable scepticism, in both the UK and the USA.
Finally die level of violence around warfare and civil unrest is considerable and no longer only affects
soldiers or those who are in the front line. Wars, and civil unrest, are all fought within the normal
living and working areas of populations. Civilians become indistinguishable from combatants.
Women and children can become accidental and incidental victims. There is also the far more
sinister fact that increasingly armies are less likely to fight according to the Geneva conventions, and
use sexual violence as a tool or weapon of war. This almost always lead to women being
disproportionately victimised.
At the same time societies face increasing pressures to deal witii the complexities of everyday life add
to survive in a hostile economic climate. The “Reaganomics” factors still hold sway with little value
given to helping Others, or to caring for those less fortunate than oneself. Thus die will to care for
victims is low, as the cost rises. Politically it is rarely if ever seen as a vote winner, reducing still further
the likelihood of financial or state support.
All these factors interact to make the positioning of support centres complex and sensitive; unless
done based upon an understanding of these factors funding and other resources will be increasingly
hard to secure.
British Medical Association - CEHAT Conference - Bombay 1998
FORGING THE LINK BETWEEN
HEALTH AND HUMAN RIGHTS
UNIVERSAL DECLARATION
HUMAN
0 F
ifty years ago the
These goals represent an ideal
United Nations Gen
that cannot be achieved
eral Assembly adopted
unless the fundamental rights
the Universal Decla
set forth in the UDHR are
ration of Human
recognized, respected, pro
Rights (UDHR) to
tected, and fulfilled.
guarantee all human beings
The celebration of the 50th
security, dignity, and well
Anniversary of the UDHK,
being in every country of the
throughout 1998 and culmi
world. Drafted as a response to
nating on Human Rights Day,
the horrors of World War II,
December 10,1998, is an
the UDHR set the founda
occasion for institutions con
tion for dozens of interna
cerned with the teaching and
tional treaties and laws that
training of health professionals
protect the rights to life and
to explore and embrace the
the integrity of the person, to
critical link between human
health, food, shelter, clothing,
rights and health.
and education, to freedom of
There are many connec
expression, to participation in
tions between health and
cociety, and to the benefits of
human rights. These are some
Jence, to equality in mar
examples:
riage, to move freely within
DISCRIMINATION
one’s country and across bor
ders, to seek a safe haven from
persecution, and more.
The United Nations
rightly intended that the
UDHR be taught at every
institution of learning and at
every level of education
throughout the world.
Discrimination against ethnic, reli
gious and racial minorities, as well
as on account of gender, political
opinion or immigration status,
compromises or threatens the
health and well-being and, all too
often, the very lives of millions.
Discriminatory practices threaten
physical and mental health and
great stake in the UDHR
because human rights and
health concerns share the
common goals of alleviating
conditions for health and
well-being of all people.
I 948 - I 998
deny people access to care alto
gether, deny people appropriate
therapies, or relegate them to infe
rior care. In extreme forms of dis
crimination, as exemplified by
Apartheid, ethnic cleansing and
genocide, the devaluation of
human beings as “other” has had
devastating consequences.
I
CDNSUniUMFDR
HEALTH &
HEALTH POLICIES
THAT VIOLATE RIGHTS
Violations of human rights exist
in the design and implementation
of health policies. For example,
population policies which fail to
respect the conditions necessary
for individual decision-making are
less effective. In the past few
decades, governments and interna
tional agencies have increasingly
recognized that women must be
able to make and effectuate free
and informed choices about
reproduction.Yet these choices are
routinely infringed in the design
and implementation of health
policies, including clinical deci
sions. The promotion and protec
tion of such human rights as
education, information, privacy,
and equal rights in marriage and
divorce are necessary if population
policies are to be successful.
TORTURE
Health professionals have a
suffering and promoting the
RIGHTS
Torture remains epidemic in dozens
of countries around the world. It
brings both acute trauma and longlasting physical or psychological
suffering to victims, their loved
ones, and society at large. Physicians
themselves become complicit in
torture when they certify individuals
ns
Sr
as able to withstand torture or fal
sify or fail to report evidence of
torture in detention facilities. Physi
cians, psychologists, and forensic
pathologists have been at the fore
front of efforts to document and
expose the practice of torture in
dozens of countries. Treatment and
prevention programs are emerging
on every continent in response to
tliis epidemic.
A .
“The destiny
of human rights
is in the hands
of all our citizens
in all our
communities. ”
- ELEANOR ROOSEVELT
COMPROMISE OF MEDICAL
INDEPENDENCE
People seeking health care are
often denied the independent
judgement of health professionals
when the state imposes demands
that the professional show greater
allegiance to state ends than to the
needs of the patient. Prisoners,
detainees, undocumented immi
grants, military personnel and
others are especially vulnerable to
the effects of these conflicts of
interest.
LACK OF ACCESS TO
HEALTH CARE
Throughout the world, in countries
rich and poor, people have no
access to basic physical and mental
health care and to immunizations
from infectious disease. Some peo
ple have no access because they
lack the resources to buy it and the
state does not provide it, others
because there are no services avail
able in their communi ties,and oth
ers because of discrimination or
social stigma, such as their status as
prisoners, detainees, refugees, inuni
grants, or members of a lower class
or caste.Victims of displacement,
torture, and war, as a result, receive
insufficient help in coping with the
physical and psychological impact
of these traumas.
LACK OF BASIC SUSTENANCE
One fifth of the world’s popula
tion live in abject poverty.They
lack adequate food, clothing,
housing, and social services, and
the opportunity to work. Exten
sive evidence, moreover, demon
strates that, in addition to absolute
poverty, relative poverty within
nations is associated with both
diminished access to health care
and to diminished health status.
INHUMANE LABOR PRACTICES
Inhumane labor practices the world
over significandy compromise the
health of millions. Women, men,
and children toil under brutalizing,
unsanitary and hazardous condi
tions for long hours or work with
out wages sufficient to support
dieir families’ basic needs.
OPPRESSION OF WOMEN
In many countries, women are still
denied full participation in society
and the protection of basic rights.
Women work more than twothirds of the world s working
hours, yet they earn less than ten
percent of the world s income and
own less than one percent of the
world’s property. Also, practices
harmful to their health, such as
genital cutting, are carried out in
some cases to further social poli
cies or cultural traditions.The
effects of discrimination on the
health of women is devastating.
VIOLENT CONFLICT
AFFECTING CIVILIAN
POPULATIONS
Throughout the world, people are
exposed to violent conflicts over
which they have no control. Con
sequently, in dozens of ongoing
civil and international conflicts,
people are suffering the health
effects of armed conflict and the
wta
> sJ
systematic disregard for human
rights. Since the fall of the Berlin
Wall, violent conflict has claimed
the lives of some four million
people. In early 1997 alone, over
35 million people were refugees
or internally displaced as a result
of violent conflict and forced to
live in conditions contributing to
spread of disease,malnutrition, and
early death. Moreover, these con
flicts are often characterized by
rampant and gross disrespect for
the principle of medical neutrality,
which guarantees the provision of
health care without discrimination
to all injured and sick combatants
and civilians during periods of
conflict.
•
<<
INDISCRIMINATE HARM
FROM WEAPONS
Every human being's right to life
is threatened by the existence and
active deployment of the most
destructive weapons ever devised nuclear, biological and chemical
weapons. The lives and health of
millions of people are jeopardized
daily by landmines, which kill and
maim indiscriminately, and con
tinue to do so for decades after
the cessation of a conflict. The
work of health professionals trying
to obliterate these weapons has
earned recognition with the
awarding of two Nobel Peace
Prizes—one in 1985 to the Inter
national Physicians for the Pre
vention of Nuclear War and the
other, in 1997 to the International
Campaign to Ban Landmines—
a campaign co-founded by
Physicians for Human Rights.
DENIAL OF DIGNITY
Respect for human dignity is an
essential element of health and
well-being of all people. In clinical
settings, failure to respect dignity
has stigmatized people with condi
tions such as HIV/AIDS and men
tal or physical disabilities and
resulted in denial of access to
appropriate treatment and/or being
subjected to inappropriate clinical
interventions or unwarranted long
term institutionalization.
Unethical
research
PRACTICES
which poor or minority people or
others susceptible to discrimina
tion live, often termed "environ
mental injustice," is an egregious
form of denial of human rights.
DENIAL OF FREEDOM OF
EXPRESSION
Promoting and protecting human
rights is fundamental to promoting
and protecting health. Too many
nations suppress the independence
of the health professions and the
uncensored voices of medical and
public health officials, compromis
ing the ability to contain the
Conventional practices in biomed
ical and behavioral research all too
often violate human rights. Con
temporary medical research studies
often lack adequate informed con
sent procedures and have dispro
portionate risks in relationship to
benefits. Some members of the
medical research community con
tinue to use disenfranchised and
vulnerable populations for human
experimentation at great detriment
to their physical and mental health.
FORGE THE LINK WITH US
■B
s this anniversary year
begins, we invite all
schools of medicine,
public health, nursing,
and allied health pro
fl fessions to join with
fl
us to increase awareness of the
inextricable connection between
health and human rights. During
the past decade, this awareness
has led to new education and
training about human rights for
health professionals. Schools of
medicine, public health, and
nursing have inaugurated full
courses, seminars, short-courses,
and sponsored conferences to
advance understanding and
familiarity about health and
human rights.
Activities for the 50th
Anniversary of the Universal
Declaration of Human Rights
can include the following:
J
LACK OF EDUCATION
Although education is one of the
congest predictors of health sta
tus and an intrinsic quality of
well-being, more than 900 million
adults are illiterate, two-thirds of
whom are women, and more than
300 million children are not in
primary or secondary' school.
Health professionals should pro
mote adequate standards of educa
tion, which include human rights
concerns, because these standards
promote health and dignity of all
members of the human family.
EXPOSURE TO DANGEROUS
ENVIRONMENT
Prevention of environmental haz
ards, and mitigation of these haz
ards where they exist, are critical
factors in the promotion of health
and the prevention of illness.
Selective pollution of areas in
spread of disease, sustain vaccina
tion and immunization programs,
address humanitarian emergencies,
raise alarms about environmental
threats to health, and put into
place effective health policies and
programs that reach all members
of affected populations.
O
• Distribution of copies of the
Universal Declaration of
Human Rights (see enclosed
sample) to all students;
• Support for the development
and work of health and human
rights student groups;
• Initiation of a health and
human rights course;
• Sponsorship of a series of sem
inars linking human rights to
health issues;
• Linkage to other efforts at
your university, in your com
munity, and around the world
marking the 50th anniversary;
• Declaration of a designated day
or month at your university or
in your community to cele
brate the connection between
human rights and health;
• A commemorative event on
Human Rights Day, December
10, 1998, the 50th anniversary
date; and
• A commitment to undertake
an activity in support of
human rights.
Resources, including
publications, syllabi, speakers,
and actions are available
through our respective orga
nizations. Please see contact
information on back page.
Health tuorkers have a key role to
play in affirming the universality of
human rights and in promoting
respect for them. By affirming and
supporting human rights, practition
ers in allfields of health enhance the
ethics of their profession and advance
their commitment to health.
r
coiwniM
HEALTH &
meins
FRANCOIS-XAVIER BAGNOUD
CENTER FOR HEALTH AND
HUMAN RIGHTS
HARVARD SCHOOL OF PUBLIC HEALTH
651 HUNTINGTON AVENUE. 7TH FLOOR
BOSTON. MA 02115
TEL (617) 432-0656
FAX: (617) 432-4310
EMAIL: fxbcenter® igc.apcorg
www.hri.ca/partners/fxbcenter
GLOBAL LAWYERS
AND PHYSICIANS
HEALTH IAW DEPARTMENT
BOSTON UNIVERSITY SCHOOL OF
PUBLIC HEALTH
71S ALBANY STREET
BOSTON. MA 02118
TEL (617) 638-4626
FAX: (617) 414-1464
EMAIL: glp@bu.edu
www-busph.bu.edu/DeptsAW/GLPHR.HTM
INTERNATIONAL PHYSICIANS
FOR THE PREVENTION OF
NUCLEAR WAR
126 ROGERS STREET
(AMBRIDGE. MA 02142
TEL (617) 868-5050
FAX: (617) 868-2560
EMAIL: ippnwbos@igcapc.org
www.healthnaorg/IPPNW/
PHYSICIANS FOR
HUMAN RIGHTS
100 BOYLSTON STREET. SUITE 702
BOSTON. MA 02116
TEL (617) 695-0041
FAX: (617) 69S-0307
EMAIL: phrusa@phrusa.org
www.phrusa.org
FRANCOIS-XAVIER BAGNOUD
CENTER FOR HEALTH AND
HUMAN RIGHTS
legal and medical/public health pro
PHYSICIANS FOR
HUMAN RIGHTS
fessionals to protect the human rights
Physicians for Human Rights (PHR)
The Francois-Xavier Bagnoud
and dignity of all persons.The
mobilizes the health professions and
Center for Health and Human
founders are George J. Annas, JD,
enlists public support to protect and
Rights was founded in 1993 at the
Edward R.Utley Professor and Chair,
promote the human rights of all
Harvard School of Public Health to
Health and Law Department, Boston
people. PHR believes that human
promote and catalyze the health and
University School of Public Health
rights are essential preconditions for
human rights movement; to influ
and Michael A. Grodin, MD, Profes
the health and well-being of all
ence policies and practices in health
sor and Director of Law, Medicine,
members of the human family.
and human rights; and to expand the
and Ethics Program, Health Law
knowledge about linkages between
Department, Boston University
worked to stop torture, disappear
health and human rights in specific
contexts such as HIV/AIDS,
School of Public Health.
ances, and political killings by gov
ernments and opposition groups; to
children’s rights and health, and
womens health and rights.
The Center has developed and
reinvigorate the collaboration of the
INTERNATIONAL PHYSICIANS
FOR THE PREVENTION OF
NUCLEAR WAR
Since 1986, PHR members have
improve health and sanitary condi
tions in prisons and detention cen
ters; to investigate the physical and
professional training courses on health
and human rights. Current research
and thinking in health and human
International Physicians for the Pre
vention of Nuclear War (IPPNWj is
psychological consequences of viola
tions of humanitarian law in internal
a non-partisan international federa
tion of physicians' organizations ded
and international conflicts; to defend
medical neutrality and the right of
rights is published in the Centers
icated to research, education, and
journal, Health and Human Rights and
advocacy relevant to the prevention
civilians and combatants to receive
medical care during times of war; to
additional publications.The Center
of nuclear war.To this end, IPPNW
seeks to prevent all wars, to promote
protect health professionals who are
victims of violations of human
conducts a variety of academic and
seeks to influence policy and pro
grams through its collaboration with
non-violent conflict resolution, and
rights; and to prevent medical com
various UN agencies and in partner
to minimize the effects of war and
ship with NG Os, international agen
cies, and governments worldwide.
preparations for war on health, devel
opment, and the environment. For its
work to educate the public about the
plicity in torture and other abuses.
As one of the original steering com
Daniel Tarantola, MD, is the Act
ing Center Director and the Director
of the International AIDS Program.
medical consequences of nuclear
war, IPPNW was awarded the Nobel
mittee members of the International
Campaign to Ban Landmines, PHR
shared the 1997 Nobel Peace Prize,
awarded to the Campaign and its
coordinator, Jody Williams. PHR
currently serves as co-chair for the
U.S. Campaign to Ban Landmines.
Sofia Gruskin,JD, MIA, is the Direc
tor of the Human Rights Program.
Peace Prize on December 10,1985.
Founded in 1980, in the midst of
the Cold War, IPPNW came together
GLOBAL LAWYERS AND
PHYSICIANS
with the vision that physicians, shar
Global Lawyers and Physicians’
human health, could unite globally in
Carola Eisenberg, MD.The
(GLP) mission is to work collabora
opposition to nuclear weapons and
Executive Director is Leonard S.
tively toward the global implementa
nuclear war. IPPNW's mission has
Rubenstein, JD; Deputy Director is
tion of the health-related provisions
of the Universal Declaration of
evolved from a singular focus on the
Susannah Sirkin; Advocacy Director
reduction and eventual elimination of
is Holly Burkhalter; Senior Program
Human Rights and the Covenants on
nuclear arsenals to broader concern
Associate is Richard Sollom; Direc
Civil and Political Rights and Eco
nomic, Social, and Cultural Rights,
with a focus on health care ethics,
patients’ rights, and human experi
with three major components of
global violence and the measures that
can address them: military conflict
tor of Communications is Barbara
Ayotte; Development Coordinator is
ing a common duty to protect
mentation. GLP was founded in 1996
and the need for disarmament;
poverty and economic inequality and
at an international symposium held at
the need for justice and equitable
the United States Holocaust Memor
development; and environmental
ial Museum to commemorate the
destruction and the need for universal
5Oth Anniversary of the Nuremberg
Doctors Trial. GLP was formed to
stewardship of the earth's fragile
resources. As with its founding work
on nuclear abolition, IPPNW
believes that primary prevention is
the only approach for remedying
such types of global violence.
The President is Charles
Clements, MD,Vice President is
Steve Brown; Campaign and Educa
tion Coordinator is Gina Cummings;
and Senior Medical Consultant is
Vincent lacopino, MD, PhD.
MV ”'(+
I
WOMEN’S HEALTH AND DEVELOPMENT
WORLD HEALTH ORGANIZATION
Multi-Country Study on Women’s Health and Domestic Violence Against Women
Summary Description
1.
Background
In 1996, the Women’s Health programme in WHO (WHD) held a consultation with researchers,
health care providers and women’s health advocates active in the field of violence against wompn
from several countries, to explore the potential role of WHO in addressing the issue. The main
recommendations included that WHO should support international research to explore the
dimensions, health consequences and risk factors of violence. In response to this
recommendation, WHD/WHO is developing methods for and implementing a multi-country
study on women’s health and domestic violence against women.
The rationale for this study is further supported by the Beijing Platform for Action which
recommended, among other things, the promotion of:
‘research and data collection on the prevalence of different forms of violence against
women, especially domestic violence, and research into the causes, the nature and
consequences of violence against women 1
2.
Study objectives
The population-based study will:
Obtain reliable estimates of the prevalence of violence against women in several
countries.
Document the health consequences of domestic violence against women.
Identify and compare risk and protective factors for domestic violence against
women, within and between settings.
Explore and compare the coping strategies used by women experiencing domestic
violence.
The study will provide important data on prevalence, determinants and related risk factors, and
health consequences of violence against women from a diverse group of countries. WHD is also
committed to several corollary outcomes including (1) developing and testing new instruments
1 Paragraph 129a Beijing Platform of Action, September 1995
1
for measuring violence cross-culturally; (2) increased national capacity of researchers and
women’s NGOs working in this field; and, (3) increased sensitivity to the subject among
researchers, policy makers and health providers.
3.
Participating countries
There has been a strong interest from a number of countries. Possible countries to include were
selected with the WHO Regional Offices, on the basis of the following criteria:
presence of local anti-violence groups positioned to use the data for advocacy
a)
and policy reform;
absence of existing population-based data;
b)
presence of strong potential partners known to WHD;
c)
receptive policy environment that is open to taking up the issue;
d)
absence of recent war-related conflict;
e)
representativeness.
regional
0
The Steering Committee has recommended that in a first phase, the research take place in
countries where potential research teams have already been established. The Steering Committee
also recommended that at least one industrialised country should be included in the study. The
confirmed countries are Brazil, Peru, and Thailand and two or three others are to be determined.
A number of countries from various regions are interested in participating in the study should
funds become available at a later stage (phase II). In addition, the methodology is being shared
with others undertaking studies in this field to encourage comparability of results.
4.
Methodology
Country study team
Within each participating country, the study will be implemented by a research team, in general
consisting of two researchers, a statistician and at least one representative from a women’s
organisation working to address violence against women. The researchers will have experience
in quantitative and qualitative research, and conducting research on sensitive issues.
An advisory group or consultative committee will be established within each country to support
the implementation of the study and ensure dissemination of the results. Members of each
country research team will meet regularly with this group to discuss emerging issues.
WHD/WHO has developed a core protocol for the study. The country study teams will develop
implementation protocols, with the option to include additional modules to explore country
specific areas of concern.
Quantitative data collection
The quantitative component of the study will consist of a cross-sectional household survey of
women aged 15 - 49 in urban and rural areas in the study locations. Much of the analysis will
focus on documenting the patterns of violence experienced by women who have ever been in a
relationship. Interviews will be held in the local language by specially selected and trained
2
I
female interviewers.
Prevalence estimates for the occurrence of different forms of physical, sexual and psychological
violence will be obtained by asking female respondents direct questions about whether they Hiave
experienced explicit behaviours over specified time-frames. Follow-up questions will be dsed
to explore whether the violence is ongoing and to identify the perpetrators of different form^ of
abuse. The study will pilot the reliability of asking about violence in the last month, the last year,
and ever, as well as asking about the worst event.
The survey will collect indicators of the female respondent’s current physical and mental health
status (through standard screening questionnaires), and measures of whether she has been ill and
used health services in the last year. Multivariate analysis will be used to investigate the
relationship between these indicators of health and women’s reported experience of different
forms of violence.
The survey will measure the presence or absence of a number of hypothesised risk and protective
factors in each country. Potential risk and protective factors will be identified at the individual
and community level using the following criteria: applicability for intervention development,
theoretical importance and feasibility of measurement. Individual factors are likely to include
socio-demographic factors, witnessing family violence as a child, a history of previous
victimisation, and female access to and control of resources. Community factors include levels
of male on male violence, levels of male unemployment, male and female attitudes towards
violence and the availability of services. For each cluster sampled, community indicators will
be developed by aggregating responses from the individual questionnaires, supplemented by
information collected using rapid appraisal techniques. Multi-level statistical analysis will be
used to investigate the relationship between individual and community variables and the reported
forms and levels of violence by different perpetrators.
Women experiencing physical violence will be asked about forms and frequency of injury,
health care and other support received, and where they would have liked to get more help.
Information on the extent to which women seek help from different formal and informal sources,
and make efforts to leave or change their relationships, will also be explored.
Study location
Within each country, the survey will not aim to obtain national prevalence figures. Instead, the study
will aim to collect prevalence estimates from the country’s largest urban centre and from one
province, selected to incorporate urban and rural communities. Within each location, cluster sampling
will be used to randomly select households for interview. One woman will be randomly selected for
interview from each household. This sampling design will enable direct comparisons to be made
between different strata in the same country, and between similar strata in different countries (such
as between the largest urban area in different countries). Preliminary calculations suggest that a
total sample of 3000 women will be required. Detailed sampling regimes and sample size
calculations will be made for each participating country.
3
I
I
I
Qualitative data collection
A range of complementary qualitative research techniques will be used to help inform the
development, interpretation and presentation of the quantitative research findings. This will
include key informant interviews, focus group discussions with both men and women exploring
community attitudes towards violence, and in-depth interviews with survivors of domestic
violence.
5.
Project structure
WHO will provide strategic and technical oversight to the study through two means.
Dr Claudia Garcia-Moreno will have overall responsibility for the study. She will coordinate
the input of an expert Steering Committee established to guide the development and
implementation of the study. The Steering Committee, consisting of international leaders in
the field of violence against women, will meet at least three times over the three-year period
of the study. Secondly, WHO has established a Core Technical Assistance Team which
includes Ms Lori Heise and Dr Mary Ellsberg from the Center for Health and Gender Equity
who will service the needs of the country teams, together with the Senior Technical Advisor
from the London School of Hygiene and Tropical Medicine and a full time statistician who
will assist with all aspects of data collection and analysis. The Senior Technical Advisor is
responsible for developing the study protocol and core questionnaire, organizing bi-annual
research team meetings, and coordinating other forms of technical support to the study teams,
e.g., statistical methods. Additional input will be provided by an Administrative Officer who
will be responsible for developing management and financial systems and overseeing the
financial reporting and contract management with the countries.
6. Current status of this initiative
The study will be implemented over a period of three years. The core protocol for this study
has been developed and a note on ethical considerations was discussed and approved by the
Scientific and Ethical Review Group (SERG) of the UNDP/UNFPA/WHO/World Bank
Special Programme of Research, Development and Research Training in Human
Reproduction (HRP) in October 1997. This core protocol was reviewed by the expert Steering
Committee and a statistical sub-committee in March 1998, and was discussed at a Research
Team meeting in April 1998.
Country visits to identify potential collaborating institutions and members of the multi
disciplinary research team have been made to Bangladesh, Namibia, Peru, Thailand, Ghana
and the Philippines. At this stage, research teams have been identified in five countries and
discussions are underway in others. The Steering Committee has recommended to start with
these countries, with other countries joining in a second phase of the study. The Steering
Committee also recommended the inclusion of at least one industrialised country. (Japan and
Italy are exploring funding to join the study).
4
>
i
7.
Budget
WHO has raised some funds for this research initiative, in particular development of the
protocol and core questionnaire, and identification of research teams in several countries, We
are seeking additional support for the country studies and the cross national data analysis.
Further information about the WHO Multi-Country Study can be obtained from:
Dr C. Garcia-Moreno
World Health Organization
Avenue Appia 20
CH-1211 Geneva 27 Switzerland
fax: (41-22) 791 4189
tel: (41 22) 791 4353
e-mail: garciamoreno@who.ch
summvaw7.rev29.6.98
5
STATE VIOLENCE
- MONICA SAKHRANI
WHAT IS STATE VIOLENCE
‘State Violence' is any act or omission on the part of the State and its agencies
which hampers or impairs the physical and/or psychological development of the
individual.
It would include any act which impinges on the social, cultural,
economic, political and civil rights of individuals whether the same is legal or extra-
legal. Thus violence would not only include torture and other forms of custodial
violence but also include laws which target specific groups and individuals and
interpretations by the Judiciary which favour State violence.
This Paper seeks to explore the methods employed by the State to appropriate
exclusive control over use of violence by its agencies and the role of legislation and
judiciary' in achieving the same.
ROLE OF LEGISLATION
Law is the system of rights which devolves through one’s caste, gender, religion,
class and nationality. A right is a claim which has a nature of title conferred by
established legal authority publicly and unambiguously announced by law and
excludes access by others to it Infringement of the right has sanctions prescribed
by law which may be remedial in nature as in case of infringement of civil rights or
punitive in case of infringement of criminal law. This division of illegalities into
-2civil and criminal wrongs, is to prevent transfer/loss of power and maintenance of
political and economic status quo. Thus most “blue-collar’ illegalities committed
by the poor are governed by criminal law and “white-collar’ illegalities committed
by bourgeoisie enter the domain of civil law. The State places at the disposal of the
bearer of criminal law rights, the entire coercive machinery of the state, which can
be activated on threat to right. The State thus exclusively appropriates the righ to
punish “offenders”.
The corollary to this is that the responsibility of punishing
State excesses also lies with the State.
PREVENTIVE DETENTION LAWS
The Constitution of India permits implementation of preventive detention laws and
denial of access to the Courts in cases of preventive detention [Article 22(3) to (7)].
Post-Independence India can boast of only a two-year period (1969 to 1971)
without preventive detention legislation.
Each successive preventive detention
legislation has been more repressive than its predecessor.
Security Act prohibits representation by a lawyer.
The present National
The Supreme Court while
upholding the constitutionality of the Act in A. K. Roy’s case (AIR 1982 SC 710)
stated, “Howsoever much would have liked to hold otherwise, we experience
serious difficulty in taking the view that the procedure of the Advisory Boards in
which the detenu is denied the right of legal representation is unfair, unjusi or
unreasonable.
If Article 22 were silent on the question of the right of legal
representation, it would have been possible, indeed right and proper, to hold that
the detenu cannot be denied the right of legal representation in the proceedings
-3 >.
before the Advisory Board. It is unfortunate that Courts have been deprived of the
choice by the express language of Article 22(3)(b) read with Article 22(1).”
The Courts have consistently upheld the preventive detention laws. In A K. Roy’s
case, the Supreme Court abrogated the power of judicial review on grounds that the
* Courts are not equipped to deal with cases where the person has not yet committed
an offence but is likely to do so.
LEGITIMATE STATE VIOLENCE
It is widely accepted that poverty is an important factor leading to criminality, A
dramatic example of this is that most contract killers are poor, unemployed,
illiterate, male youth who are willing to kill for as little as Rs.2,000/-. Another
example is the high crime rate in slums. Another indicator is that 31.7 percent of
the cases registered in India in 1995 were theft cases (Crime in India, 1995).
However, the flip side of this is that most crimes affect the poor. Studies reveal that
most victims of abuse are the poor.
However, cases by the poor are rarely
registered while cases against the poor are frequently registered. In fact, it would
not be an exaggeration to state that in India poverty is a crime. This fact is apparent
by even a casual analysis of the penal provisions.
Ticketlcss travelling is an offence under the Railways Act.
A?
Begging is an offence under the Prevention of Begging Act.
Hawking without a license is a cognizable office, though the Mumbai
Municipal Corporation rarely issues ficenses and there are no hawking
zones. This is because the official fines collected from hawkers generate
•5
-4-
revenue of over Rs.One crore per month for the Corporation (Times of
India, 09 November 1998).
Prostitutes are punished for soliciting while the clients are not.
While embezzlement by a servant is punishable with imprisonment upto
seven years, withholding of salary by employer is only a contractual breach.
Even in the few penal provisions in labour laws where the penalties in the
form of petty fine amounts make it more profitable for the employers to
flout the same, prosecution cannot be launched by the aggrieved parties
except with the permission of the Inspector within stipulated periods.
<=?
Public housing in India is non-existent, so is legal housing for the urban
poor, who cannot afford the exorbitant rents. But “squatting” is an offence.
A typical demolition by the authorities is conducted in this manner :
“On 24 February 1995, the demolition squad burnt 125 structures
at Maharashtra Nagar, Bandra (East), Mumbai during a demolition.
Not only were the structures burnt but so were the personal
belongings and documents of the residents. Four children and a
man were injured and were treated for burns at the LTMG Hospital,
Sion.
Women who protested the demolition were beaten and
arrested and later released on payment of fine of Rs.200 each.”
(Adenwalla M., Evicting the Right to Shelter from the Lawyers
Collective, September 1998).
-5 Arrests during demolitions are routine.
In many cases the people are accused of
setting their own houses on fire. The list is endless. There were 411 legislations
containing penal provisions in Maharashtra in 1995 (Crime in India 1995).
Furthermore most of the offences committed by the poor are cognizable giving the
police the power to arrest any person suspected of having committed the same
(Section 41, Code of Criminal Procedure). The National Police Commission in its
Third Report has observed that the single most cause of corruption in the police
force is the power to arrest. The Commission has also stated that by and large
nearly 60 percent of the arrests were either unnecessary or unjustified and that such
unjustified police action accounted for 43.2% of the expenditure of jails, (quoted
by the Supreme Court in Joginder Kumar -v-. State of UP, 1994 Cri.L.J. 1981).
Thus the poor are the people most likely to be victims of abuse of authority.
The poor are also likely to stay in prison for the longest, fhe bail system in India is
property based and anti-poor. Hence, the prison population comprises of around
75 percent undertrials many of whom are in jail because of inability to furnish jail.
The period of undertrial detention is not set-off against sentence in lieu of fine
(Section 428,Cr.P.C.).
Many mentally ill persons aid juveniles are also in jail.
Several persons are incarcerated for periods beyond the maximum punishment
imposable by law due to inability to afford lawyers. Though legal aid is provided
for in law for indigent persons, in practice most undertrials are denied legal aid.
The courts also prefer to ‘plea bargain’ with the accused many of whom plead
guilty to be let off. This pulls them further into criminality creating records wliich
makes them ‘habitual offenders’.
Detention of ‘habituals’ is permissible by
institution of chapter cases (Chapter VIII, G.P.C.), extemment proceedings
t—z-/I *■ '*
-6(Mumbai Police Act, Section 56), through incarceration in preventive detention
laws or exercise of preventive powers of arrest of police (Section 151, GrP.C.).
Taking of photographs, finger-prints and surveillance of the convicts is permissible
under law. Criminal antecedents is also an important factor considered by courts in
the grant or denial of bail.
The purpose of punishment is ostensibly deterrence and/or reformation but
incarceration has the opposite effect. It increases recidivism by exposing persons to
criminals of different hues, by its negative labelling, by pushing famihes to
destitution and by failing to address core issues which lead to crime. In criminal
law, ‘actus reas’ and ‘mens rea’ i.e. the physical act and the intention to do so, are
the relevant considerations. Motive is irrelevant.
Hence, the socio-political and
economic factors which perpetuare crime are beyond the scope of law and the
courts. This individualisation of crime justifies pumshment, the purpose of which
is to prevent organised rebellion.
CASE FOR CUSTODIAL VIOLENCE
The number of custodial deaths in India doubled from 444 in 1995-96 to 888 in
1996-97 (National Human Rights Commission) with Maharashtra leading the
brigade with 201 deaths registering an increase of almost six times over the
previous year. The “Crime in India - 1995” report of the National Crimes Record
Bureau states that incidence of police firing increased by eight percent in 19^5 as
compared to the previous year.
In Mumbai 135 “encounter deaths” took place
between 1995 to 1997, while in November 1998 itself the figure is fifteen deaths.
-7-
The Maharashtra Government has gone on record stating that “the encounter policy
will continue” and these extra-judicial killings are being defended vociferously by
the State in the public interest petitions pending before the Bombay High Court.
Various citizens groups representing bourgeoisie class interests have intervened in
these petitions supporting the “encounter policy”. Lost amidst this hype, are the
facts that the report of the Principal Judge of Sessions Court, Mumbai enquiring
into two “encounters” found them to be fake and that at least eleven of the persons
killed in encounters by the police are ‘unknown’ according to their own figures.
Prosecution and conviction of officers for abuse of authority or misuse of the same
is rare. Often no legal steps are taken including mandatory provisions required by
law in investigating these deaths.
The 1992 Amnesty International Report on
Torture, Rape and Deaths in custody found that of the 415 cases of custodial deaths
between 1985 to 1992, in only 42 of them were magisterial enquiries held aid in
only three cases were pofice officers convicted.
This despite the mandatory
requirement of inquests in all cases of custodial death under Section 176 Cr.PC.
The law also protects pofice officials in cases of use of violence. Section 46 of tlie
Cr.P.C. permits a pofice officer effecting arrest to use force upto causing of death
while arresting a person accused of having committed an offence punishable with
death or life imprisonment.
Section 197 of the Cr.P.C. stipulates that all
prosecutions against police officers accused of any offence alleged to have been
committed by them while acting or purporting to act in the discharge of their
official duty shall be instituted after obtaining sanction of the State Government.
Section 161 of the Bombay Police Act further states that suits or prosecutions in
respect of acts done by police officers under colour of duty or in excess of
-8authority shall be dismissed if instituted more than six months after the date of the
act complained of. These provisions literally help the police get away with murder.
The Amnesty International in its Report “Amnesty International and India” deals
with factors which encourage resort to custodial violence by the police.
The
sense of impunity generated by the infrequency with which the police have been
held publicly accountable for their actions, the rare convictions of those responsible
for rape or deaths in custody and the length of legal proceedings, further encourage
the perception that resort to torture is acceptable. Police are given wide powers
under a variety of legislation which allows them to arrest, detain and investigate.
Detainees can be kept in police custody for long periods, particularly under
legislation permitting preventive detention, during which they are at risk of torture
and ill-treatment. In violation of Indian law and police procedure, the practice of
unrecorded police detentions is common and there is little doubt that it facilitates
police abuse such as beatings and other forms of ill-treatment or torture such as
rape.
Moreover lawyers and relatives are routinely denied access by police to
people held in custody. Most torture and ill-treatment in India occurs during the
first state of detention in police custody, when access to outsiders is routinely
denied. Indian laws are virtually silent on the procedure for questioning suspects in
police custody and no provisions exist detailing safeguards in the Criminal
Procedure Code”.
Many special Legislations such as The Narcotics Drugs And Psychotropic
Substances Act shift the burden of proof on the accused, contrary to the basic
principle of criminal jurisprudence that the prosecution must prove its case.
Section 27 of the Indian Evidence Act permits confessions made to police officers
-9-
to be used as evidence if they result in any recovery of article or discovery ol fact
relating to the offence. This encourages the use of third degree in investigation of
cases.
Section 15 of the now repealed Terrorist and Disruptive Activities
(Prevention) Act (TADA) pennitted confessional statements recorded by the Police
to be used as evidence against the accused, provided the same are voluntary,
low
these “voluntary confessions” are obtained is described graphically in an eye
witness account titled “Voices from the Draconian Dungeons” detailing instances of
torture during investigation of the Bomb Blasts case by the Mumbai Police,
example :
“One day the police took her (Nooqahan, wife of accused
Shahnawaz Abdul Qader Qureshi, 19 members of whose family
were illegally detained by the police during investigation), along
with her 45 days infant, to Dadar Police Station. Her husband was
already there. Due to electric shocks administered to him, his face
had turned black.
Nooijahan was molested and humihated in a
most degrading manner.
undress her.
Suddenly an officer order his men to
Her husband who could hardly speak due to Ids
condition pleaded not to touch her. Shahnawaz was thus left with
no choice but to agree to sign the papers. His sister’s mother-inlaw, Zubaidabi, 60, became mad during detention. The family was
kept under unlawful detention for a period of one month”.
“...His last named 4 sisters (Firoza, Sara, Niloufer and Reshma) had
fled their home to escape the police torture, seeking shelter in one
relative’s house to another. They were on their heels for more than
An
- 10-
a month.
They returned home after they came to know of
Shahnawaz’s arrest.
His 75 year old father, Abdul Qader was
forced to undress his daughter Najma and she was forced to play
with his penis.
His beard was plucked with pliers and in the
process they peeled off both his hair and skin.
During torture
Abdul Qader faeceted and his daughter Najma was forced to eat his
shit” (pages 13 and 14).
ROLE OF MEDICAL PROFESSION
The Supreme Court in D.K.Basu -v- State of West Bengal (1997 Cri.L.J. 743) has
laid down guidelines to be followed in all cases of arrest and detention till legal
provisions are made in that behalf as preventive measures, which interalia include:
police personnel to have accurate and clear identification to be entered into
a register.
memo of arrest to be prepared attested by at teast one witness.
information of arrest to family friend of arrestee within 8 to 12 hours after
arrest.
medical examination of arrestee at his request at the time of arrest and major
and minor injuries, if any, present on his/her body to be recorded.
medical examination every 48 hours during detention in custody by a doctor
on the panel of approved doctors appointed by Director Health Services of
the concerned State or Union Territory. Director, Health Services should
prepare such a panel for all Tehsils and Districts: as well.
-11 -
copies of all the documents to be sent to the Illaqa Magistrate.
Medical professionals play a crucial role in the detection of torture, apart from their
recognized role as providing treatment for torture and trauma.
The profession
could also help in accurately identifying the incidence of torture and cases of
custodial violence, as they have access to the victims which is denied to other
outsiders, and also help in defining torture. However in most cases, the doctors
attached to prison hospitals and even public hospitals are unwilling to even
accurately enter the injuries received by the victim thus playing the role of
protectors of the perpetrators of violence and do not consider themselves
accountable to their patients (victims of torture) nor the judiciary, under whose
custody the patient is.
Medical professionals also fail to document the
psychological trauma that incarceration produces, despite overwhelming incidence
of mental illness amongst detenues, especially women. The most shocking failure
however is not in their complicity in covering-up torture, but in failing to provide
adequate treatment to detenues. The single most cause of death in pnsons is not
custodial violence but lack of medical care, with people dying due to malaria,
diabetes and heart attacks, after being denied proper treatment despite funds being
earmarked for the same.
ROLE OF THE JUDICIARY
“There are several types of separatist and terrorist activities in several parts of the
country. They have to be subdued. Whether they should be fought politically or be
- 12-
dealt with by force is a matter of policy for the Government to determine, The
courts may not be the appropriate forum to determine these questions.”
Justices B.P.Jeevan Reddy and Suhas C.Sen (People’s Union for Civil
Liberties-v-Union of India, 1997 (3) SCC 433).
This remark sums up the attitude of the Judiciary in cases of state violence. In the
aforesaid case, the enquiry by the District Judge into an encounter killing instituted
by the Supreme Court, had concluded that there was no encounter. The Supreme
Court ordered compensation to be paid to the victims. No direction for prosecution
was given. This has been the response of the Judiciary in almost all cases of ^yoss
violations of fundamental rights. The message that the courts seem to be sending is
that no rights are sacrosanct and can be violated at a price.
The Supreme Court has also consistently upheld the constitutionality of all
legislations which give special powers of arrest and detention to the State agencies
and provide for harsher penalties.
upheld by the Supreme Court.
Capital punishment
has been consistently
Every post-independence preventive detention
legislation from the Preventive Detention Act (A.K.Gopalan -v-State of Madras,
AIR (37) 1950, SC 27) to the National Security Act (A.K.Roy-v-Union of India,
.MR 1982 SC 710) has been upheld.
The Supreme Court during emergency
abdicated its right to issue writs to enforce rights of personal
liberty (j XDM
Jabalpur-v-S.S.Shukla, 1976 Sup.S.C.R.172). The Bombay High Court has upheld
extemment proceedings and the power of the police to detain persons for upto one
month under its preventive powers of arrest and the Supreme Court in Madhu
Limaye’s case (AIR 1971 SC 2486) has held that the power of Executive
Magistrates (power exercised by Assistant Commissioner of Police) to require bond
- 13 of good behaviour from persons and detain them lor failure to furnish the required
surety or breach of conditions of bond under Chapter VIII of the Cr.P.C. is not
violative of Article 19.
The Supreme Court also upheld the Terrorist and
Disruptive Activities (Prevention) Act (Kartar Singh -v- State of Punjab, 1994 (3)
SCC 569). This despite the misuse of TADA which was routinely applied to even
cases of robbery. In Sanjay Dutt’s case (JT 1994 (5) SC 540) the Supreme Court
held that the onus was on the accused to prove that possession of arm in a
designated area was not for purposes of terrorist activity. Recently the Supreme
Court upheld the Armed Forces (Special Powers) Act which empowers non
commissioned officers effecting arrest of any person who is acting in contravention
of any law or order for the time being in force m “disturbed w areas to use of force
extending to the causing of death of the said person. The Supreme Court held that
the likelihood of misuse or abuse of powers by such junior officers does not render
the provision invalid. The court also stated that if the legislature is competen to
enact a law, then its motive, whether bonafide or malafide, is not relevant. (Naga
People’s Movement of Human Rights -v- Union of India, 1998 (2) SCC 109).
The Courts have failed to check the abuse of authority by State agencies and rarely
punish the contempt of the directions issued by the Supreme Court for protecl ion
of human rights. The Supreme Court in In re M.P. Dwivedi (1996 (4) SCC 142)
accepted the explanation of police officers who handcuffed activists that they were
not aware of the specific directions of the Supreme Court not to handcuff the
accused without permission of the Magistrates. The Supreme Court has not aid
down a clear policy of grant of bail on personal recognizant bond in petty cases or
when the accused are poor, despite expressing concern in series of judgements
r
- 14-
starting from the first Hussainara Khatoon case that the bail provision is anti-poor.
The Apex Court has also not specifically laid down the responsibility of the
Magistrates to check custodial violence and it is not mandatory for the Magistrate to
ask the accused produced before him/her - whether he was subjected to torture.
This prejudices the accused who may be too scared to voluntarily complain of
torture, and the evidence collected through torture which would otherwise be
inadmissible could thus be used against him. Magistrates while granting remand
routinely note that the accused made no complaint of torture - without questioning
the accused. It is only when the accused voluntarily disclose torture that a noting is
made in the remand application. That part, little else is done. Magistrates rarely
follow the directions of the Supreme Court including those in D.K. Basu’s case.
There is no instance of a Magistrate visiting a lock-up. The Supreme Court has
stated that the presence of the accused is not a mandatory requirement for grant of
remand, and remands are routinely granted in the absence of the accused. In cases
where extreme injuries are caused due to torture, accused are rarely produced
before the remand court, and the ill-treatment goes unchecked. No punitive steps
are taken by the Magistrates in most cases of custodial violence even when brought
to light. This encourages use of third degree. Rarely is a case quashed when the
accused is tortured and that too only in cases where the same affects “voluntary”
disclosures made by the accused. The appalling apathy of the courts can also be
seen in the delay in conducting trials, long periods of incarceration of persons as
undertrials and stringent conditions of bail.
-15 -
CONCLUSION
In conclusion, it can be said that the legal and judicial system aid and abet state
violence, whether it be through the mass of penal legislations, their selective
implementation, the refusal of the judiciary to monitor the administration of
criminal justice and the system of penalties imposable by law. The reason for this
is that criminal law “was made for the few and it was brought to bear upon oth ers;
that in principle it applies to all citizens, but that it is addressed principally to the
most numerous and least enlightened classes ; that, unlike political and civil laws,
their application does not concern everybody equally ; that in the courts society as a
whole does not judge one of its members, but that a social category with an interest
in order judges another that is dedicated to disorder : ‘visit the places where people
are judged, imprisoned or executed
one thing will strike you everywhere,
everywhere you will see two quite distinct classes of men, one of which always
meets on the seats of the accusers and judges, the other on the benches of the
accused’, which is explained by the fact that the latter, for lack of resources and
education, do not know ‘how to remain within the limits of legal probity’.” (Michel
Foucault, Discipline and Punish. Penguin Books, 1977, pg.276)
i
I
VIOLENCE AS EXPERIENCED BY SEX WORKERS
IN THIRUVANANTHAPURAM-EVOLVING
STRATEGIES FOR RESISTANCE
Paper presented in tbe International conference on ” Preventing
violence, Caring for Survivors: Role of Health Profession and
services in Violence" Nov 28-30, 1998 Mumbai.
Women engaged in sex trade rarely enter into the mainstream of society including health care system.
They were excluded from feminist discourses also. Now there is a space for them to have an interaction wi h
people in the mainstream, as a result of AIDS prevention activities. Their voice is much more audible to
healthcare providers and social workers. But the existing medical care system and its analytical devices are not
sensitive enough to address the complex issues related to them. Health problems related to violence are such
complex issues.
Violence against sex workers must be considered as a form of gender related violence. Domestic
violence experienced by housewives and all forms of violence towards sex workers are different manifestations of
common etiopathology of a patriarchal society. But the nature, extent, and severity vary for different groups. The
present diagnostic tools used in medical care are not sensitive and specific to diagnose, cure, and prevent these
problems. They are not property addressed by the existing welfare system too. The complexities of gender
violence in general and sex worker’s problems in particular are to be approached, in culture specific and gender
sensitive manner. For this, the present outlook of profession and services has to be changed. In this paper, an
attempt is made to understand the complexities of violence experienced by sex workers. This understanding is
prerequisite to evolve strategies to sensitise the system.
INTERACTION WITH THE COMMUNITY
A systematic data collection from the community of sex workers is difficult and unethical when they are
left amidst the miseries of life. Hence, study of the community will be integrated with intervention. Intervention
include opening a dialogue with them, creating a comfortable environment for sharing, providing medical aid,
providing legal aid, facilitating the process of organising themselves etc. As the first step, rapport building was
initiated through informal talks. That is difficult, because most of these women do not have their own houses.
They can be met at pick up points where they are busy with searching clients. Building trust with them also is
difficult. In such circumstance, maximum effort was put to collect as much information as possible along with an
intervention programme. The sampling followed snowball technique. 37 women gave very short interviews
during which questions were asked about violence. Content analysis of the notes prepared after each interview
and informal talk was done. Detailed case histories of a few women were taken. The period of this interaction
lasted from June 1998 to October 1998.
From informal talks and short interviews following observations were made.
Almost all women [sex workers] have experienced some form of violence in last one month. (Prevalence of
domestic violence [among housewives] varies from 13 to 70 % in different communities in India.) The
prevalence is more among sex workers.
2. The form of violence produces injuries varying from mild to severe.
3. Violence is inflicted by state agencies like police, clients, pimps; agents involved in legal action, caretakers,
family members, co-workers, and life partners.
1.
1;
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I
4. About 40 % of women undergo deliberate self-harm.
5. The forms of violence include beating, kicking, throttling, and cutting with sharp weapons, rape, and so on.
6. Most of the women who attempt self-harm are cutting wrist or neck with blade or swallowing blades.
7. Sometimes these violence ends in death.
8. Accidents occurring at the time of running away from the police are very common. Sometimes they
deliberately harm themselves to escape from police arrest.
The following case histories reveal the complex situation under which women experience violence and how it is
reinforced through different institutions and individuals so that the value system is maintained in the society in
favourable to the privileged gender and communities
Case history. 1
Syama was encouraged to talk about her history in a drop-in-centre setting through free association.
She was under the effect of alcohol but was coherent in speech and oriented to time and space. She was very
co-operative in sharing her past. She was well known for repeated suicidal attempts. Two days before the
interview, she was admitted in the hospital after severe bleeding from the wound made by her in the forearm.
The very next day of admission, she absconded from hospital and went to the street. Social workers in the centre
told that she used to come with bleeding wound. She never takes medicines given for healing the wound. She
asked for a tonic to the visiting doctor. Talking with the doctor in the centre for a few minutes made her happy.
With all these notions in mind, I talked with her. She told that she was married 8 years back and was 20
when got married. Her husband was a daily wage labourer. She spent the initial months with him without many
problems. Gradually, he started beating her even for minor reasons. Her in-laws were also with her, but they
were also contributing to this. Years passed. She became mother of two boy children.
She was asked to bring money from her house. Since her parents were very poor and she failed in
obeying him in this respect, brutality towards her became worse. At the same time she noticed that her husband
initiated another relationship with a woman. She could not bear with this and started quarrelling with him. This
made him more provocative and the degree of violence increased. She was loosing her moral and started
thinking about suicide. One day, after severe beating, she jumped into the well. Somebody saved her. This
incident also did not change the attitude of her husband and other relatives.
Gradually, her husband stopped giving her money. Along with that she was harassed by the in-laws.
She could n't leave them because she didn't have any other means to look after the children. During this period,
she was craving for love. She wanted to be loved by someone. Helplessness and hopelessness led her to
further suicidal attempts. These days she opened some relations with other women in the village. One among
them told that there was somebody who loves her and wants to talk with her alone. They went to the city and her
friend introduced her to the man. They spent time in a lodge. Later she came to know that her friend had
received money from him and it was a deal. This left her in a more difficult situation. She could not go back to
her house. She started living with the other woman and entered into sex trade.
Even now she hope for someone who loves her. In between she gets into severe depression and
attempt suicide. Occasionally, she visits her children. Sometimes she falls in love with some clients and finally
ends up in bitter experience. This is what I heard from her. Let us know other's opinion about her.
Her co-workers say "Oh. She is worthless. It is because of her, police take us into custody. Damn her."
Welfare officers in prison said," If Syama is severely punished, she can be managed. Otherwise very difficult.
She harms herself."
Police officers said," She can not be changed. She repeatedly attempts suicide. She often gets beating
from clients also."
2
A few days after the interview, she was severely injured by a co-worker in the drop-in centre. Wounds
were very deep and she screamed so loudly that all neighbours gathered and they called police. Police and other
people tried to take her to hospital, but she was not co-operating. This made others angrier. Finally she was
taken to the causality of a tertiary hospital. All the wounds were stitched without local anaesthesia. Nobody was
there to stay with her. As soon as the stitching was over, she left the hospital. In the following day, she
consumed some poisonous fruits and directly approached the police. She was arrested and sent to the prison.
Violence experienced by Syama can be approached by different ways. The conventional approaches
are based on bio-medical, psychopathologicai, subcultural or motive attribution theories. The victim may be
blamed or the assailant will be justified. This case exemplifies the complexities and intricacies of violence and
self harm as constructed and propagated in patriarchal societies through various agencies like family, state,
group, and individual.
And also it shows that domestic violence is related to other forms of violence experienced by sex
workers outside the family. Dowry problem and wife beating are characteristics of the patriarchal Indian society.
Here domestic violence has contributed to the construction of her negative self-image and learned helplessness
resulting in her behaviour like easy susceptibility to violence, provoking others, harm even from her co-workers
and self-harm. Police and prison officers think that she can be controlled only by punishment. They warn others
not to be with her. It is an indirect message to these women to obey social rules. Since she does not
compromise, become susceptible to more violence from others who think that she is a problem-creating woman.
This case shows how different agencies work to maintain the status quo of male dominated society.
Neither the wife status nor sex work was the choice of the woman. The woman was searching her identity in her
given situation, later turned out to hopelessness and helplessness through her interactions with society. From the
confinement of family, she was transferred to another arena where once again she developed hope for friendship
and love, again leading to hopelessness .She realised that those were false values, which added to her negative
self-image. Her co-workers hate her because she becomes a threat to them, where they struggle to cope with
state violence through compromise or accepting themselves as immoral. Health care givers want to dispose her
as early as possible so that these women do not 'pollute' the hospital environment or they do not have to spend
time in the court unnecessarily. She herself accepts her crime of being a victim and want to die, eventhough her
ambivalent state brings her glimpses of hope.
In summary, different sections of people contribute to women's oppression and to maintain state
ideology of morality. All these factors should be taken into consideration when strategies for violence against
women are discussed.
Case history 2
Vanaja shared her life experience while walking together in an evening. She was under tension
because of a cold war with her cohabitant that is another woman named Deepti. They started living together after
a ritual" thalikettu" and have idealised concept of romance. Eventhough two women started an ideal life one has
taken the dominant role of a man. Deepti looks after the financial matter and physically hurts her counterpart.
But Vanaja earns money through sex work and her daughter is looked after by Deepti. Here certain roles are
opposite to that of man-woman relationships. Anyhow Vanaja has to undergo physical violence from her partner.
Since they have a comparatively stable emotional relationship, and have a better financial set up she is not
suffering from violence from co-workers. But she had severe experience from police. Once her hand was
broken. She entered into sex work as revenge to her family members because they wanted to protect her uncle
who raped and made her pregnant. Hence, she undergoes severe mental torture, whenever she visits family
members. She cannot stay back in her family. She chooses a life with Deepti even if she is subjected to physical
torture. She showed wound marks in neck and hands. Deepti also used to undergo self-harm.
3
In this case, the woman who has taken the submissive role in a relationship experiences torture from her
dominant partner. The dominant-submissive relationship internalised by these women is the reflection of the
societal values, though the relationship was started as a rebellion against the oppressive and sexually
discriminated society. Since there is no movement in society to support them emotionally or morally, the whole
responsibility of the relationship is ascribed to the partners themselves. They found this relation as a survival
strategy to establish mutual support and resist harassment from the stakeholders of sex trade and social pressure
for conformity. These women undergo torture under severe pressure from outside to conform either to
hegemonic culture of the society or to the subculture of sex workers. Hence, the violent behaviour is not only due
to the interpersonal conflicts, but also determined from outside pressure.
These two cases are presented here to demonstrate the varied nature, generalities, and specificities of
violence experienced by sex workers and gender violence in general. Any preventive measures will be
successful only if we look into the complexities of these issues and all social institutions must be sensitised on
this.
CONCLUSION
1.
2.
3.
4.
5.
6.
7.
8.
Domestic violence and violence experienced by sex workers in a gendered society are varied manifestations
of the same etiopathology of male dominated ideology. Violence against women is practised in all
institutions and towards all categories of women.
The frequency, prevalence, and severity of violence is more experienced by sex workers than by
housewives.
The nature of violence inflicted upon sex workers is specific. This includes more number of sexual violence,
murder, and self harm.
Violence towards sex workers is operated through various agencies such as police, clients, caretakers family
members and sex workers themselves which are reinforced each other.
Abolition of violence towards sex workers and domestic violence can be done together only because both
are inter-related.
Violence cases of women should be managed under a speciality of medical system, since it requires special
attention and gender sensitive diagnostic tools. There should be counselling facilities in this department.
Women of different categories must organise themselves to resist violence. Different groups should support
mutually to resist male dominated moralistic values.
All social institutions must interact with women's movements to reconstruct a new value system and social
order.
A.K. JAYASREE
Foundation for Integrated Research in Mental Health
Kannammoola
Medical College. P. 0.
Thiruvananthapuram.
695011 Kerala. India.
E-mail iayasree@md3.vsnl.net. in
4
Mp k
A Violation of Citizens Rights :
The Role of the Health Sector,
particularly of the State Health and Related Services,
in regard to Tuberculosis in India.
by
Dr. Thelma Narayan, MBBS, Ph.D.
Community Health Cell,
Society for Community Health Awareness, Research and Action,
No.367, ‘Srinivasa Nilaya’, Jakkasandra I Main,
I Block, Koramangala,
Bangalore - 560 034.
Phone:91 -80-553 15 18 & 91 - 80 - 552 53 72
Fax: 91 -80 - 553 33 58 (Mark Attn. Community Health Cell)
Email : sochara@blr.vsnl.net.in
Paper presented at the International Conference, organised by CEHAT on “Preventing
Violence, Caring for Survivors : Role of Health Profession and Services in Violence"',
November 28-30111, Mumbai, India.
I
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Summary
Country-wide government sponsored anti-Tuberculosis public health measures
were introduced in India since 1948. Despite some gains, serious implementation
gaps between goals and performance have resulted in an insignificant impact on
the magnitude of the disease problem. Official estimates are that 500,000 persons
die due to tuberculosis every year and 14-17 million people suffer from it !
(prevalence). This is largely preventable as tuberculosis is curable at low cost. I
Poor TB case management due to systemic failures of the health and related
services results in a large proportion of patients receiving inadequate, wrong and
irregular treatment in the development of drug resistance and in an increasing ,
number of chronic cxcrctors who continue disease transmission in society. Is this a
form of indirect violence of citizens rights by state agencies?
The state has abrogated its constitutional mandate to protect the health and wellbeing of its citizens by under-funding the National Tuberculosis Programme, by
not ensuring the development of basic health services through which TB care can
be provided, by not heeding the recommendations of its own specialised National
TB institutions and researchers, and by allowing/promoting the unregulated growth
of the private sector without ensuring that minimum scicntific/profcssional norms
are maintained in diagnosis and treatment.
Efforts are required by all sections of civil society to pressurize the health sector to
perform with a sense of accountability, to prevent the ongoing chronic violation of
health rights by ensuring provision for early diagnosis, completion of effective
therapy and supportive care to patients suffering from all forms of TB. This would
require the strengthening and non-fragmentation of basic health care services
through Primary Health Centres in rural areas and through Municipal Corporation
Dispensaries and hospitals in urban areas. Additionally, social security and
rehabilitation measures for advanced cases is required.
|
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1. Introduction
Tuberculosis was recognised by the new government of independent India in
1947 as one of the country ’s biggest public health problems. Interventions
were introduced in 1948. This formed part of Government’s constitutional
mandate and pledge to protect and promote the health and well being of its
citizens. BCG vaccination within a vertical programme was the main strategy
with a focus on urban areas and children, among whom TB was then
considered to be the major problem. With limited finances, it was felt that
prevention was the best approach. Fortunately, indigenous research was
initiated and supported by Government through establishment of new
institutional bodies, in order to understand the problem better.
Over the years, research findings challenged then current assumptions and gave
shape to the National TB Programme (NTP) in 1962. By this time, effective
chemotherapy was available at low cost. Better drug regimens were developed
by the 1970s. The functional unit of the NTP was the District TB Programme
(DTP). BCG, early case detection, domiciliary chemotherapy, integrated with
general health services, are being supported by District and State TB Centres
The NTP idea
were conceptualised as the key strategic components.
influenced TB control programmes globally through the WHO. Later, the
' world ’s largest controlled BCG trial in Chinglepet, India, found that the
vaccine did not prevent adult pulmonary TB and that it played no role in
controlling disease transmission.
Infrastructure for the NTP at State and District level began to be established
Major problems in
and team training of DTP teams was undertaken.
implementation became recognised and reported by Government and other
research institutions and bodies from the early 1970s. However, these findings
and evaluation reports resulted in little change in action and performance.
Poor implementation has resulted in more than half a million deaths annually.
Thus, from 1947, about 25 million people have died of a disease that has been
curable at low cost from the 1960s. Many more millions suffer needlessly.
The poor, at greatest risk, are most affected, having less access to effective
care. A proportion get functionally disabled due to advanced disease and a
substantial proportion also become indebted due to the disease.
3
2, Understanding and Defining the Problem of Tuberculosis
Policy makers and planners conventionally define and therefore understand the
problem of tuberculosis within epidemiological, bio-medical, public health and
programmatic parameters.
This is necessary and important and these
dimensions are outlined in the next paragraph. However, they are insufficient
to bring about a change in practice or in implementation of the programme.
Hence, they are insufficient in producing an impact on the preventable disease
burden among people and populations.
|
2.1 Epidemiological Dimensions of Disease Burden
Tuberculosis has been known and named in India as Rajya Roga, the king
of diseases, since many centuries. High rates of infection and disease have
been noted from the early 20th century. Before this, it was reported to be
more rare or infrequent.
A large proportion of 30-52% of the population get infected. Only a small
proportion of those infected break down into disease at some point of time.
The disease in all its fonns (lung and extra-pulmonary disease where other
organs are affected) currently affects 1.6-2.2% of the population. This is
the disease prevalence. It is inclusive of 0.3-0.4% of people suffering from
sputum positive TB of the lungs who are infectious to others. Public health
planners focus on diagnosis and treatment of this smaller sub-group of
patients with the hypothesis that the chain of transmission would be cut and
the disease would be controlled. Patients with sputum smear negative,
active pulmonary TB or with childhood or extra-pulmonary TB, being noninfectious and consequently not threatening society, receive cheaper, less
effective drug regimens, though physically suffering as much or more.
Justified by resource constraints, this policy is discriminatory and
represents societal relations and state priorities.
The disease and infection prevalence rates increase with age and TB is
largely an adult problem, with 8% occuring in children. While disease
prevalence is higher among poorer socio-economic groups, this fact docs
not receive any particular policy attention. Disease prevalence is lower
among women than men. But women have less access to general health
care and hence possibly to TB care. More young women in the
reproductive age die of TB than of other causes.
Though declining, the mortality from this preventable and curable disease
is still unacceptably high at 50-84/100,000.
Currently India has approximately 13.5 - 17 million TB patients of whom
3.6 million arc infections. In absolute numbers, more persons are affected
now than in 1947. While this is due to demographic or population growth,
4
it also indicates that control strategics and interventions have been
ineffective.
TB is equally prevalent in rural and urban areas. With a predominantly
rural population of 74%, the TB problem is thus largely rural based.
Patients arc widely dispersed with roughly 10-12 patients in each village,
This requires widespread basic health care services in order to make TB
care available and accessible.
These epidemiological understandings and other findings derive from
several good quality research studies undertaken by government research!
institutions such as the National Tuberculosis Institute - Bangalore, the
Tuberculosis Research Centre - Chennai and the Indian Council for
Medical Research. They countered the current thinking which perceived
TB as an urban problem and one of children, etc.
2.2 Public Health and Programmatic Parameters
These include rates concerning case-finding, case-holding, default, relapse
and treatment failure. The research bodies mentioned above and others
have repeatedly and consistently reported
gaps between expected
performance and outcome (ICMR 1975, ICORCI 1988, GOI/WHO/SIDA
1992). After 40 years of intervention into what was termed India’s most
important public health programme, only approximately 8-16% of expected
cases of TB received complete treatment from the public health services
annually (Radhakrishna 1988). Case detection in 1987 was l/4th the
annual incidence of TB (ICORCI 1998). This was too low for any
significant impact on the problem. Only 27% of those starting treatment
made 12 or more monthly drug collections from 1982-86. Furthermore,
poor functioning of the programme among those registered / treated is
indicated by high case fatality rates - 25% in a district using short course
chemotherapy (Datta et al 1993), high ratios of prevalence to incidence,
increasing proportions of chronic cxcretors and increasing drug resistance.
This scenario is further compounded since the mid 1980s by HIV-TB co
infection, rates of which are increasing. A review in 1992 stated that ‘T'he
programme is not having a measurable impact on transmission and appears
to function far below its potential” (GOI/WHO/SIDA 1992)
2.3 Policy Process Perspectives
The technical indices mentioned in 1.1 and 1.2, though crucially important,
do not explore or reveal the reasons for the dismal scenario or for the
disparities and discrimination that exists within those affected by TB. It
has been observed that techno-managerial approaches to TB control
policies are insufficient to grasp important socio-political and policy
process factors that influence and determine implementation (Narayan
Underlying epidemiological and public health indices are
1998).
5
conflictual societal relations and interests which surface in sectoral action
and non-action. These include inadequate manufacture of TB drugs bp
pharmaceuticals despite indigenous availability of technology and
expertise. Production meets market demands but not epidemiological need
(ICS SR / ICMR 1981) and government Primary Health Centres and District
TB Centres chronically report inadequate and irregular drug supplies
preventing good chemotherapeutic practice. There has been a lack of
research into newer TB drugs till the re-emergence of TB in “developed”
countries. Another factor has been the promotion of the growth of the
private medical care sector, which dominates TB care with little regulation
or standardization of diagnostic and treatment practices. Irrational
prescribing practices for TB by private practitioners (Uplekar and Shepard
1991), overmedication and overdiagnosis of X-ray positive suspects
benefits the industry and providers. The poor are financially unable to
complete treatment with the private sector.
Distressingly high rates of indebtedness have been reported among this
impoverished group of patients (Uplekar and Rangan 1996, Narayan 1998).
This pushes their families further into the cycle of poverty, which with the
associated under-nutrition and poor housing is itself a breeding ground for
TB.
Governmental neglect of the NTP is evident in the under-financing of the
programme, which received only about 1.5% of the Central health budget
till a few years ago. Budgets below critical levels, with most expenditure
on salaries and maintenance rather than on effective services are wasteful
and counterproductive. Drug resistance in TB due to low funding and
consequent irregular, poor quality drug supplies is additionally harmful and
costly, besides violating the human rights of patients and society.
In the absence of effective public sector services, 80% of health care
utilisation occurs in the private for profit and voluntary sector. Rough
estimates suggest considerable national spending on TB, with gains
accruing to the diagnostics and drug industries and to medical professionals
whose macro interests differ from those of patients and of public health
(Narayan 1998).
Weakness in State intervention is further evident in infrastructural gaps in
the public health care system. For instance, the large proportion of
vacancies in microscopists/laboratory technicians posts at Primary Health
Centres (PHC) makes diagnosis difficult. Frequently absent staff, including
of doctors and rude behaviour towards patients, particularly the poor, also
aggravates the situation. It has been found that the programme is the
weakest at the PHC level, which was conceptualised as being the main
interface between the majority rural population and the general health
service with which TB care was integrated. This was the point closest to
peoples’ homes. The District TB Centres, supposedly the technical
6
backbone of the programme arc reduced to being curative centres for those
living nearby. In the absence of adequate trained staff and vehicles, their
move important role of providing professional leadership and support
through training, supervision, analysis of records and research is not
performed. Poorly functioning and weak peripheral institutions serving the
majority rural population, reflect power relations in society and comprise
an important reason for poor implementation. Even here, better off patients
can access the private sector or the services of the government sector for a
fee, exemplifying the stratification of Indian society and the lack of
entitlement of the poorest to essential health care. This stands in sharp
contrast to the Family Welfare programme, with its population control
undertones, which received Rs. 65,()()() million or 1.5% of the total Ninth
Plan Outlay (1992-97) as against the entire Health budget which received
1.7% of the total plan outlay. Another contemporary comparison is with
the national AIDS programme which in the early 1990s received 25% of
the central health budget though its epidemiological magnitude is much
smaller than TB. The use of conditionalities and aid as leverage for policy
change, by multilateral and bilateral agencies is one of the factors
responsible for this.
More broadly support to the growth of an unregulated private for profit
sector, including the pharmaceutical sector, has undermined the NTP and
public sector. Direct and indirect policies have promoted the private sector
such as subsidies to medical education producing graduates for the private
sector, support to capitation fee medical colleges, allowing or turning a
blind eye to private practice by government medical officers and others.
Thus TB services were made available in the market. More powerful
sections of society with ability to pay accessed these private services
reducing pressure on the public sector to perform
3. Jinplication of Problem DefinitioH on Strategics
It has been hypothesised that the way one understands the problem of TB
influences the choice of intervention strategics (Narayan 1998). This is
indicated in the table below.
7
i
TB and Society : Levels of Analysis and Strategies
Levels of Analysis of TH
Causal Understanding
Control Strategies
Surface phenomenon
public
(medical
and
problem)
health
Infectious Disease /
Germ Theory
BCG, Case Finding and
Chemotherapy
Poverty/deprivation,
Underlying cause
access
( symptom of inequitable unequal
resources
relations) _____________
Basic cause
(inter and intra-national
relations)
to
social
Land
reforms,
movements towards an
egalitarian society
& More just inter and intraContradictions
socio national trade, finance
inequalities in
and political relations.
political
economic
&
systems at international,
national and local levels
Modifiedfrom Ganapathy 1985
These are not either/or approaches. One needs to recognise that groups
working at different levels are in solidarity with one another and better linkages
and alliances across sectors would be beneficial.
Another illustration is the strategies employed, depending on the way in which
an issue such as default gets understood. In one approach, patient related
failures and factors get stressed with an element of victim blaming, without
adequately addressing health system failures or the circumstances of
deprivation and difficulty in which the person lives. This approach then
focuses on patient education that maybe guilt producing and on supervised
» therapy to ensure compliance. This is justified on technical grounds of
preventing transmission and development of drug resistance. Other approaches
see default as also resulting from poor TB case management deriving from
systemic failures of the health and related services. This approach would stress
the need for increased funding, improved infrastructural functioning (with
microscopes, microscopists, doctors, uninterrupted drug supplies, follow-up by
illnesses/drug
sidehealth
workers,
management of concurrent
effects/complications etc), supportive supervision and humane attitudes and
behaviour of health personnel with patients. While theoretically an integrated
approach is used, in practice, the second approach has been greatly neglected
by the state sector in India. The experience of NGO’s who have adopted these
approaches shows much better success in terms of cure rates and patient
satisfaction.
8
I
4. Impact of implenieiUatioii (japs on Patients, Families and Society
Loss of life often in young adulthood, disablement and indebtedness comprise
the heavy price paid by patients and their families. This situation is
particularly true for the poor. While the middle class and rich also get TB, they
have access to early care and cure and hence do not suffer these consequences.
The economic loss to patients, families and the nation is significant, while
suffering is immeasurable. Economic costs from TB have been estimated at
Rs.20,000 million a year through person hours of work lost (Ram Kumar
1993). Indirect costs of treatment to affected families are high, including
transport, food, costs of accompanying person, loss of economic productivity
of the patient and at least one other member of the family. These are larger
than direct costs of diagnosis and treatment (Narayan 1998).
It is a reflection of the structure and priorities of our society that we spend
millions obtaining the latest medical technology, even in Government
institutions, to diagnose relatively unbeatable conditions, while resource
constraint arguments are put forward to fund killer diseases like TB which can
be diagnosed relatively easily and cured. When one considers the amounts
spent for sports extravaganzas and defence of borders, the disparities become
more stark and obscene. Somehow, the loss of half a million lives is not
considered a national security problem calling for the best and urgent social
defence. Some lives perhaps are more important than others.
5. Preventing Violence, Caring for Victims/Snfferers, and those Disabled by it.
IB
The magnitude of the human problem caused by TB, especially with its current
co-infection status with HIV, is such that it is ethically imperative for all to
respond in some measure. If morals do not convince, at least from a point of
self-preservation, it is important. The spectre of drug resistant TB may touch
anyone. The government sector has to be pressured to perform with a sense of
accountability. This is because the major source of funding of the government
health services is from the tax-payer who is largely the common person, as
indirect taxes form the major source. Also, the Government has now taken a
large loan from the World Bank for the TB programme on which interest will
be paid, also by the tax payer. Besides, it is a Constitutional mandate. For
NGOs, critical collaboration needs to be established with the Government in
which one’s watchdog role and issue raising capacity as citizens of the country
need to be acknowledged. This should not be swamped over by playing the
alternate service provider role which is what may often be looked for. NGO
expertise, personnel and services need to be specifically focussed on the poor.
While the role of the private sector is recognised, regulation of standards of
care in maintaining accepted norms in diagnosis and treatment needs to be
ensured. The public sector will have to be a major actor in what is still a major
public health problem.
It has to take the responsibility of ensuring
implementation of its own strategy of early diagnosis and provision and
9
completion of effective treatment and supportive care for all forms of TB in
partnership with the major stakeholders of the programme, namely, the
patients. This requires the strengthening and non-fragmentation of basic health
care services through Primary Health Centres in rural areas and Municipal
Corporation Dispensaries and hospitals in urban areas. Additionally, socia
security and rehabilitation measures for advanced cases is required. More
flexible, area specific, community based, humane approaches are required
These have proven to work in India and elsewhere. Inspite of adverse
economic trends, countries like Cuba have achieved success in their TB control
programmes.
We need to be alert regarding the functioning of the NTP and supportive of TB
work in whatever way we can. TB is also in a way, a case study, and, much of
what is said would be applicable to infectious disease and more importantly, to
general health care services.
*****************
References
r
1. ICMR (Indian Council of Medical Research), 1975. A Review of the National
Tuberculosis Programme. Report of the ICMR Expert Committee. ICMR,
New Delhi.
2. ICORCI (Institute of Communication, Operations Research, and Community
Involvement), 1988. In-depth Study on National Tuberculosis Programme of
India. Unpublished Report for GOI. ICORCI, Bangalore.
3. GOI/WHO/SIDA, 1992. Tuberculosis Programme Review: India 1992
Unpublished Report. GOI/WHO, New Delhi and Geneva.
4. Radhakrishna S, 1998. Direct Impact of Treatment Programme on Totality of
Tuberculosis Patients in the Community. Ind J Tub. 35,110.
5. Narayan T, 1998. A Study of Policy Process and Implementation of the
National Tuberculosis Control Programme in India. PhD Thesis, London
University.
6. ICSSR/ICMR (Indian Council of Social Science Research and Indian Council
of Medical Research), 1981. Health For All: An Alternative Strategy. Indian
Institute of Education, Pune.
7. Uplekar MW and Shepard DS, 1991. Treatment of Tuberculosis by Private
General Practitioners in India. Tubercle. 72, 284-290.
8. Uplekar MW and Rangan S, 1996. Tackling TB: The Search For Solutions.
Foundation for Research in Community Health, Bombay.
9. Ganapathy RS, 1985. On Methodologies for Policy Analysis. In Ganapathy
R.S. et al (eds) Public Policy and Policy Analysis in India. Sage Publications,
New Delhi.
10. Ram Kumar ER, June 5-11, 1993. The Illustrated Weekly of India, New Delhi.
10
(
Abstract of Paper to be presented at International Conference on ^Preventing
Violence, Caring for Survivors : Role of Health Profession and Services in Violence
(November 28-30th, Mumbai, organised by CEHAT)
Title
A Violation of Citizens Rights : The Role of the Health Sector,
particularly of the State Health and Related Services, in regard to
Tuberculosis in India.
Author
Dr. Thelma Narayan, MBBS, Ph.D.
Community Health Cell,
Society for Community Health Awareness, Research and Action,
No.3677, ‘Srinivasa Nilaya’, Jakkasandra I Main,
I Block, Koramangala,
Bangalore - 560 034.
Phone : 91 - 80 - 553 15 18 & 91 - 80 - 552 53 72
Fax: 91 -80 - 55333 58 (Mark Attn. Community Health Cell)
Email : sochara@blr.vsnl.net.in
ABSTRACT:
Tuberculosis (TB), a major public health problem in India since the 1900s currently affects 14-17
million people (prevalence) and causes the estimated annual death (mortality) of 500,000 persons.
Country-wide government sponsored anti-TB public health measures introduced in 1948,
developed into the National Tuberculosis Programme in 1962. Despite gains, implementation
gaps between programme goals and performances over 35 years have been such that there has
been insignificant impact on the magnitude of the disease problem. Poor implementation results
in millions of citizens receiving inadequate, wrong and irregular treatment. Tuberculosis is easily
curable at very low cost, and, suffering and death due to TB is preventable. Though technology
for TB drug manufacture is indigenously available, production is inadequate for the need.
Inadequate drug supply in government health services, and inability to access drugs by poor
patients occurs frequently. Poor TB case management due to systemic failures of the health and
related services have resulted in the development of drug resistance and in an increasing number
of chronic excretors who continue disease transmission in society.
Unequal societal relations affect not only the development and transmission of TB, but also the
implementation of control programmes, particularly for the underprivileged, among whom high
levels of indebtedness due to the disease and difficulties in accessing private services have been
noted.
The State has abrogated its Constitutional mandate to protect the health and well being of its
citizens by under-funding the National TB Programme, by not ensuring the development of basic
health services through which TB care can be provided and by not heeding the recommendations
of its own specialised national TB institutions and researchers. Efforts are required by all
sections of civic society, particularly the health sector, to prevent the violation of health rights by
ensuring early diagnosis and completion of effective therapy so as to achieve cure. Additionally,
social security and rehabilitation measures for advanced cases is required.
C:\OFFICE\november correspondence.doc
Custodial Deaths : Delhi Experience
Kiran Shaheen
Between 1980 to 1997 ninety three people have died in the custody of
Delhi Police, 47 in the last eight years ( 1990-1997 ) alone.
This is a report on how deaths happen in police custody and on what
happens afterwards. It also tries to see the lives of those who then wait endlessly
for paltry sums of compensation. Deaths in police custody need an urgent and
immediate response.
Custodial death is a routine occurrence and does not usually merit more
than a passing mention in the media. This is because the hapless victim is
invariably a poor migrant residing in a slum settlement, is very often a minor
law breaker, and perhaps even a habitual bad character or a social dropout,
whose death is of little consequence.
Such killings are not normally premeditated, being the most aggravated
and accidental outcome of merciless torture and neglect. The average of five to
sex persons who die in this fashion even’ year comprise a miniscule proportion of
the persons subjected to such treatment in custody. These deaths therefore point
to a larger context of routine and habitual humilation, beating and torture meted
out to those detained in lockups.
Background of the victims
The economic and social background of the victims invariably provides
the context in which they confront the might of the police, since most of them led
precarious lives as migrants struggling for adequate livelihood and decent living
conditions in the city’. Unable to find either, they are forced to become
’encroachers', without any right to the civic amenities provided to Delhi's other
citizens. Any attempt to find a livelihood or create one, involves the violation of
one or another rule; and failure to do so pushes some of them into the world of
petty crime. Trapped in this situation of perpetually breaking the law, the agency
of the state they face constantly and directly is the police. The social roots of
custodial deaths therefor lie beyond custody, in the lives of the victims.
The occupations they belong to
The peripheral and precarious nature of their lives is exemplified through
some of the occupations of the victims: fruit vendor, auto-driver, auto-driver,
shop-employee, rickshaw-puller, watchman. While it is difficult to ascertain
exact income levels as most of them held irregular and intermittent forms of
employment, a broad categorization can be evolved based on the nature of
occupation and consequently the degree of vulnerability to police brutality . A
majority of them were migrants -either first or second generation - who resided
in urban villages, slums and resettlement colonies.
The most vulnerable were those who were forced in rag picking or else hawking
their wares on footpaths. Out of the 93 victims, occupational details are not
available in 18 cases. Of the rest, 19 were either seeking employment or were
employed on a casual basis, 26 worked in traditional occupations such as
blacksmith or dhobi or else were engaged in hawking, rickshaw pulling or
vehicle repair, 8 worked as drivers in autorickshaws, taxis, trucks and buses, 12
were organised workers in factories or else in government departments, another
6 w ere petty traders, shopkeepers or small entrepreneurs.
Most of the victims had come to Delhi in search of employment. The
desperation and aspirations which drive people to leave their native village!;,
often end in a bitter struggle for survival in the cities. The 1991 census recorded
that Delhi’s population grew' by 51.45% between 1981 and 1991, over a half of
which was accounted for by in-migration. 60% of these migrants who came in
search of employment, stayed on as squatter population. Not surprisingly, the
growth rate of jhuggi ghompri (JJ) clusters is eight times the overall growth rate
of the city. Of the 47 victims between 1990 and 1997, 13 resided in resettlement
colonies, 15 in slums and JJ cluster, and 7 urban villages.
A Case Study
The lack of basic civic amenities was the context for the death of Dilip in
Shaheed Sukhdev Nagar in January 1995. Unaware of a trespass notice, Dilip, a
newcomer to the city,used the nearby park for defecation. A constable guarding
the park beat him up and he died on the spot. The park separating the JJ cluster
from the middle class locality of Ashok Vihar , had over the years become a
contested area. Since there are no toilets in the Basti, residents often used the
park for defecation, apart from using it as a short cut to the market and a nearby
go^’t school.
But the Residents Association of Ashok Vihar filed a writ petition in the
High Court demanding exclusive rights over the park for leisure purposes. The
court gave injunctions against misuse of the park, and the police was posted to
guard it
The irony can not be missed. While there are no basic amenities in the
basti which serves as the labour market for the Wazirpur Industrial Area, the
court observed that there seems to be little justification for taxpayers money
being spent in favour of law breakers.
(2)
Dilips death and the subsequent firing on protesting residents of the
basti, were explained away by the police as an inevitable and necessary
intervention in a conflict between haves and have-nots. The custodial death of
Dilip is thus utterly consistent with the logic that governs the lives of Jhuggi
Jhopdi dwellers.
The Age Group of the Victims
The majority of the deceased were young men between the ages of 18
and 35. Almost half of those killed were below 30 years of age. Many of thse
victims had no steady source of livelihood. Frequently such unemployed young
men residing in unauthorised colonies, end up being seen as habitual offenders
who are then routinely picked up by the police.
The classification of such men as bad character means that irrespective
of their involvement in a particular crime, they will be rounded up by the polic^
and interrogated.
Law and Lawlessness
Prolonged beating by lathis, iron rods, boots or belts is common.
Frequently, electric shocks or burns are inflicted.sexual abuse and other forms of
humiliation are also used. And this despite the fact that under section 25, 26 of
the Indian Evidence Act, confessions made to the police are not admissible as
evidence in courts. There are also provisions against the use of torture under
sections 330 and 331 IPC. Article 20(3) and Article 21 of the costitution hold
torture as violative of fundamental rights.And there are several supreme courts
judgements holding torture as illegal.
Police Versions
In every case of custodial death, the police offer thier version of the
relevant events leading to the death, and of the causes of the death. These are the
favourite police versions:
1. Suicide : Out of 93 deaths in Delhi, at least 29 victims are alleged to have
committed suicide. Police yarns of suicide wilfully conceal the aggravated mental
torture that is also a sinificant cause for deaths in police custody.
2. Ill-health and Injuries : Other police versions revolve around prior ailments
and injuries. 13 persons are alleged to have died due to injuries sustained prior
to their detention, 6 due to fever or illness, 5 due to heart attack, 3 due to
stomach pain, 3 due to heat stroke or dehydration, 2 due to tuberculosis, 2 due to
chest pain, and 5 due to accidents.
(3)
Such claims firstly have to confront the fact that the victims, in general,
were in the prime of their youth - barely 8 percent of them being over 40 years of
age. It is difficult to believe that the overw helming majority of young men suffer
from a variety of chronic ailments, secondly, police needs to explain how the
ailments — old, new and hitherto unknown — miraculously blossom once the
person is in custody, to cause death within hours and sometimes minutes.
3. Not detained : The version offered by the police does not hinge upon cause of
death alone but covers all the events leading to death, starting with the detention
itself. Unofficial ( Illegal) detention in the name of inquiries or interrogation are
quite common, without a record in the Daily Diary of the police station. The
practice of not keeping a record of detention or release is then useful in
concealing the actual period of detention.
4. Death outside police station : Even if the police admit hat a person was
detained in the police station, they deny that it was a custodial death if the victim
died afterwards outside their custody.After a detained person is subjected to
severe torture he may be released: Dilip Chakraborty was released after being
detained illegally by special task forcein North East area of Delhi. He lapsed into
a coma caused by the head injuries and died six days later in a private hospital.
5. Not our custody : Another option available to the police is to shift a person
from their custody to the custody of another police station or to judicial custody.
When more than one police station is involved, each can deny its culpability and
blame the other.
Aftermath
1. SDM INQUIRY : It is mandatory’ that the nearest exicutive magistrate shall
hid an inquiry' into every case of death in police custody. The SDM inquiry has
the power to indict the police. How ever, SDM inquiries are not held in every case
of custodial death. They are usually held only in cases where the police prima
facie accepts the death as having taken place in its custody.
2. POST MORTEM : Clinical causes of deaths such as heart attack or
dehydration are common conclusions of post mortem reports in custodial death
cases.
POLICE INVESTIGATION : It is mandatory in law' for the police to
>
record any information about a cognizable offence, in the form of a written FIR.
Registration of the FIR must then be followed by police investigation of the case.
FIRS have been filed against police officials in less than one third of the total
deaths. In the 35 cases since late september 1991, FIRs were filed, and that too
either because of public protest or because of the recommendation of SDM
reports, in only 19 cases.
(4)
(A) DEPARTMENTAL INQUIRIES : Another strategy ’ used by the police fo •
not lodging an FIR and therefore not conducting investigation, is to hold a whole
range of internal inquiries.These are Departmental Inquiries, Vigilance
Inquiries, Crime Branch Inquiries, District Crime Cell Inquiries, and so on.
These are conducted by police men of a different police station, or by senior
police officials. The family of the victim has no rights in such an inquiry, no say
as to w ho should be interrogated, and no right to present evidence of their ow n
or to cross-question witnesses.
The police create huge obstacles in the course of criminal investigation,
by harassing and intimidating witnesses and the victims family. Persons w ho had
been detained together with the suspect, are threatend with dire consequences i'
they disclose w hat actually transpired in custody.
Judicial Indifference
To date, there have been only two convictions in the last 18 years. Few
cases ever reach the courts. Between 1990 and now of the 22 FIRs lodged, only 6
cases have reached the trial stage.
The existing laws, mechanisms, procedures and safeguards have
therefore not only failed to check the menace of custodial deaths, they have also
failed to deliver justice to the families of the victims.
The frequency w ith which people die in the custody of Delhi police does
not exhibit any tendency to decline over time. There is also a significant
difference in the two decades in the period of detention. In the eighties, a large
number of people died after prolonged periods of illegal detention. This
phenomenon largely upheld the arguement that apathy and negligence
aggravated the physical and mental assaults suffered by the victim and finally
led to death.
In the nineties, however, over 60% of the victims died after spending
only a few hours in custody.
These two decades have however witnessed an increasing attention by
the media, as well as protests by civil rights groups and local residents
concerning such deaths. Yet this entire process of crime, lies, apathy, and still
more crimes, is achieved without any apparent denial of peoples rights. For, the
people are free to approach the courts, even to the highest level. That their
poverty and social status prevent them from knocking at the doors of justice.
And the custodial deaths continue to occur.
★*★★★★★★**★**
C/o, MARG
( Media Action <& Research Group )
109, Kalavihar, Mayurr Vihar-I, Delhi-110 091.
Phone : 91-11-2718597,2715311. Fax:91-11-2719366.
Email : growcnter a nda.vsnl.net.in.
VIEWS AND EXPERIENCES OF THE MANIFESTATIONS
AND IMPACT OF COMMUNAL VIOLENCE IN MUMBAI :
A COMMUNITY PERSPECTIVE.
PRESENTATION MADE AT THE CONFERENCE ON
‘PREVENTING VIOLENCE, CARING FOR SURVIVORS:
ROLE OF HEALTH PROFESSION AND SERVICES IN
VIOLENCE’
FOR THE THEME DISCUSSION CASTE AND COMMUNAL
VIOLENCE.
ORGANIZED BY CEHAT, AT YMCA, NOV 28 TO 30, 1998.
BY NASREEN CONTRACTOR, YUVA, MUMBAI
The material for this presentation is drawn from the experiences of
YUVA of working in the slum community of Jogeshwari East,
Mumbai for the last 14 years and from a research study that was
conducted during the period 1993 to 1995. For more information see
“Planned Segregation: Riots, Evictions and Dispossession in
Jogeshwari East, Mumbai, India”, YUVA COHRE, 1996.
ABSTRACT
This presentation describes the context of violence, its manifestations
and the response of the health profession and services as experienced
in a slum community located in Jogeshwari East, a suburb of
Mumbai. The population of this community is about 40,000, with the
majority being Muslim households. This community is unique in the
sense that over a span of three decades this community has
experienced periodic riots that have impacted the social, economic
and political fabric of the community.
The first section profiles the community in terms of various
dimensions, namely the demographic and physical profile of the area,
the housing and living conditions of its residents, and its history of
communal nots. The specific demographic profile of this area
coupled with its complete lack of services has rendered this
community highly vulnerable to violence and to the access of its
residents to health facilities.
The second section describes the manifestations of violence through
the impact the nots have had on residents. The impact is described
both in terms of its physical manifestations (injury, death, destruction
to property) as well as its socio-psychological manifestations
specifically on women, children and youth.
The third section contains actual experiences recounted by residents
of their attempts to seek medical help during the time of crisis. These
experiences highlight not only inadequacy but non-responsiveness
and at times even callousness that was exhibited by the health system,
police force and the communalized environment as a whole.
The madequacy of facilities is true to several other communities in
Mumbai and is indeed the case tor the entire city. But what this
presentation seeks to highlight are the serious consequences of
inadequacy of services coupled with inaccessibility at the time of
crisis that the residents of this community face.
L PROFILE OF THE AREA
Demographic and Physical Profile
The area referred to in this presentation is a community of about 3,
50,000 people living in slum settlements spread over 6 sq.km in
Jogeshwari East, Mumbai. The community lies approximately 2 kms
east of the railway line dissecting Jogeshwari, a suburb situated about
30 kms north of Mumbai’s commercial and political centre. The
population consists primarily of Hindus (about 60%) with a large
concentration of Muslims (about 35%). Other religious groups like
Christians and Sikhs comprise the rest (about 5%). More than half of
the Hindu population falls under the category of Backward Castes.
Living in small one/two room tenements, the majority of residents
belong to the poor working class. While some are employed in the
formal sector as clerical staff in government offices or private
busmesses or as factory workers, the majority form part of the
informal and unorganized sector, being carpenters, masons, painters,
artisans, hawkers or labourers in small manufacturing units. A few are
involved in business, trade or own shops. Women work in home
based industries or as domestic help m middle and upper class
neighbourhoods.
The settlements are located on and around a hillock. Whereas earlier
residents from diverse religions lived in interspersed clusters, today
there is a clear divide in the geographical location of the Hindu and
Muslim residents. The Hindu settlements are located at the base and
around the slopes of the hillock with a dense concentration of Muslim
residents at the apex of the hill. Over the years there has been a
phenomenal increase in the population of the entire community.
Joaeshwan East has drawn several migrants to it in the last 15-20
years. Increase in the density of population stands higher in the
Muslim settlements than in the other settlements.
Profile of Housing and Living Conditions
The settlements of the slum community of Jogeshwari East are located
on lands owned by the Municipality, State Housing Board, private
trusts or individuals. Each of these are governed by differing
legislations. The extent of security and amenities enjoyed by the
residents is determmed by these laws as well as the duration of their
existence on the land. For instance, some of the settlements are
declared as ‘slums’ under the Maharashtra Slum Areas Improvement
Act and enjoy certain basic amenities, whereas other settlements
within the same area are more deprived. The process of securing
amenities is usually through people’s initiative and struggle. For
instance the settlements of Indiranagar and Shivtekdi had a perpetual
waler problem as they are located at a height. The Municipality made
no attempt to manage the water pressure so that water could reach
these areas. People were told to purchase their own pipelines which
they did, only to be left frustrated at the contmued absence of water.
The availability of civic amenities is very often determined by the
negotiating power of residents or their connections with the local
politicians, officials and even goons As the amenities are not granted
as a right to all residents, they become opportumties for speculation
by the goons.
Toilets, dramage and sanitation are also in a severe state of disrepair
or prove madequate. Residents are not permitted to build their own
toilets It is only recently that the Municipality in certain areas have
entered mto contracts with private welfare groups to construct toilets.
While civic amenities m terms of toilets, dramage, water, electricity
are generally madequate m all the settlements, schools, banks, post
boxes and other government welfare services are almost nonexistent
3
in the Muslim settlement. While most tenements are constructed with
formal building materials like brick, cement and concrete,
approximately 20% of the structures are built of informal materials
like plastic, bamboo, tin and jute sheets. A maze of narrow lanes,
open dramage, queues at water taps and ration shops - these are some
of the most vivid descriptors of the community and its living
environment.
In terms of transport, it has again been only very recently that more
than one bus route goes through the entire community. There is no
public transport to the centre of the area and even auto rickshaws can
ply only upto a point. This leaves certain settlements completely cut
off, confined within a maze of intricate lanes and gullies that are
accessible only by foot.
With regard to educational facilities, there are only three Municipal
run primary schools and no State run secondary schools. The few
secondary schools which exist are private and unaffordable for
several of the poor residents. Health facilities are also poor. The
closest Municipal run general hospital is located at least 5 km. away.
There is only 1 matenuty home and 1 municipal run dispensary in the
entire community. Residents are compelled to depend on private
doctors and even quacks.
Profile of Riots
As a site of communal violence, the slum community of Jogeshwari
East is both unique (there have been riots here alone while rest of the
city was peaceful) and illustrative of the general characteristics of riots
all over the country. There have been five riots during the last two
decades: in 1964, 1974-75, 1984, 1990-91, 1992-93. The most
important pattern that has emerged through the trajectory of riots is
the alarming demographic alteration of space within commumties
caused due to eviction and uprootment. The demographic profile of
Jogeshwari has been radically altered from one of religion wise
interspersed population clusters to polarized population clusters.
Since the population of Muslims in Jogeshwari is in a minority in the
area the physical polarization has lead to these families being huddled
together into one geographical pocket The pecukarity of the pattern
in which the community has developed is such that this pocket lies in
the centre of the community, which is al the peak of the hill,
surrounded by settlements of Hindu families all around. All access
4
routes out of the commuruty, except one wluch leads directly to the
highway, is through the Hindu settlements. At times of crisis such as
communal riots, this pocket, which as described above is starved of
public health facilities, faces a particularly vulnerable situation.
IL IMPACT AND MANIFESTATIONS
The consequences of the nots have been both immediate and long
term. The immediate consequences relate to: threat to life/evictions,
the trauma of relief camps, damage and destruction of homes, impact
on work and income, effect on women, impact on children s
education, impact on mental health. The long term impacts relate to:
uprooting and dispossession, decline in economic status, loss of
educational opportunities, break up of famihes, impact on women and
cnmmalization. These mamfestations have been defined on the basis
of a survey of 78 famflies that was conducted in the post 1992-1993
not penod.
Threat to Kfe/evictions
Most people experience immense tear and insecurity and threat to
their lives on the outbreak of a riot. Of the 78 uprooted families
interviewed, 71 families had to flee from their homes though only 13
reported that they were actually injured. 7 did not flee but later shifted
residence.
The Trauma of Relief Camps
The difficulty and discomfort of temporary stay is yet another
important impact to be considered. The feehngs of anxiety about
one’s home, of being unsettled, the dependence on outsiders on all
basic necessities like food and clothing, the feeling of being a burden
on relatives, overcrowding and lack of privacy are conditions of
being nothing more than refugees and the trauma of this experience
must be considered so.
Damage and Destruction of Homes
Another very real impact of the riots and evictions is the physical
damage caused to homes. Besides families have lost valuable
documents pertaining to the legal security of their homes, ration cards,
birth certificates, medical papers and education certificates.
5
Impact on Work and Income
During the period between the riot and resuming of normalcy, people
are unable to work, be it at their work place or at their homes. Being
unable to move out during the periods of noting and curfew and the
subsequent time spent in resettling, remaking documents, medical
treatment and arrests, have all resulted in loss of valuable workdays.
Effect on Women
Riots are a period of great insecurity and vulnerability for women.
They become targets of male sexual abuse and sometimes even assault
to symbolize the attack on the particular community which they
represent. Taunts, abusive language and eve teasmg have been used
freely Besides this, the trauma of fleeing, feeling unsettled, fall in diet
patterns, illness or arrests of family members are particularly severe
on women as their role of nurturers and housekeepers undergo stress.
The experience of witnessing their husbands, sons or brothers rioting
or being attacked and injured is traumatic and debilitating. An
alarmmg trend that was observed after the ‘92-’93 nots was a spate of
suicides among women. Five to six suicides occurred within a span of
a couple of months. While a direct link between these incidents and
the nots cannot be established, a weakened copmg capacity leading to
depression was defimtely observed among women.
Impact on Children's Education
Just as the adults are unable to go to their work places, children are
compelled to absent themselves from school. If the not penod
corresponds with exammations, then it might lead to the loss of an
entire academic year. This leads to drop outs. Girls are kept back at
home due to the sense of insecunty and unwillingness to send them to
schools outside the community.
Break up of Families
Families which were joint have become nuclear. As a result of
dispossession, families that were once joint are unable to find similar
kind of accommodation that they enjoyed earlier and are hence forced
to become nuclear This disintegration has led to a loss of the physical
and emotional support
6
Impact on Mental Health
Forty two persons from the 78 interviewed mentioned loss of sleep
due to fear and shock. 12 spoke of having nightmares. In 24 families
the children/elders suffered fever. Three persons spoke of temporary
loss of mental balance due to the trauma of the liots.
Uprooting and Dispossession
One of the most significant long term impact of evictions has been the
overnight uprooting and dispossession of people from homes in
which they have lived in peace and harmony for 20-30 years, to seek
shelter in places where they feel more safe and secure.
Dedine in Economic Status
The economic status of riot affected families has fallen sharply. This
is a result of, loss of capital assets, fall in income, loss of ownership
of one’s house, change in quality of house, reduction in size of house,
indebtedness.
Criminalization
Youth have taken to anti social and even criminal activities. Bitter
experience and frustration push youth to the brink.
Hence the impact of riots is not just physical injury and destruction of
homes but impacts on peoples’ lives, livelihood, productivity
ultimately impacting mental health.
III. EXPERIENCE OF THE ROLE PLAYED BY HEALTH
PROFESSIONALS AND SERVICES
Residents of the community reported that the experience with injuries
that were comparatively small and those that were more serious were
completely different. Families whose members had suffered from
small injuries were just not willmg to have these treated as they feared
that if they did so they would be faced with a police case. Major
injuries had to be rushed to the nearby hospital. But given the
ghettoized condition of the community and the tense situation patients
could just not be taken to hospitals. The area was heavily guarded and
7
families could not respond to their injured. Many a times, victims
were just left lying on the road and when the police came they would
be taken to hospitals. Ambulances driven by residents have been
attacked at borders by both residents of the opposite community and
the police and people had stones to tell of heroic attempts to drive
through all odds to rush victims to hospitals. At hospitals, till the
panchnama was not done, medical attention was not given. There are
even instances of preferences being given to patients of one
community over another. Victims have even been refused medical
attention. In this case, the local pohtician took out a demonstration to
the hospital to ensure that members of one community were taken
even over and above urgent attention required by others.
Hence m a not situation, this community becomes completely
fortressed with all exit routes cut off due to heavy secunty and
violence. In the absence ot any health facilities in the community,
residents are left to the mercy of the police to take them to hospitals.
Doctors are unable to enter the area and the few doctors who reside
locally are afraid to work openly. Medicines are unavailable. Such a
situation is particularly dangerous for pregnant mothers and patients
suffering from high nsk medical disorders as during such a crisis
there is no possibility of treating any emergencies of this kind.
Thus the madequacy of facilities is true to several other communities
m Mumbai and is indeed the case for the entire city. But what this
presentauon highlights are the serious consequences of inadequacy of
services coupled with inaccessibility at the time of crisis that the
residents of this community face.
8
Response of Doctors to Communal Conflict
'Illis Presentation is based on our experiences, working in the Communally sensitive
areas of
Hyderabad - mostly the old city. The old city, congested, with very few basic amenities and
inhabited
mostly by poor, uneducated masses and liustratod youth - both from the Muslim anil Hindu
Communities, is a ripe breeding giound for cannon fodder for the political and vested interests who al
the slightest opportunity stoke the communal fires to achieve their dubious ends. The cormjion man
has come to view the Peoples Representatives, the Government and the Administration with t
suspicion
Every thing is either ‘Them or Us”, ‘Theirs or ours”. They or we” . The Government
mid the
administration usually belonging to ‘Them1 mid working for ‘their’ good. The mutual susp „
cions of
the Muslims and Hindus are based on the perceived well being of the other communities anil
J on the
false premise that the Government and the elected representatives always work for the bene
it of the
other community.
'Hie influence of Political and Religious groups on the students through their respective students
youth wings is well known. All major educational institutions have students unions w lich are
affiliated to different political and religious groups. These groups make no bones about using the
student unions to propagate their ideologies and influence the young minds. Medical Colleges and
Medicos arc no exception to this influence. The cleverly designed propaganda of (he political parties
percolates the sub conscious of the people. Few people who are conscious of this and see through it
remain immune . The rest who are more occupied about the routine mundane things in life get
life get
swayed and accept the stereo types created by the communal forces, which in the long run dictates all
their actions - both professional and personnel. Doctors Jitter all are human beings ~ can they be free
of such influence ?
Hie doctor during a conflict period is in a very unique situation. The doctor-patient relationship at
such times is a very delicate one. For the patient who is undergoing severe mental andI )hysical
trauma, the doctor is the only person who can save his life. He views the doctor as one notclli above
everybody else close to a super human who has the power to restore life to the dying. One the other
hand he is also convinced that he has suffered because of his identity. “'I’hey” have made him suffer,
lhe slightest inconvenience in the hospital shatters this image of the demi-god, and every act of the
doctor or his associates il they happen to be from the other community is seen as an attempt to inflict
more suffering on the patient. On the other hand, for the doctor (he patient is one more numerical mid
hardly any effort is made to regard him as an individual in need of care, counselling, treatment and
rehabilitation. This is not supposed (o be the work of the doctor.
Information sought by anxious family members is seldom readily given. A young student( - Airoze of
10th Standard who was injured in (’■
'
‘ho ventured‘ out to «fetch
• tea for his urjcle was
the 11
Police *’firing when
operated upon 12 hours idler he was admitted in the hospital, ’fhe blood procured on the doctors
prescription was not infused for more than 2 days. Anxious inquiries by his father was met either by
stoic silence or with remarks like “Doctors know what they are doing”. Finally after 2 days one doctor
cared Io explain that since the blood was not screened properly and since the patient was young they
did not want to risk infecting him with unscreened blood. Din ing my work amongst the riot
victims
such instances where doctors really took the trouble of explaining the line of treatment to Relatives
were rarely found. Doctors on other hand feel dial the sheer number of patients during riot periods
makes it impossible for them to satisfy eveiy querry. Intel Terence from political activists, who
demand immediately attention for their supporters or lor victims of one particular community add to
the pressures on the doctor. Instances ot doctor being threatened and manhandled have occurred many
times.
Communal riots do not erupt all al once. There is usually a build days before the actual riot takes
place Even a common person on the streets feels the riot coming But surprisingly no government
hospital has any contingency plan. As a result of this the hospitals are ill-equipped to handle the huge
inih x of riot victims. Victims are asked to get medicines from outside. One fails to understand how
a riot victim who has been brought to the hospital either by police or some good sninaritmi. who may
not have sufficient money on his person is expected to go out and purchase medicines when the whole
city is up in Hames. The hospital authorities cite -'No Funds*' as the reason for not stocking even life
saving drugs. Indeed the budget allocations for health services do not increase proportionately to (he
increase in the numbet of people utilising the services.
Meagre budget allocations reduce the utility of the hospitals in more than one way.
Since the hospital cannot provide transportation, doctors ai'e unable to reach the hospitals during
the riot period. An overworked police force makes matters worse by not recognising their identity
cards and insisting upon a ciudew pass. As a consequence doctors ‘Caught’ inside the hospital are
forced to work non stop sometimes for days together.
Lack of funds is cited frequently .for not tilling up vacant posts. In the Osmania General Hospital
number of posts have been vacant for almost a decade now.
Life saving equipment is usually in a state of dis-repair . Even an ordinary X-Ray has to be done
outside.
Drugs, saline solutions even syringes and needles have to be procured from the niai ket
Co-ordination between different Government departments especially between police and health
department can help alleviate most of the problems to a certain extent. Sharing of police intelligence
reports with the hospital authorities will enable the hospitals to be prepared for a huge inllux of riot
victims.
Instances of riot victims being turned away from private hospitals abound. Laws relating to the
medico- legal cases rue quoted by the private practitioners to keep away the helpless victims Under
section 39 of Criminal Procedure Code a medical practitioner is not legally obliged to give inlbrmalion
to the police officer or magistrate of the commission of or ofthe intention of any person to commit the
oilense of criminal miscarriage Yet (he private practitioners resort to the plea of police harassment to
avoid treating poor patients. The supreme court has also directed the private practitioners to attend to
the victims of accidents or disasters if they are called upon to do so. Most ofthe effected people I
spoke to opined that private practitioners fear that the riot victims- since they aie usually from the
poorer sections may not be able to pay the hospital bills.
U is important that riot victims be attended Io at the nearest hospital. This will save lives which are
needlessly lost, 'fins will also help reduce pressure on the over burdened, ill equipped 8c under staffed
government hospitals, it is essential that doctors especially the medical students be sensitised on
issues relating to victims of communal violence.
Although prevention of communal conflict is of prime importance, the response of doctors to
communal violence is necessarily curative in nature. It is therefore imperative that legislative reforms
for treatment ofvictims at private hospitals be brought in, contingency plans be drawn up., life saving
drugs stocked, steps taken to make hospitals free of political interference and co-ordination with other
government agencies be made Lastly Hviisilibalion of doctors and para-medical staff on issues relating
Io communal conllicl is needed not only at the medical college but also al periodic intervals in the
hospitals.
-Ali Ab’ghar
COVA
20-4-10, Near New Bus Stand,
Charminar, Hyderabad 500002,
C:\word\Medical\26-l 1 -98
11-10
Key-Note Address
Jaap A. Walkate
Chairman of the Board of Trustees of
The UN Voluntary Fund for Victims of Torture, Geneva
To the International Conference on
’’Preventing Violence, Caring for Survivors
Role of health services and professionals in violence"
28-30 November 1998, Mumbai, India
Mr. Chairman, distinguished Participants,
1.
It is a special honour for me to have been invited by Dr.Amar Jesani as a guest
speaker at your conference which addresses such as important subject. Much to my
regret my agenda did not allow for a visit to Bombay in the last week of November and
therefore I had to find another way to communicate to you. Fortunately, my good friend
Dr.Adriaan van Es told me that he would participate in the conference and> would be
prepared to read what I have to say. The subject you are about to discuss is of an actual
and urgent nature and, moreover, a problem of enormous proportions. It is a problem
which is not confined to one country but is common to many countries in the world,
albeit in various degrees and forms. The programme of your conference is ambitious and
well focussed violence by state agencies, violence against women a and caste and
communal violence. You will find that after the three days that you have set aside to
discuss these topics you will leave with the idea that you only have touched upon these
subjects and’that you will need much more time to grasp the implications of the
undisciplined use of force and to come to grips with the ramifications of each of these
types of violence.
2.
The use of force by state agents citizens is and should be the subject of
constitutional and statutory rules and regulations in every state. In addition to that
international law provides for a large number of rules which are contained in treaties,
codes and resolutions drafted and adopted by the United Nations, Specialized Agencies
of the UN, the Council of Europe and other regional organizations. The best know of
these texts is the Universal Declaration of Human Rights whose 50th Anniversary will be
celebrated on the 10th of December, only a fortnight from today. That Declaration has
been the foundation of and inspiration for these international norms and rules of decent
behaviour by State agents in relation to the citizens of that State. The drafters of that
Declaration were driven by their ‘‘to free mankind of barbarous acts which have
outraged the conscience of mankind and the advent of a world in which human beings
shall enjoy freedom of speech and belief and freedom from fear and want “ as the
Preamble to the Declaration enumerates a variety of rights and freedoms which will
enable the citizens of a State, the members of a society, to live peacefully together in a
democratic constitutional framework in which the powers of the government are
exercised only in accordance with the rule or law. The Declaration’s ultimate goal seems
to be the creation of a sound, sane and safe society. A society not subjected tot he rule of '
law and dominated by force and violence produces fear in its members and fear is
crippling, paralyzing and debilitating in its effects. In fact, it would constitute a negation
of health as conceived by the World Health Organization. The constitution of that
specialized agency of the UN defines “health” as “a state of complete physical. Mental
and social well-being, and not merely the absence of disease or infirmity”. The absence
of physical and/or of mental and social well-being, therefore, would in itself constitute
under the definition a lack of health. A fortiori, the occurrence of violence, the
uncontrolled use of force or the persecution on grounds of race, sex, religion, descent or
class, causing fear in and damage to the individual constitutes a negation of “health” as
defined by the WHO-constitution. But at the same time it will constitute a violation of
national and/or international Law. Lawyers, human rights activists, physicians, health
personnel and all of you present have the common duty t maintain and, wherever
necessary and possible, to restore the physical and mental sanity of all members of the
society to which they belong. They must do their utmost in the maintaining of the rule
of law, in the administration of justice, on the execution of lawful punishment, in the
safeguarding of the individuals dignity and integrity and the guaranteeing of his human
rights, including his right to, and I quote from one of those treaties, i.e. the UNCovenant on Economic Social and Cultural Rights: “the enjoyment of the highest
attainable standard of physical and mental health”.) the protection of the human integrity
of each individual is their sacred duty.
3.
The use of force by state agencies, such as the police, personnel of detention
centres or, as the case may be, military units, not seldom involves such measures as
torture or other cruel, inhuman or degrading treatment or, in some countries, corporal
punishment. These (illegal) measures sometimes require the co-operation of healrh
personnel: physicians or paramedical staff. According to reliable reports on the
occurrence of torture medical personnel are used by the perpetrators of such acts. They
contribute sometimes by devising methods of torture which do not leave visible scars on
the victim, sometimes by preventing torturers to go too far and to lose a valuabe
detainee who still should disclose more information, sometimes by reviving victims io
prepare them for another round of beatings. In the past we have seen that medical staff
of detention campus issued false certificates of mental illness, thereby subjecting their
victims (‘‘patients” is not the appropriate term) to a treatment with drugs that had bad
effects on their psyche and body, thus constituting a form of torture. This conduct has
been declared not only as illegal and punishable but also as a “gross contravention of
medical ethics” by the UN General Assembly in 1982 by the adoption of its Principles
of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in
the Protection of Prisoners and Detainees against Torture and other Cruel, Inhuman or
Degrading Treatment or Punishment. These principles were drafted on the basis of
preparatory work undertaken in the WHO and the World Medical Association which
adopted the declaration of Tokyo in 1975, still the most comprehensive statement
produced by the medical profession on torture. There are many more texts adopted by
the medical and paramedical profession in relation to the treatment of detainees, such as
national codes of medical ethics and statements on nurses in relation to detainees pnd
violations of human rights, such as torture. However, what the UN principles do is put
the subject in a legal context and qualify violations as gross contravention’s of medical
ethics and as a (criminal) offence under international law. The same body of Principles
declares inadmissible and a contravention of medical ethics the certifications or
participation in the certification of the fitness of prisoners or detainees for any form of
treatment or punishment that may adversely affect their physical or mental health, nor to
’ a
participate in any way in the infliction of any such treatment or punishment. This is
clear reference to the participation of medical doctors in the application of - as is the
practice in a few countries - corporal punishment, such as beatings or amputations, a
participation which should be avoided under any circumstance except in the cases where
the physician is called upon to treat the person as a patient needing medical care.
4.
Physicians and more in general, health personnel, have, therefore, an important
role to play in the prevention of violence, more in particular of torture an din the
treatment of victims. First of all, in no case shall they participate in the infliction of
torture of cruel treatment and/or corporal punishment. In cases where they are called
upon to examine persons who declare to have been tortured, and to verify their
statement, the physician’s role may be crucial in saving the accused from^detention an
prosecution, and thus in abating mal-practices. Also and more obviously, medical
doctors will play a vital role in treating and curing victims of torture. It takes special
skills to assess their statements and to treat the sequelae of torture. In the first place,
often very refined means of torture have been used so as to leave no physical scars. But
the deeper are the wounds of the mind and the soul. To ascertain a broken arm or Idg is
easier than to determine that the person has undergone electric shocks. Modem torture
technology is developed with an eye on medical scientific publications on the subject in
the endeavor to make treatment of victims more difficult through lack of physical traces.
In the second place, victims - or survivors as they are called by some centers - do not
necessarily say they have been tortured, not seldom ashamed of what has happened to
them (especially sexual torture can reach intimate places) or of the fact that they were
forced to give up and “confess”. A physicians must have special experience or get
without scaring the
special training to find out what happened and he must do so gently
[
patient who may be reminded of the past by the cell — like treatment room and the
traditional white doctor’s garb. It is a sad but inevitable conclusion that probably no
victim of torture will ever recover completely from what he or she has suffered. In many
cases the only thing we can hope for is that the victim will be able to live with his past
and play a useful role again in society - and be a true survivor!
5.
The systematic use of torture and maltreatment all over the world creates an
impressive number of victims — and members of their families — who have t>een
seriously traumatized and are in urgent need of psychological, medical and other
C3;
assistance in order to overcome the sequelae of torture. WE do not know an exact
number of victims, but there must be hundreds of thousand; we do not know exactly the
costs of treatment and assistance required, but it runs into tens of millions of dollars.
Fortunately, there are all over the world small and medium size centres for treatment of
victims, staffed by physicians, psychologists, lawyers, social workers and, often,
volunteers. What is needed is money to assist the survivors of torture and their families.
The UN General Assembly has assumed some form of “collective” responsibility for the
rehabilitation of torture victims by establishing a Fund in 1981 to receive contributions
for distribution, through established channels of assistance, as humanitarian, legal and
financial aid. This Fund depends entirely on voluntary contributions from governments,
private organizations, institutions and individuals. It is not financed through the regular
UN budget. Over the past 16 years a group of donor states have contributed tot he Fund
on a yearly basis. This has enabled the Fund to set up a system for equitable distribution
of the funds to a great number of centres for treatment in a variety of countries. Many
centres are in countries where victims have found refuge (that accounts for the number
of centres in western countries), but at the same time many centres have been set up in
countries where torture is practiced. This may pose specific problems. In one country,
for instance, medical doctors that are treating victims are arrested by government agents
and forced to give the names of their patients to the authorities so that they can take
action against these people and their families.
6.
]I have spoken already for too long but, as I said before, the subject has so many
<-.4tkzx1v44-Ji. I* T -.4 JXie
dealt with briefly
ramifications fkat
that it
it can r»/vt
not be Miritk
without doing injustice
to it. Let
wish you, distinguished participants, a stimulating exchange of views, a careful
consideration of all items on your agenda and the drafting of practical recommendatk >ns
in the conclusion of your work. Many colleagues in your field are looking forward to he
results of your conference and tot he collective wisdom you manage to generate. Mr.
Chairman, you have the delicate and rewarding task to guide the conference through this
complex subject-matter. I wish you much success.
Thank you for giving me the floor.
GC.
a
FOR DR. ACHALA DAGA, DEPT. OF PREVENTIVE AND SOCIAL MEDICINE
CVs of Delegates:
BRITISH MEDICAL ASSOCIATION, LONDON
Staying at: Hotel FARIYAS, Near Colaba Market, Tel: 204 2911
(1) Dr Vivienne Nathanson
Dr Nathanson qualified as a doctor at the Middlesex Hospital Medical School.
She joined the BMA in 1984 and has held a number of senior BMA offices, including Chief
Executive in Scotland (she is Honorary Professor, Department of Healthcare Management,
University of Stirling). She is currently Head of the BMA’s Professional Resources and
Research Group (PRRG), which encompasses all the professional areas of work of the
BMA including Health Policy, Medical Informatics, Medical Education, Ethics, Science,
International Affairs, Conferencing and Legal Affairs.
Dr Nathanson lectures and publishes extensively on a range of ethical and human rights
issues and has worked closely with the International Committee of the Red Cross. She is
chairperson of the BMA’s steering group on Human Rights and is also responsible for
BMA work with the Commonwealth and World Medical Associations.
(2) Ms. Ann Sommerville
Ann has a BA degree from London University, a post-graduate diploma in Russian and a
master’s degree in Medical Ethics & Law from King's College, London.
She joined the British Medical Association in 1987 and is now Head of Medical Ethics
and advisor on ethical issues.
Her role involves preparing BMA books, papers and briefings on ethical issues; briefing
members of Parliament and occasionally giving evidence to Parliamentary committees;
drafting guidance notes on current UK legislation; presenting papers on medical ethical
issues at national and international conferences and publishing articles on behalf of the
BMA. She has a special interest in human rights and, before joining the BMA, worked
for five years in the Research Department of Amnesty International.
(3) Dr John Chisholm
Dr John Chisholm is a general practitioner in Twyford, Berkshire.
He has been a member of the General Medical Services Committee of the British
Medical Association (now the General Practitioners Committee), which represents all
National Health Service general practitioners, since 1977. He has been a GMSC negotiator
since 1990, Joint Deputy Chairman of the Committee since 1991, and since 1997 its
Chairman. He is also a member of the Council of the BMA and its Executive Committee
and Finance and General Purposes Committee. He was Chairman of the GMSC's Trainees
Subcommittee from 1978 to 1980, of the BMA's Junior Members Forum from 1981 to
1982, of the GMSC-Royal College of General Practitioners Joint Computing Group from
1984 to 1986, and of the GMSC's Practice Organisation Subcommittee from 1986 to 1990.
He is a member of the Standing Medical Advisory Committee and of the Joint Committee
on Postgraduate Training for General Practice.
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DINAZ A. CONTRACTOR
H.A. LL.B. ADVOCATE
Dt. 26-10-98
REPORT OF INVESTIGATION OF VIOLENCE
Before discussing about the subject let us see the defination of the
word ’‘VIOLENCE” Violence means to torture, to injure, to harass some
body, specially to supress that person. In general it is a coercive
method to assert one's will over another in order to prove one's power
on the weaker sex. Thus behind occuring Violence clear concept is to
supress others by certain force or assaultation. It is a bureaucrat
desire of a rulling person to crush his subordinates to establish his
power. Thus the weaker section always becomes a victim, irrespecti' /e of
class, creed, community or sex. This we observed, from the ancient time,
i.e. from the time of monarchy, that powerful king snatched the kingdom
of weak king and then tortured his subject to set up his power on them.
In brief it is a clear human tendency to supress the subordinates and
since ages as woman clearly depending on man specially for economical
status and for physical protection, she obviously becomes second class
citizen. Her submission turned her into slave. As per historical facts 9
there was no discrimination between man and woman in the stone age. But
with the set up of society, economical responsibility came on man's
shoulder and woman, because of her anatomy also; started staying at home
looking after household affairs. Man become the master and ruler o1 the
house and family his domination and control started prevailing in the
house and to sustain that power he started supressing, torturing, har—
assing woman to keep her under his control. Like that Violence against
women ranges from simple supression to abuse, aggression, exploitation
and attack till death.
Like that Violence against women is universal and also since ages, We
are celebrating women's Liberation Day Sth March to pay homage to i^omen
workers of phi 1adelphia„ who started agitation for their rights in 1860.
This proved that this situation existedall over the world since ages. In
our country India patriarchy prevailed since the time of Manu. As per
Manu Smrutij, women are not entitled to use the sacred texts or to inher
it besides she is not entitled to independence, she is supposed to be
protected by father in maiden hood, by husband in youth and by son in
old age. It is her destiny. In mediaeval epoch, our poet of the era 5
Tulsidasji compared woman with cattle, slave and stupid and added that
to control all these four beating is essential. Thus this Patriarchy
Prevailed since the time of Manu. which clearly shown the predominance
of male and subordination and subservience on the part of women and to
sustain this position women weresupressed and tortured in various whyswhich is continued till today. Thus the important factors behind
DINAZ A. CONTRACTOR
M.A. LL.B. ADVOCATE
violence towards women are our male sovereignist culture and our patriarchy system.
This harassment to women started from the embryo. Since ages girl chi Id
was unwanted in the family, former they used to kill a newly bornei baby
girl by dipping her in the vessel full of milk. In this advanced age !•
by amneousynthesis test, knowing a girl child in embryo, abortion t^f the
female foetus was getting done, though now it is prevented by law. As
per result general proportion in our country is extremely imbalancid,
and getting dropped continiously to the extent of 1000 males to 921
females as per the census report. While in the Bhatti community in
Rajesthan sex ratio is 550 women to 1000 men. As per the medical termi
nation of Pregnancy Act also without the consent of woman, if she is
forced to abbot it is crime and accused get the ten years imprisonment
but our society set up is such that no woman ever will complain against
her husband or inlaws even if she is forced for abortion. Then com4s the
under noursihment of girl child, denial of education, though it is free
in Gujarat and compulsory upto the age of fourteen in whole of Indila
Female literacy in India is 24.8 7. as compare to male literacy of 46.9 %
same is her condition at work and labour and also at home. There is no
remuneration for woman performing household duties, though she is w|orking like a mule, at home, in field in office etc. As a working womdn has
to perform double duties by single handling. Result is as per U.N.O
report, woman is doing 2/3 of the total work and she is getting 1/10 of
the total world satary. As per law equal right is given to women in
parental property but generally it is on paper only as her rights are
snatched by emotional black mail by persuading or by pampering her ior by
social blackmail by harassment of various types like boycotting her from
the family etc. Thus as per U.N.O's report women possess only 1/100
shares in world's property.
In support to this statement I like to narrate some cases of my 12 years
experience as a Past President of Astitva Mahila Utkarsh Sanstha Valsad
as our organisation has handled more than 2000 cases of harassment to
women in various ways like mental and physical torture. Dowry problems,
rape cases, situation of unmarried mother, property problems maintenance
and divorce cases. Dowry death, sexual harassment etc.
Woman is getting supressed generally because she is not independent so
first I like to naratte the property case we have handled and how t^e
male sovereignist people had snatched the right of a poor widow. It was
a case of a joint property of four brothers. Unfortunately two brothers
of the family expired, amongst which one was marrired and one was bache
lor. Remaining two brothers applied in city survey office with false?
witness that their two brothers were expired and both were unmarried and
with that false pretextion got. the property trasfered in their names
only and drived that widow out of the house with her two children. After
some years those two brothers decided to sell that property to a bu.il-
DINAZ A. CONTRACTOR
M.A. LL.B. ADVOCATE
der, but that builder asked for the consent letter of that widow also so
they approached her with five thousand repees to get her signature, That
poor lady had no money to pay lawyer's fee also; she came to us, we
studied the case found out the real facts and threated that both the
brothers and their witnesses also to get them behind the bar for giving
the false statement in city survey office with lots of termagancy we
made thempay the full share to that widow along with the penalty of Rs.
50000/- for torturing that widow for the years so the amount she re
ceived was Rs. 150000/-. In most of the cases women are getting excluded
from her rights because of her ignorance or because of her emotions. No
Hindu woman insists to get her name writtened in property card or in
land 7*12 etc. though she may be a rightful heir. In one such case a
couple started their life from the scrape as both were working, hoi. sehold expense was done from the salary of wife while husband took loan
and purchased flat and otheraccessories, flat was purchased in the
husband's name. After twenty years of marriage some dispute occured to
the extent of getting divorce and husband very flatly refused about the
wife's income involved in purchase and set upof the house. Thus it is
quite obvious that women are not alert about their rights. If she should
have got her name entered in property card from the beginning no problem
would have been arised in laterdate. Even in the case of sepration or
divorce women gets maintenance only of Rs. 500 per month as per I.P.C
125 which is just a farce or she received certain amount as alimony at
the time of divorce, but in both the situation no one is thinking of
where she should stay after sepretion or divorce.
Domestic violence started to a girl from her childhood which ends with
her life only. They are getting supressed in various ways, psychologi
cally being made aware to them that marriage is their primary carrier
while educational achievement or professional carrier is subsidiary
matter for them working women has to perform the duties at home and
office together and they are expected to hand over their salary to their
in-laws. As per W.H.O. report about the women in India that every year
number of women died in delivery because of Animia and hamrage. Reason
behind her being Animic is not getting proper nourishment and reason
behind hamrage is not getting proper treatment. This negligence towards
her health is also a part of Violence. Mental torture of the wife is
more devasting than the physical assaults. Taunting insulting, ignoring,
every such drastic behaviour she has to suffer silently, as a part cbf
her life. Most drastic conditon of a women arised if she becomes a w idow
she is forced to live on sufferance, she is considered inauspicious!
sometimes physically disfigured by shaving of her head. And in olden
days forced to die even as being Sati after her husband's death. Though
there is an anty dowlry law, Violence due to dowry is still very common,
every year dowry deaths goes on increasing. In many cases parents of the
burned bride do not pursue the matter in the court sometimes because of
their grand children sometimes because of their false fame or social
status and sometimes because of their poverty. Dying women also quite
often gives wrong declaration of accident thinking about her survival or
about her children like that every year cases of killing women or of
DINAZ A. CONTRACTOR
M.A. LL.B. ADVOCATE
suicides are increasing as per the report of National Crime Record^
Bureau one women is raped at every 54 minutes one kidnapped at ever -y 43
minutes and killed because of dowry or some related reasons at 42
minutes and harassed at every 33 minutes. As per record more than ‘thou
sand cases of Dowry death increased every year. Very lately we have come
across the case of a suicide but before death she had written a letter
of 13 pages regarding how she was tortured by her husband her step
children and by maternal grandfather of those step children. In this
case very well to do party is involved so though there is a dying clecleration, we are quite doubtful about the justice.
This type of Violence she faces at home then equally she is getting
exploited at the work place also. If boss found her in need of service
he tries to take best of her advantage and if they refuse to satisfy the
sexual demand of higher-ups, they will be harassed by their seniors in
various ways. In rural area poor women become a prey of the land lords
and other affluent individuals. They have to make their both ends mleet.
so they surrender to their lust and demand against their own will Bi
har's past is full of instances when dalit women have been brutalised.
Very lately there is the infamous incident of Bhulidevi who was paraded
naked becaused she stole four potates from a field in the samstipur
District in 1996 (News given in Times of India) when men fail to supress
women in other way saxual harassment is their easy weapon to set up
their monopoly. Every day we read such cases in daily News paper Bahloo
Yadav a leading politician of Bihar rape champa - B Vishwas wife of a
I.A.S. Officer, Gangrape of four nuns at Navapara Bhandriya village
all these gangsters are moving freely as the general public is afraid of
testifying or complaining against them. Like that crime flourishes and
sexual harassment becomes an easy weapon to supress the women. In Africa
now a days number of "Sugar Daddies" are increased, who are interested
in enjoying the sex only with the girls of their daughter's age. Accord
ing to the last statement of Home Secretary Shree V. N. Kaul, "after
Delhi and Rajesthan the maximum numbers of rape cases are reported j.n
Madhya Pradesh". And rape is the worst torture for a woman child rape is
very common and it is very painful to imagine what a Violence and tor—
ture that innocent immature girl might have suffered during such forci
ble intercourse. Besides society and law both; make the poor victim feel
more guilty by their attitude. Accused lawyer rape her mentally in the?
court by asking her most humiliating questions just to save his client.
So in most of the rape cases complaints are not getting lodged thus
thousands of cases of rape remain unreported in our country because
overall attitude of society towards victim is quite cruel. Invariably in
most cases women is only blamed and is forced to undergo torture. Here
also works the male monopoly to supress women in both the ways. Along
with this today's most burning problem is of unmarried mother. Either a
girl is forced or lured but under any circumstances both are responsible
while women only become a victim because of her Physical Anatomy. Many
girls are approaching us with this problem and we have no solution t^s
secure her, to assist her to establish her social status again. That
DINAZ A. CONTRACTOR
M.A. LL.B. ADVOCATE
culprit can move freely while girl only get humiliated because this is a
man-made world, here also male sovereignism appears clearly.
As a conclusion, here I endeavour to depict the given subject in th fee
modes. Defination of a word 'Violence reason behind its set up what are
the important factors andconcept behind forcing Violence and the methods
applied that is their Modus Operandi of various types to torture and
harass women. But this investigation is not the solution of women's
problems or harassment. Male Bureaucracy never be ended only by investi
gation, there requires the action.
First and foremost complete revolution is wanted to change our ancient
views of male dominating culture. Daughters must always be welcomed and
must be well trained, well educated and must be properly nourished, In
short there must not be any discrimination between a son or daughteiK
Equal rights should be given to them. In carrier and profession equil
opportunity should be delivered and they should be self dependent aipd
pphysically and economically independent. They should get equal rights
in property and equal political status, which can provide confidence in
themselves. Women should also not be emotinal to the level of giving up
their carrier for motherhood or for being an ideal house-wife N.G.O.
mustattempt to make them aware of their legal rights, and should assist
them to get their rights. There should be a fundamental change in the
existing patriarchal values, with that basic need is women should be>
empowered to fight her own battle, then only violence to women will be
restricted N.G.O.'s work is to inspire them, to enlighten them and ito
give them moral support to fight for their rights. With that we hav^ to
assist them in their efforts of being self sufficient and economically
independent that only can strengthen them to face their problems.
Ofcourse it is a difficult task to change the complete structure of the
society, but we are hopeful, we must not forget that every cloud ha<4
silver lining. As I talked ahead about woman only getting Rs. 500/- as
maintanance but very recently there is a landmark judgement of Bombay
High Court, in which property rights granted to wife. Bombay High Court
restrained man from entering his home, after he was found guilty of
relentlessly abusing his wife and children and all rights over his flat
have been granted to the wife. Such judgement can set precedent.
Before 25 to 30 years violence to women is considered their destiny
while today women of most conservetive muslim community gather to fight
for their rights. A handful of muslim women in Kerala started a Union
name 'NISSA' ('NISSA' is an Arabic word means woman) some 20 divorced
women are fighting a grim battle against the mighty men of their commun
ity demanding equality and also fighting against Muslim Law 'Mutta'- in
which a man marry a woman for a specific period and then divorced her
with couple of kids. Like that changes are definately there, women's
associations are also alert for each social and political movements. But
DINAZ A. CONTRACTOR
H.A. LL.B. ADVOCATE
still we have to fill up the wide gap and for that N.G.O.S. and sdcial
activist like us be more mobile and devoted; Wide net work is very mu c h
required and above all woman herself must be aware of her rights and
must be bold enough to face the situation and to fight for her rights.
Then only we can change the noms of the society and can prevent the
Violence to women completely and in true sense.
DINAZ ADI CONTRACTOR
TRUSTEE & PAST PRESIDENT
'ASTITVA' MANILA UTKARSH SANSTHA VALSAD
MEMBERS- GUJARAT STATE SOCIAL WELFARE ADVISORY
BOARD
MEMBERS- NATIONAL COMMISSON FOR WOMEN LIAS ON I NG
COMMITTEE GUJARAT STATE
Legal & Freventive aspects against violence and crime in social lite.
Dr. N. G, Bhusale
Dr. B. G. Chikhalkar
Crime is as old as the human civilisation itself. With the formation of human grouping, proclamations
were made or laws created forbidding certain forms of behaviour. Legally crime may be defined in
terms of a body of laws, which codifies a society’s rule, about proper or improper behaviour. With
socio- psychological angle, “Crime is an intentional act or commission in violation of criminal law
committed without defence or justification and sanctioned by the state as a felony or misdemeanour.
From the sociological point of view, crime can be called the violation of conduct norms of a normative
group in a given society.
Classification of assault in urban environment
1 Ihe sudden response to unpremeditated provocation e g. verbal abuse or actual assault.
2. Sudden violent reaction to sustained constructive taunting e g neighbourhood dispute, group rivalry.
3. Unplanned assault by known violent or non-violent individual under influence of alcohol or drugs.
4 Gang assaults.
5. Crowd violence: spontaneous/preplanned/associated with social or political protest.
6. Domestic violence.
7. Adult sexual assault.
8 Urban terrorism.
Criminogenetic factors:
Fourth U.N. Congress on prevention of crime and treatment of offenders (1970) identified urbanisation,
industrialisation, population growth, internal migration, social mobility, technological changes and
freedom of movements, social, moral, ethical and spiritual deterioration, socio-economic emotional,
political and other factors as criminological factors.
Legal aspects: India's main criminal law and procedure are codified in 3 volumes. The Indian ’enal
Code (I860), the code of criminal (1898 & raised in 1973) and the Indian Evidence Act, (1872) The
IPC has classified offences against state, person, property, public tranquillity, and those relating to
morals, religion, marriage, and coinage. Ihe major heads in IPC are murder, culpable homicide, ddwry,
robbery, kidnapping, abduction, house breaking, trespass, theft, criminal breach of trust, cheating,
counterfeiting and riot. So also there are a series of local and special laws that have been enacted like
possession of arms, fire arms, ammunition, explosives, drugs, gambling, prostitution, corruption,
untouchability, smuggling, hoarding and profiteering in essential commodities and traffic offences.
Another prominent trends in crime are juvenile delinquency, female criminality and white collar :rime
i.e. social offences which affects the health or the material welfare of community or these are the ;eries
of illegal acts committed by non physical means to obtain money or property. Apart from these a series
of unreported crimes and victimless crime which are particularly true of organised or institutional
crimes and various socio-economic offences are also observed in society.
Strategies for crime prevention
1. Role of legislation of police and judiciary system has limitations though it plays important part in
prevention of crime.
2. Massive efforts at national levels supported by help at regional and international levels.
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3. Counselling of people.
|
4 Detection itself is a crime prevention strategy.
5. Role of government in national strategy of crime prevention role of government is cmcial; similarly
integration of criminal justice system with national planning is imperative. Advancing criminal
justice services, health, education, social welfare, voluntary agencies and general public awareness.
6. Mass media are powerful instruments in moulding public opinion.
7. Implementation of spiritual knowledge and moral principles.
For a check on the growth and development, spiritual and moral development also is essential. It is only
the spiritual and moral development, which can give a proper direction to and determine the proper limit
of industrial growth and material development. It would otherwise lead to reckless consumerism,
materialism, and loss of values and ultimately to destruction of environment, civilisation and a great
part of mankind
Again the feeling of brotherhood, the spirit of sharing with others and the quality of self reliance are the
values that can be cultivated and nourished by a spiritual culture. Some people think that spiritual
knowledge and moral principles are only for one’s personal progress. They think that spiritual
knowledge cannot help in solving problems facing the society. They forget that spiritual knowledge
brings about self-change and is thus a great tool for social-transformation and what is urgently
necessary in the world today is social-transformation.
Most people do not realise that all our problems arise from lack or absence of certain moral values. The
solution of these problems in fact lies in the actualisation of those moral values. Without those values,
the problems cannot be eliminated satisfactorily and for a long time.
Let us suppose, for a moment that an agreement is made for destruction of all nuclear weapons and also
of other weapons and let us further suppose that this agreement is frilly implemented and all the
weapons are really destroyed. The knowledge of how these weapons are made yet remain. No)v if
hatred, suspicion, fear and spirit of revenge have not been wiped out, these weapons can again be made.
So, the real solution lies in eliminating these negative personality traits.
Since the present situation results mainly from the rapid growth in population and unbridled application
of technology in industrialised countries there is need that people exert self-control and keep in mind the
wider interests of mankind. People should, therefore, be told that sublimation of thoughts, through
practice of soul-consciousness, leads to better feelings of joy and releases from all these losses and
harms. All benefits can be had from spiritual education, soul-consciousness and practice of meditation.
The natural, best and in fact, the holy, healthy and more hygienic method is “birth” control through sex
control, ulbirth control through Brahmacharya ’ or “birth control through control over the biith of
thoughts qf sex”. This is possible only through spiritual education.
Crime rate, in almost all countries is constantly on the increase. The curve in the crime graph shows
higher spurt in urban as compared to the rural areas. The decline in the moral authority of the head of
the family and the teacher and the break up of the family and the overall decline in the elements of
cohesion, love and adjustment in the family seem to have been major factors leading to increase in the
crime rate.
Crime is mainly a social deviant behaviour. It may spring from revolt against the old and established
values, the traditional social norms or the laws passed and enforced by a machinery which itself is
corrupt and breaks law or has lost its credibility. It may also have its birth in a sense of guilt and the
desire to be punished. Tension, is an important factor associated with many kin of crime, temptation
and sex-drive are the two other such factors. Greed for money leads to bribery, adulteration, tax
I
3
evasion and number of such other crimes. Anger and the motive of revenge also lead to many case? of
violence. All crime is due to one or the other of the six well-known evils - sex, lust, anger, greed,
attachment, pride and laziness.
Crime now permeates in almost all sections and aspects of society, it is prevalent on a worldwide scale.
The modem society has a lawless law. Law is observed more in its violation than its obedience. Crime
debases the quality of life. It limits the freedom and opportunities of those who wish to abide by law. It
thus induce^ or forces the law abiding sections also to commit crime.
Crime is subversive of development and national achievement and creates tear and feeling of mseebnty
and one feel? that one’s legitimate rights are thwarted in such an atmosphere where even the agencies
responsible for law enforcing and crime-prevention also indulge in crime.
Obviously, such education helps a person to lay strong foundation of his character and be free from
corruptive inifluence; temptation and tension can help eradication of crime. Spiritual education and
meditation are better means of eradication of crime than enactment and forcible enforcement law.
I
Need for religious tolerance:
The dust and debris of history, narrow-mindedness and obscurantism, jingoism, fanaticism and
communalism are made into a three that enlightens man, uplifts his soul, gives it a link with God and
lays emphasis on spiritual values and on love, non-violence and purity above all. There is need for
universal religion which should work as force for integration of mankind and should emphasise upon
unity of minds with one God.
Discrimination against women:
It is time to give women a higher place and a better role in the society in order to bring a qualitative
change. Wojnen will definitely prove to be of help in establishing peace due to their special qualities. It
is now time that men accepts the equality of women in society. Person’s education is to realise soul
rather than the boy and one’s moral and mental iquaiities'rather than une ’s physical weakness of some
sort.
Stress and stress related diseases
Modem age is known as the age of stress. Hate, anger, enmity, jealousy, inferiority complex, lack of
self-control, strong sex dnve, highrnnbitronors, habit ot'^'veiyiast irfe, tack of love m one’s relationships
easily lead to stress. It has been found that Meditation or Yoga helps greatly to attain a state of mental
realisation, Release from stress and a feeling of assurance, security, rest and peace Medication has been
found to. be of great value in treating these diseases, to absorb the stress that one faces in various
diseases, an^to absorb stress and tension.
Spiritual and moral education to children and youth
Indiscipline in schools and colleges gives rise to crime in cities and moral debasement in the wh<iole
society. The youth are turbulent and out of desperation they indulge in imparting such education as
enables the youths rhannehse their ^energy-to creatroe work -antt tor achievement of social good
through universal spiritual education which is different from religious education.
I
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INTERNATIONAL CONFERENCE ON
"IJRE\ ENT1NG VIOLENCE, CARING FOR SI R\ IVORS
!»
ROLE OF HEAL TH PROFESSION AND SERVICES IN VIOLENCE
Organized Ky
CEHAT, MUMBAI
November 28-30, 1998
DOCTORS ARE JUDGES AT THE FIRST INSTANCE
By
S. MARTIN, Advocate
Federation of Consumer Organization - Tamil Nadu
ASS I ST A NCE TO VICTIMS OF STATE VIOLENCE
A lady with swellen face, blinking eye, limping and with bleeding injuries
approached Dr. A for emergency treatment. She alleged illegal detention by Police for
three days, gang rape and torture.
Dr. A, advised to get a requisition from the concerned Police (the personnel who
gang raped her) after lodging a complaint. Dr. A did not even render any first aid in spite
of repeated request by the lady victim.
The Victim approached Dr. B who thoroughly examined her, documented all the
evidences available, collected samples for clinical analysis, and administered her the
required treatment immediately. In addition, Dr. B intimated this incident to the Local
Police
Dr B has acted as a Lifesaver, as a Dutiful Doctor, as a Judge, as an Investigator,
as per the Hypocritical Oath and as per the Law of Our Land. Above all Dr. B was
humane whereas, Dr. A was negligent in treating the victim, uncaring, irresponsible,
permitted evidences to vanish, thereby favouring the accused to conceal the crime. Thus
becoming inhuman.
Many doctors knowingly or unknowingly act, identical to Dr. A while dealing
with medico-legal cases. This attitude should be transformed and the present Conference
is one such effort focusing in this Direction. Thanks to the Organizers who are also,
Doctors for organizing such a unique conference on this topic.**
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2
Article 21, under the Indian Constitution, clearly envisages RIGHT TO LIFE
Nobody, including the State could deny this right of the Citizens. Preservation of Human
Life is of paramount importance Once life is lost, the status quo ante cannot be restored
Doctors are duty bound to render medical aid to preserve life in medico-legal cases
During an emergency, Doctors are acting as Lifesavers. This noble contribution
by the Doctors to our society is widely acclaimed However, in medico-legal cases,
Doctors, particularly Private Practitioners are very reluctant in treating victims Even the
Government Doctors are no exception to this attitude, in medico-legal cases of State
Violence. For example, police torture.
It is worthwhile reproducing Clauses 10 and 13 of the Code of Medical Ethics
which clearly state the obligations of the Doctors in cases of emergency.
OBLIGATIONS TO THE SICK1 (Clause 10)
Though a physician is not bound to treat each and every one asking his services
except TN EMERGENCIES for the sake of humanity and the noble traditions of the
profession, he should not only be ever ready to respond to the calls of the sick and the
injured, but should be mindful of the high character of his mission and the responsibility
he incurs in the discharge of his ministrations, he should never forget that the health and
the lives of those entrusted to his care depend on his skill and attention. A Physician
should endeavour to add to the comfort of the sick by making his visits at the hour
indicated to the patients.
■THE PATIENT MUST NOT BE NEGLECTED1 (Clause 13)
A physician is free to choose whom he will serve. He should, however, respond to
any request for his assistance in AN EMERGENCY or whenever temperate public
opinion expects the service. Once having undertaken a case, the Physician should not
neglect the patient, nor should he withdraw from the case without giving notice to the
patient, his relatives or his responsible
friends sufficiently long in advance of his
resi
withdrawal to allow them to secure another medical attendant. No provisionally or fully
registered medical practitioner shall willfully commit an act of negligence that may
deprive his patient or patients from necessary medical care.
No law prohibits the Doctors from treating a Victim of a medical-legal case before
informing the police. Most of the private practitioners refiise to treat such victims fearing
harassment by police, fearing appearance in the Court to give evidence. Today, large
Corporate Hospitals make advertisements, that they undertake medico-legal cases and the
3
availability of trauma wards Nevertheless, these hospitals are not within the economic
reach of the common man
Our Apex Court in its judgement, Paramanand Katara versus Union of India
(A. 1 R. 1989 Supreme Court - Page 2039) has clearly laid down the Principles in this
regard.
"Every Doctor whether at a Government Hospital or otherwise has the
professional obligation to extend his services with due expertise for protecting life No
law or State action can intervene to avoid/delay the discharge of the paramount obligation
cast upon members of the medical profession. The obligation being total, absolute and
paramount, laws or procedure, whether in statutes or otherwise which would interfere
with the discharge of this obligation cannot be sustained and must therefore, give way”
The Apex Court has further held, "Injured Citizen brought for medical treatment
should instantaneously be given medical aid and thereafter procedural criminal law
should be allowed to operate".
More particularly, in cases of Police torture or other State Violence, the helpless
victim whose fundamental rights are grossly violated should be given immediate medical
aid This will not only save the life of the victim but also lead to punish the culprits.
In several cases of Police torture, Doctors have played a vital lole in detecting the
crime and to punish the law-breaker. DOCI QRS ARE_JLUJBGES__A1—THE__FIRST
INSTANCE, they are going to furnish Expert Evidence about the time of injury, nature of
injury, manner of causing the injury and the type of weapon engaged. Without an expert
evidence in this regard, the culprit will be left scot-free and the rule of law will be
ditched.
In cases where juveniles are arrested and brought for treatment, the doctors should
make investigation as to the age of the person and reveal a crystal-clear finding in this
regard. If a juvenile is detained together with adult criminals and there is ample chance
for the former to become a hard-core criminal. Doctors could help juveniles in this aspect.
When post-mortem of cases of police torture victims are performed, arrangements
should be made for video-graphing the same.
Of course, there are certain difficulties faced by doctors while dealing with
medico-legal cases, like police harassment, waste of time m attending enquiries in police
station and court, etc. The State should ensure that doctors are indemnified in such
situations. As per the Supreme Court guidelines, the doctors should not be dragged to
court unnecessarily and made to wait for long time.
4
Nobody can deny the role of Doctors in punishing the culprits in cases of State
Violence and Police atrocities. Several reported cases on this aspect will reveal the same
finding. Doctors have played a vital role in Bagalpur Blinding Case (A. I. R. 1981;
Supreme Court, 1928), where the Bihar Police squeezed out the eyes of the suspects
arrested. Several days after infliction of these injuries, Doctors have rendered evidences
as to the nature of injuries, which helped the court to draw a conclusion in favour of the
Victims.
In another case (1980 Crp. L. J. Page 801), a person was beaten up by the Police
while in custody and died The Police declared it was suicide. However, the Court
convicted them for murder, based on the evidences of the Medical Officer examined.
Doctors should also be very cautious while insane persons are brought arrested. If
they are found insane then they should be recommended to be sent to a Mental Hospital.
Sending them to jail will aggravate the situation further.
There were also instances where Doctors have indirectly aided the culprits to
escape from the clutches of Law. In Sunil Batra's case (1980 - 3, S. C. C. 488), the court
has commented that the veracity of the Doctors are at stake. Such instances should never
reoccur.
COMMENTS
While the whole world is talking much about Human Rights Protection and when
the Police atrocities are reported increasingly the Doctors should serve as Angels of
Human Rights Custodians.
It is worthwhile to mention here that once Martin Luther King said, "Injustice
anywhere is a threat to injustice everywhere".
VI P 1 r I
HEARING THE UNSAID
Shalini
Paper presented at the International Conference on
Preventing violence, Caring for survivors
Role of health profession and services in violence
November 28 -30, 1998, Mumbai, India.
Correspondence Address: TARSHL49 Golf Links, 2nd Floor, New Delhi 110003, India
Admin, phone and fax: (011) 461 0711: Helplines: (011) 462 2221, 462 4441.
>■
Paper presented at the International Conference on
Preventing violence, Caring for survivors
Role of health profession and services in violence
November 28 -30, 1998, Mumbai, India.
Correspondence Address: TARSHI,49 Golf Links, 2nd Floor, New Delhi 110003, India.
Admin, phone and fax: (011) 461 0711; Helplines: (011) 462 2221, 462 4441.
tarshi@del3.vsnl.net.in
E-mail:
HEARING THE UNSAID
Shalini
Whether one is intrigued about how periods happen, or worried about the effects of
masturbation on health, or else furious about a stranger having flashed in public; people need
certain things. People need to be heard, want someone to listen to and validate their feelings,
need accurate information, and need help to explore various options that are available in the
specific situation. Every so often people find themselves unable to get all these at the same
time; one need is sacrificed at the cost of another. A determination to change this for the
better is what led to the birth of TARSHI.
TARSHI is an NGO that runs a telephone helpline to give information, counselling, and
referrals on reproductive and sexual health issues. TARSHI attempts to help women and men
live lives of dignity and freedom from fear, infection, and reproductive and sexual ill-health.
The helpline services are confidential and preserve the anonymity of callers so they feet
comfortable enough to ask questions of personal concern. The helpline is operated by trained
counsellors and supervised by a qualified clinical psychologist. In less than three years of
TARSHFs existence, we have received more than 28,000 calls from women, men, and
children in the age range from 10 to 70+ years. The helpline is advertised as being especially
for women, but is available to men also. Queries are answered, concerns aired, complicated
feelings discussed and worked through on the phone.
Most of the people who call on the helpline want to gel some basie information about their
bodies and/or the normal proeesses thereof. A number of times, however, the ealler starts
with asking for facts, but then as the call proceeds, the conversation unravels the caller s
i
deeper concerns. These concerns are about the caller’s emotional relationships with
significant others or about the appropriateness of one’s feelings, attitudes or behaviours.
Some callers question the prevailing social system and its basis. Often these concerns are
related to violence and abuse.
r
Sexuality is an arena where the imbalance of power is manifest. Any such manifestation that
is to the detriment of another person is violent and oppressive, regardless of the form it takes
The forms, of course as we all know, are many ranging from a leering look, to a poke in a bus
to the most gruesome forms of battering and sexual assault.
A woman’s consent is often either assumed or considered unimportant. For example, some
men think that while travelling in a bus if they get an erection against a woman co-passenger,
it is all right for them to indulge themselves and engage in what technically is termed
frotteurism . Some men, in this sort of a situation may even believe that the woman is also
enjoying the act and unless she raises an alarm, he presumes she does not object to his
behaviour. At times even when she protests, it is considered pretence in order for her to
appear socially “modest”.
Similarly, a lot of premarital sex ends up as date rape as the man assumes that if the woman
has agreed to go out with him on a date or has kissed him, having sex with her is his
prerogative. It seems as if it is difficult for some men to think that a woman can draw her own
oundaries and they may even think that if she has crossed the Taxman Rekha once, she
better be prepared for abduction, assault, a test by fire, and exile. Popular beliefs like “a
woman actually means ‘yes’ when she says ‘no’” also play a crucial role in perpetuating
violence against women. Other commonly held notions like “it is a man’s job to initiate and
perfonn sex and a woman’s duty is to provide him with her body” also contribute to women’s
abuse. These could be some of the reasons, again, for date rape as well as marital rape.
The question that arises is that if rape is happening in close relationships, then why is it
happening? Who defines what is abuse? Who is abusing? Who is being abused? Why don’t
they stop it? Most abusers, perhaps do not label their actions as abusive, in fact they often see
what they do as their right or else give some justification for it (she asked for it, she dressed
provocatively, etc). One caller justified his abusing a child by saying that “Woh to barfi ka
tukda hai, muh mem paani to aayega hi.” (She is like a delectable sweet, of course one’s
mouth will water.)
Another man called to ask if it is safe for him to have sex with his wife when she is
menstruating. After he got the information on safer sex, he went on to ask why his wife
screams and shouts while having sex during periods. On being asked what he thinks may be
the reason, he said that she never likes to have sex during periods and complains of pain and
discomfort if they do have sex on those days. But he says “since I have the urge to have sex I
have to forcibly do it with her”. It is evident that he thinks it is his prerogative to have his
vonjugal rights fulfilled by his wife whether she wants it or not.
Studies conducted across cultures show that most sexual abuse and violence is perpetrated by
acquaintances, relatives, “friends", and others in positions of power and trusted by the
survivor. It could be an "doting" uncle, a "caring” father, a “trusted” neighbour, or a spouse,
just to name a few. When we tliink of rape, what is it that comes to mind? Do we ever think
2
that a CSW can be raped? Can a wife be raped? Can a girlfriend be molested? If penile
penetration in the vagina is a requirement of rape, then what do we call the shoving of a bottle
into a woman? A father’s placing his genitals on the daughter’s genitals every night without
penetrating? A young boy's going through forced anal sex?
Fear of rape is something that all women live with all their lives - no matter how old, how
attractive, no matter where, or when. The numerous ways in which this fear is instilled in
women's minds are insidious and include their being expected to reach home before dark, to
dress in a certain way and to not dress in certain other ways, to not mix with boys, etc. How
often do we hear things like "she must have been raped because she dresses provocatively";
or "she was molested by her boyfriend's friend because she roams around with boys"? All
these words convey that if a woman goes through sexual abuse, it is because she asked for it.
These also strengthen the myth that rape is a sexual act whereas in fact it is an act of power.
Many women callers go through a dilemma deciding whether or not to have intercourse with
their boyfriends before marriage. If it is the boyfriend who proposes or initiates sex and she
refuses, she has to often go through the guilt of hurting his feelings and of being blamed for
not trusting him enough. On the other hand, if she decides to oblige him to pre-empt his
sulking and/or emotional blackmail, she is often accused of being an easy lay in a half-joking
manner and is also quizzed on her virginity and her sexual history. If the woman wants to
have sex with him she may not be able to initiate it, as she is scared of being perceived as
“too fast”. As far as sexual initiation is concerned, for men it is in the nature of an adventure,
though, of course, accompanied by anxiety and peer pressure. Whereas, for most women it is
in the nature of an ordeal because of the stories (and in many cases the actuality) of pain and
bleeding the first time a woman has intercourse.
Even married women complain about being called things like “slut” on having initiated sex
with the spouse. At the same time if the wife never initiates sex and/or does not show enough
interest, she is readily labelled “frigid”. Husbands often threaten wives to be either more or
less sexy or else they will go astray.
The kind of sexual activities that people engage in also gives interesting insights into the
power dynamics at play. Oral sex, e.g., as we all know, can be performed on both women and
men. Fellatio, however, is practised much more frequently than cunnilingus as reported both
by men as well as women callers. This difference is again not one of the first queries of the
callers and often comes across in the course of conversation. The caller may start by asking
about the possibilities of pregnancy or physical harm with fellatio. After giving the
information asked for, if they are asked if they also engage in cunnilingus, many of them
express surprise that something like that is also possible. Some others express serious concern
about their disgust with cunnilingus. A woman caller who started with asking about the
possible reason for her lack of sexual satisfaction, put it very aptly by saying “Madam, ye
husband log mukh maithun kame mein vishwas nahin rakhte, sirf karvane mein vishwas
rakhte hain" (these husbands don’t believe in performing oral sex, they just believe in getting
it performed). Many a time, husbands justify forcing anal sex on their wives during periods,
as they feel that they have to fulfil their sexual needs one way or the other.
,
What constitutes a "real sexual act" is conceptualised in male-centred terms and revolves
around the penis. No wonder so many of our callers find it unbelievable that women can
3
#•
masturbate and enjoy it even though they have no penises. The same phallocentric thinking is
what makes it easier for many people to believe that men can have sex with men but rather
difficult to think that two women can have sex with each other. It comes as a shock to them
that perhaps for some people the penis might well be redundant.
Another woman wanted to know about the possibility of tightening her vagina by washing it
with alum water on the wedding night as she did not want the husband to know that she was
not a virgin. The premium that is placed on a woman’s virginity also implies that she is seen
as some sort of a commodity that can be legitimately used by only the owner of that property.
Having had sex with the boyfriend before marriage, a woman often goes to extreme limits to
keep even a seemingly meaningless relationship going, as she believes that she has to spend
her whole life with the man to whom she has ‘lost her virginity’. Some men, who have
themselves had sex before marriage, call us up to ask how to find out the wife’s virginity
status. Some even go to the extent of taking the wife to a doctor for a virginity test if she does
not bleed on the first night. Men’s premarital sex is excused or is even eulogised as necessary
for experience; extramarital liaisons are excused, as "he is a man after all".
The impending pressure to marry that a woman almost invariably faces as soon as she reaches
a “marriageable age” makes her go through various conflicts. She has to strive to be a perfect
looking, well-educated, independent, modem and yet traditionally bound woman. Each of
these eligibility criteria, however, has a catch. Let us take just looks as an example. We see
that, surprisingly, almost all women are made to feel uncomfortable about their bodies whether it is their breasts being too big or too small, or their complexion not being right, or
their being too fat or too thin, or else their facial features not being perfect.
The culture that always makes it the woman’s responsibility to adjust in order to keep the
marriage happy (for everyone else), prevents her from sharing her agony and anger with
anyone. Men are never called upon to adjust. The custom of Kanyadaan contributes to this.
Kanyadaan is more a way of thinking than a ritual. It always keeps a woman aware that her
parents’ role in her life ended with their having “donated” her to this man and that if she can
not keep her marriage, there is no place for her in her parental home.
Violence against women begins, as we all know, even before a girl is born (in the form of
female foeticide). Language has an interesting role to play in nurturing the patriarchal psyche.
One of the typical queries we get is that" Abhi tak ladka nahin hua" (We do not have a son as
yet) when they in fact mean that they have not had a child as yet. It then should not come as a
surprise if a daughter’s birth is not celebrated, if her health and education are not attended to
as thoroughly as the son’s. Is it not only too obvious that her self-esteem and sense of worth
are hampered? Due to years, decades, centuries and generations of violence against her
dignity as a human being, she also starts seeing this degradation of her as being her due.
It is not with much ease that a woman can share the anger and agony that she experiences at
the numerous ways in which she is abused by the "culture" - in the broadest sense of the term.
As a young girl she is given caring jobs like taking care of her younger siblings. Her
interpersonal behaviour is frequently under observation. She is always kept aware that she has
to go to a house where she will be responsible for everyone else’s happiness and her worth
will depend upon their happiness. If she then finds herself in an abusive marriage as an adult,
she typically feels that she either doesn’t cook well enough, or look good enough, or is not
4-
good-natured enough, and so on. Only rarely is it possible for her to see that what is
happening is wrong and is not her fault. She either does not comprehend it as violence, or is
unable to articulate it, or has no one to listen to and understand her without blaming her.
There is no way in which violence can satisfactorily be explained away. For many women
this insidious and subtle violence results in making them feel hopeless and grey about things;
nothing excites them - including sex.
The most common responses to a woman’s complaints of violence are to either disbelieve her
account of the seriousness of the problem; or to find out what she has done to bring on the
violence; or ask her to modify her behaviour by “adjusting”; in short, to explain away what
happened. Violence can never be explained away. What an abused person needs is an
attentive ear, someone to help her sort out and validate her feelings, and to help her think of
the options she has in her specific situation.
Every so often we hear that there are laws in this country that deal with gender violence but
the problem is with their implementation for various reasons. One of them is said to be that a
woiiiiui uucs uui even icpuii violence. Bui wiieii we say mat, are we not putting the
responsibility of stopping the violence on the abused person itself? If she does report to the
law or the police, are her requirements of being heard, being treated with respect, being
understood.... met? What we at TARSHI try to do is help her with these needs as we feel that
these are more primary and immediate than legal justice. She is so used to not being heard
that she often does not even speak. It then becomes a difficult and yet important task to listen
to what she is feeling but is not able to articulate, to hear what has not yet been said.
For example, a married woman, an English speaking professional, said that her husband beats
her up very biutally but actually he is a nice person so even when she goes away to her
parents’ place, she says “I miss him and want to go back”. On being asked if she feels
comfortable at her parents’ place, she said she does not. On the occasions when she has gone
to her parents’ place, after being abused by him, she has always gone back. Taking the
conversation further, the caller and the counsellor both discovered that it was not so much a
matter of going back to him as of having nowhere else to go. Even when there maybe another
safe place to go to, an abused person needs to discover this as a viable option for herself. She
can not be bullied or coaxed into this. She has first to be heard, and only then can she hdar
what the “helper” is saying.
At TARSHI, abuse is not the primary focus but is a thread that runs through our work.
Anything that lowers a person’s dignity is abuse, whether it is shame around one’s sexuality
or restriction of individual freedom, or rape. By our efforts to provide information and
counselling, we hope to enhance people’s abilities to make choices by and for themselves. By
i
counselling what we mean is that we help individuals express, articulate, and thereby get m
touch with their feelings at the pace they are <comfortable with. Once they know what they are
feeling, the decision they take will come from within themselves and will be clearer. A
listening ear begins to give them a sense of autonomy and dignity and enables them to
develop a sense of identity that is the first step towards a violence-free and abuse-free life.
The goal of attaining a violence-free and abuse-free life may seem closer for some than fc:
or
others, but one wonders if there is anyone who has actually reached there.
International Conference on
“Preventing Violence, Caring for Survivors : Role of health Profession
and Services in Violence “
Mumbai, India
28th to 30th November, 1998
“ Mass Violence in Non-Combat situations : Caste and Communal Violence; in
Tamil Nadu - Health Problems, Role of Medical Profession and Human Rights
by
Dr. V. Suresh,
Advocate, Madras High Court
General Secretary - People’s Union for Civil Liberties - Tamil Nadu & Pondicherry State
Units
Preface
This paper is a rather tentative exploration of an issue which, until recently, I had
not paid much attention to. The writing of this paper represents a very new endeavour on
my part. Despite being involved with a mass organisation of tribals for over 6 years,
having completed a doctoral study on caste violence, and in spite of being actively
involved in the last five years with a national level human rights organisation, the People’s
Union for Civil Liberties (PUCL), until recently I had not been paid much conscious
attention to the health problems faced by surviving victims and their families in particular
, and by the victimised vulnerable social sections of society in general, to both systenic
(i.e. structural), as also incidents of outbreak of violence.
I was forced to grapple with the issue of health and mass violence rather
forcefully when, as a member of two PUCL appointed Fact Finding Teams (FFT), I was
confronted to respond toand deal with the trauma experienced by victims and survivors
(and their families) of widespread caste and communal violence in Tamil Nadu. The
experience made me painfully conscious of the fact that I had neglected to examine the
broader issue of health problems, policy and role of medical profession during times of
mass caste and communal violence
This paper attempts to redress this situation by exploring the subject of health
problems of survivors of mass caste and communal violence. The subject of examining the
effects of systemic (and endemic structural violence) is a topic of its own requiring a very
different frame of reference, and which will not be explored in ims paper
Introduction
On 29th November, 1997, in the southern Indian city of Coimbatore, a Hindu
police constable was killed by three Muslim youths over a minor traffic incident. The
minority Muslim community handed over three youths who had committed the murder to
the police. The communal problem instead of subsiding only exploded. Over the next three
days a major pogrom of the minority Muslims took place led by communal elements in
■M
2
the local police force and a Hindu fundamentalist party. Over 20 people were killed, many
dying gruesome deaths. Property (of Muslims) worth over Rs.500 - 1,000 Crores were
reportedly looted or destroyed One month after the incidents when the PUCL FFT
visited the area most people talked of three events which evoked strong feelings of
anger, resentment, helplessness, alienation and vulnerability.
(1) Soon after the outbreak of violence in the Muslim areas, injured Muslims
being transported to the nearby Government Hospital were surrounded by a violent mob
of
aimed policemen (in mufti, i.e. not in uniform) and majority community
fundamentalists and burnt alive right at the entrance to the hospital and in front of the eyes
of senior police officials who did nothing to prevent the killings
What shocked the minority community even more was the news that frenzied
Hindutva mobs chasing fleeing Muslims inside the hospital did not spare even the morgue
Men with knives pulled out dead bodies from the freezer and stabbed randomly across the
dead bodies to ensure that they were not live Muslims hiding in the morgue.
This deed, more than many other black event that occurred on those three fateful
days, caused such a deep psychological and emotional shock amongst the minority 1
community that many people complained of emotional and psychological feelings of fear,
distrust, anger and resentment when dealing with Hindus after the events.
(2) There were heroic tales too of the role of doctors during the violence An
unnamed Hindu doctor helped two injured Muslim youths escape from a bloodthirsty mob
bent on burning them alive by driving them away in his motorcycle. He not only took
them to a nearby medical clinic, introduced them as Hindus and provided life saving first
aid but also immediately therafter gave them some money and asked them to flee before
the clinic staff discovered that the injured boys actually belonged to the minority
community
This incident contrasted sharply with what occurred several days thereafter. As the
government hospitals were no longer safe for the injured Muslims, many of them sought
medical aid from large private hospitals, far away from their areas, owned predominantly
by members of the majority community. Within a short time, majority fundamentalist
groups threatened to attack the hospitals unless they stopped providing medical assistance
to the injured minority people. Without any protest, almost all the hospitals complied with
the threats and closed their doors to injured Muslims. Almost no hospital chose to
complain to the authorities seeking state protection to ensure that their professional duties
were not thwarted
The deafening silence of mainstream media to challenge such bigotry, and the
silent acquiescence of the medical profession to threats to bar medical assistance to the
minority people created such a sense of shock, dismay and disappointment that attitudes
towards doctors and medical institutions owned by the majority community has become
tinged with bitterness, rancour and suspicion.
3
(3) Following coittnuing clashes between the Dalits and upper castes in the
southern districts of Tamil Nadu over a period of almost two years, scores of Dalit youths
have been arrested by the police and jailed for long periods The fear of the arrest and
implication in false cases iad become so prevalent amongst the Dalit community that in
many villages, most able bsdied youth and young men fled their homes Continues raids
by policemen in the dead ef night resulted in many children and older people developing
symptoms of neurosis, sleeplessness, anxiety and stress The fear of the midnight knock
had become so acute in seme places that people contracted many non-specific psycho
somatic illnesses Mere recounting the experience of violence (experienced twice over,
first at the hands of the upper castes and later, from the police) was sufficient to drive
some people into a catatonic or trancelike state
A similar experience was recounted in the village of Melavalavu in Madurai
District On June 29th, 1997 six Dalits (Scheduled Caste persons) were killed by upper
caste Thevars Their main crime was that they belonged to the ex-untouchable castes and
contested for the posts of President and Vice-President to the village local body (called
Panchayats), which were reserved for members of their community under law Since they
did not heed the warnings of the upper castes not to stand for election for positions
traditionally occupied by the upper castes alone, the elected President was beheaded in
public sight in the middle of the day and the head thrown into the main drinking water
well The traumatic events produced serious medical and psychiatric problems amor gst
.
the Scheduled caste section of the village. As the firstanniversary of the beheading; and
killing approached on June 29th, 1998, many Dalit villagers complained of variety of
illnesses and also exhibited signs of great emotonal and psychological stress
These issues, apart from the human rights angle, brought to the fore the issue of
the role of the medical profession in the context of mass caste and communal violence
How equipped are ordinary doctors to deal with the physical and emotional health issues
produced as a result of such mass violence 9 How should the human rights movement
address these issues 9 What should be the approach of state health policy towards this
problem9 These and other issues pressed for serious attention from all sections
concerned -the medical community, the human rights fraternity, legal experts and the
government What causes a sense of urgency is the fact that the incidence of miss
violence in Indian society is only showing signs of becoming more endemic, rooted and
recurring
Mass Violence in Non-Combat Situations : Caste and Communal Violence
A major proportion of current literature on the impact of mass violence on
individuals and communities seems to concentrate on issues of violence perpetrated
during situations of internal or civil strife, or in warlike contexts as exists for example in
Bosnia or Rwanda Fewer studies seem to exist which have examined the medical i:r.
issues
caused by events of mass violence in non-combat situations
4
During events
i recourse
or armed oonfhct Most often there is a breakdown of civil sodety and lecml m ft
problem^altosetta' h Za^Xiat^cX’“an?''''0' Z""8‘°W,y diflfcre“
Firs, and most importantly, while mass violence tn i
invaiiably
socially engineered
V the dominant caste or community, the role of the State
i
is very ambiguos and
o~.^ s
cvtl society ThusTeX
*,K
*"to“
8‘|U,, b0“nd '° m,inlain
a"<i
™
being uncultured, uncivilised and violence orone I Hn Tn
J
stlgmafsation as
l
*rOniC manner the victims of
violence are very often characterised as h 'P • i
unruly and vioient Xmtimties
Warra"led a"d
t0 tol ™‘h s“"
Of ma.iZX’XX10 ZalnZXtelXs effKtf°?VS,en,iC Vi‘"e,'“ ’"8*
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unjust, unfair and
“P6"6™6 a 8,reat amount of institrnmnliisS XTelT' Thus aly
5
castes, and in communal context, the majority Hindu community) These sections, yho
most often also occupy important positions in bureaucracy, business and in the
professions, by virtue of their posiiton are able to put forward an artificially engendered
social consensus on the necessity of taking firm action against the subaltern sections,
which becomes the rationale for violent suppression by the state authorities of the
minorities demanding social equity and equal status in society and polity
What is sought to be put forward here is not a discussion on the sociological
dimensions of caste and communal violence but on the relatively poorly examined issutp of
health problems faced by these communities What is striking is that the victims are
sufferers are two levels On the one hand, they are the victims of structural violence which
takes a toll of their psychological and emotional well being, while at the same time they
also suffer from the problem of poor access to health facilities. On the other hand, these
communities experience another variety of health problems when they become victims of
mass violence As targets, they are the ones who suffer considerable physical
traumatisation ranging from killings, mutilation to rape As patients they have access to
few infrastructural facilities for treatment. What is the sum effect of both these levels of
violence is the moot question which requires more systematic study. As remarked earlier,
this paper addresses only the issue of the problems created by the outbreak of mass
violence against members of the minority Dalit (or Scheduled Castes) and Muslim
communities
Ghettoisation, Access to Medical Assistance and Health problems during Mass
Violence
It needs to be emphasised that while in this paper we seek to examine in a common
frame health issues vis-a-vis the outbreak of mass violence against Dalits and Muslims, it is
not suggested that the causative reasons resulting in mass violence against both
communities are similar Actually there is a great amount of complexity and diversity
underlying the problem of caste and communal problems within various geographical areas
of the same region, not to talk of the whole country. But despite the vast differences in
economic and social contexts, there are nevertheless a few common aspects marking the
lives of the Dalits and Muslims in India
In many parts of the Indian countryside Dalits are socially forced to live in ghettoes
outside the main village into which no non-Dalit would generally enter In the towns,
Dalits are refused rental accomodation in upper castes localities of the town, and are
perforce made to live in economically run down areas of the town or city which then
While the situation in big cities is not so marked by
become socially marked.
geographical stigmatisation, the sheer impoverished economic context of large section^ of
the Dalits results in them living in geographical concentrations, generally in poorer or
middle income areas of the cities Very seldom have Dalits managed to buy properties in
elite or upper class areas. Even if they have, such Dalit families would seek to hide their
social origins
6
A similar situation prevails amongst the Muslims
Generally Muslims are
concentrated in towns and cities and live in clearly marked out geographical locations.
By and large, Muslim areas of the city are distinct in appearance and population, and
during times of communal unrest can be easily targetted. Though in some cities some
wealthy Muslim families own large mansions or estates in wealthy sections of the city or
town, and are also involved in business, in porportion to both the overall Muslim people,
as also the general population, their numbers remain small. The bulk of Muslims across the
country remain in economically poor conditions.
Another common aspect is the fact that generally the areas where Daits and
Muslims live is distinguishable by the economic levels of the people. Over crowding, poor
water, drainage and sanitary facilities, and lack of public facilities like schools, colleges,
hospitals and so on mark these areas Thus for most but the basic facilities, both Dalits
and Muslims will have to travel to other areas of the village or town to access public
faciltities like Municipal offices, colleges, big hospitals,banks and so on. (Here we need to
clarify that in some mega cities like Mumbai, Muslims live in such concentrations that they
occupy major areas of the city and since a considerable section is involved in economic
enterprises,there are relatively better infrastructural facilties present. But when viewed in a
national context, such situations are more exceptions than the rule).
Ironically, whether proper infrastructural facilities exist or not, an ubiquitous
institution always to be found is the police station I In sharp contrast, in most towns and
cities most higher level medical institutions are located in non-minority areas, in the midst
of the majority caste/community localities.
The spatial locations of both Dalit and Muslim habitations, which in many
situations resemble ghettoes, clearly identifiable and distinguishable from other areas of
the village, town or city, plays an important role during outbreak of mass violence The
very fact that these minority sections live in geographically distinct areas makes it easy for
the perpetrators of violence to target their violence on the living areas of the minority
sections
The Dalits and Muslims in most instances, become sitting ducks for the
aggressors
The ghettoised living also has another dimension. It become easy to localise the
problem and deal with it by sealing the living areas of Dalits and Muslims. It is easy to
pour in police forces into the areas to quickly suppress any reaction or backlash from the
victimised communities. In sharp contrast, the upper caste or majority community
aggressors come from a much more geographically dispersed area, which makes both
localisation and identification difficult.
During such periods of mass violence, the minimal medical faciltities existing in the
areas prove totally insufficient to deal with the problems of the injured people What
causes the problem to become more acute is the fact that to access higher institutions,
injured Dalits and Muslims have to travel to other localities of the city making them more
vulnerable to attacks by the majority community. Additionally, since State (meaning
7
police) response also invariably victimises the victim by accusing them as the originator s
of the trouble, there is the problem of arrest and apprehension if Dalits 01 Muslims travel
outside their living areas which inhibits their immediately trying to access medical faci ties
outside finally, as the recent Coimbatore incident ievals, if injured persons end up
becoming targets of mob attacks in hospitals meant to provide them medical succoui and
relief, then fewer people will access the government hospitals, invariably situated in
majority localities, for medical assistance
Impact of Inadequate Health Professionals and Medical Facilties
Similar to the issue of spatial location, both Dalits and Muslim communities share
another common characteristic In both sections the number of medical professiona s is
inadequate and pitifully small in proportion to their population While there are historical
and sociological reasons as to why there are fewer
professionals amongst these
communities, the reality is that there are fewer people from amongst the minorities
themselves serving their own people.
The situation has been redressed somewhat in the context of Dalits because of the
reservation of seats in educational institutions and in jobs through a Constitutional
provision The numbers of health professionals amongst Muslims are far fewer in contrast
However event hough there are more Dalit doctors today than say two to three deacdes
back, the reality is that for economical survival most of them have to seek employment in
government
There a very instances of Dalit doctors becoming successful private practitioners
There are fewer cases of Dalit doctors setting up big medical institutions If at all they are
successful, Dalit doctors have to rely on their own brethren living in concentration in the
Dalit areas of the town
Socially there is a caste and communal dimension to this problem In the case of
Dalit doctors, very few amongst the non-Dalit sections of the populace will approach Itiem
for medical care or assistance if they know the caste background of the doctoi While the
problem with regard to Muslim doctors is not so acutely exhibited, apart from the fact that
there are far fewer Muslim doctors, there is the fact that the practice of these doctors is
largely concentrated in areas wheretheir own people live In both situations, the lack of
adequate number of medical professionals amongst the Dalits and Muslims becomes one
more factor inhibiting the reach of medical services to victims of mass violence at the
actual time when violence has broken out
Rehabilitation Policy, State Action and Post Traumatic Stress Disorder (PTSD)
An unfortunate aspect of State Health Policy is the fact that at times of mass
violence the state stops with the provision of immediate medical relief This invariably
covers only those victims who have suffered physical injuries That victims need not be
only those who are physically traumatised is a factor not acknowledged, let alone be
8
accepted, by the state Despite literature abounding about the psychological effect and
impairment of not just physically affected victims, but even by their relatives, neighbours
and bystanders is never factored into state policy determining the nature of health facilities
provided to victims and survivors.
As discussed earlier, victims are not just those physically affected. There are a
whole lot of others equally seriously affected The following is a listing of different types
of situations which results soon after mass violence which produce different types of
traumas amongst people, as has been witnessed during various FFTs of the PUCL
1 The psychological trauma ol having near relatives and/or friends becoming
victims of mass violence either in terms of being killed, injured, mutilated or inother ways
physically traumatised.
2 The mental and emotional trauma of having personal belongings and properties
vandalised, destroyed, looted and burnt by attacking mobs
3 The practice of immediate and random arrest of persons belonging to Dalit or
Muslim communities from the isolarted areas they live in on the basis that they are the
ones who were responsible for triggering the violence in the first place The resultant
tortures, illegal detentions and other psychological trauma experienced by those arrested
is matched by the trauma experienced by the entire extended family, as also the
community at large
The stultified attitude of the state is more explicitly revealed when we consider that
the state extends compensation only to those direct victims of mass violence who bear
physical injuries only The main emphasis is on those killed. Followed by those who suffer,
in what is known in bureaucratic and legal parlance, as grievous injuries meaning injuries
to limbs which caused drastic physical impairment. All other injuries which do not strictly
fall in the legal definition of grievous’ are treated as simple for which no compensation is
provided ' As can be easily inferred there is noplace in such a scheme of things for the
state to provide any assistance to persons who physically bear no outward symptom or
injury, but nevertheless are psychologically scarred for life because of their experiences
In fact, it would not be untrue to state that the State in India does not perceive
psychological trauma and psycho-somatic illnesses as health issues. The whole gamut of
issues ranging from somatic illnesses to psycho-somatic illnesses, including the prevalence
of Post Traumatic Stress Disorder’ (PTSD) finds no place in state rehabilitation policies
or activities in relation to victims of caste violations.
Ironically it took the International community more than 45 years to accept that
PTSD is the discrete psychiatric disorder with unusual medical, pscyological and
physiological features. Much slower has been the development of legal principles to cover
the issue of liability and compensation in cases of victims and survivors traumatised by
mass violence Ihus in the absence of clear cut health policy to enable provision of
appropriate treatment facilities for victims suffering from PTSD, and with no lei>al
principle to enable us to demand to provision of such facilities, there is a great need for a
9
forceful campaign from amongst health professionals human rights activists, advocates,
policy planners and others demanding re-examination of state health policy, vis-a-vis
victims of mass caste and communal violence
Role of Medical Profession.
At this juncture it may be instructive to briefly consider the response of general
medical community to the prevelance of PTSD amongst victims and survivors of mass
violence A noticeable feature is the general lack of awareness about the nature of PTSD
or the type of intergrated, multi - disciplinary medical treatment required by victims
suffering from PTSD There is also not much knowledge about the various international
conventions that have been evolved from time to time calling upon the medical profess on
to maintain the highest standards of professional conduct and practice the profession with
intergrity and ethics The Geneva Convention (1948, 1968, 1983), the Tokyo declaration
(1975) and the Declaration of Hawaii (Worlds Psychiatric Association, 1977, 1983)
which called upon doctors not to countenance, condone or participate the practice of
tortures and other cruel, inhuman or degrading procedures exists more in the books rat ier
than in a knowledge of the general medical practitioner
The illustrations given in the introductory portion of this paper clearly points out
that there are good doctors and bad doctors There are doctors who enable the police end
other aggressors to get away literally with murder by doctoring medical records and post
mortem reports. There are yet others who would under no condition betray the oath they
have taken to maintain the highest standards of the profession The worrying aspect is that
the latter type of doctors are becoming smaller in numbers as compared to the greater
numbers of doctors who seem willing to bend the rules for a consideration.
There are thus two types of issues which crop up in the context of trating violence
victims On the one hand, lack of expertise or knowledge to treat patients afflicted by
PTSD and related illnesses is a serious handicap in ameliorative services. On the other
hand is the issue of unethical medical practice on the side of the perpetrators of violence
both directly by covering up medical symptoms of violence, and indirectly by refusing to
extend medical assistance either wilfully or due to coercion
Issues before the larger Medical, Human Rights and Legal Community
It is under these circumstances that we have to visualise the type of policv shifts
that we have to aim for so as to bring about a more comprehensive policy regime to treat
the problems of victims of mass violence.
(i) First, and foremost, the state health and rehabilitation policies should recognise,
acknowledge and accord importance to the phenomenon of PTSD and make it a part of
the policy framework both of the health, as also other related departments who prov de
other support services
10
(ii) Special training should be given to medical personnel belonging to government
services to the various dimensions of the problems of victims of mass violence and the
psychological and emotional trauma they undergo. Multi-disciplinary treatment should
become the norm
(in) Core courses on PTSD should become part of the regular syllabii of medical
colleges throughout the country.
(iv) The emphasis should be on recognising that the problems of PTSD is not
merely clinical and that mere clinical or medicene based treatment will not suffice,a nd that
there is a need for more supportive treatment and response from immediate family
members of victims of PTSD and also friends and the general community.
Community involvement in the treatment of those suffering from PTSD is crucial
to tackling the problem in the long run.
(v) There should be widespread dissemination of information about the various
Medical Conventions and regarding the ethical and Moral duties of Doctors It is only by
involving greater numbers of general practitioners and conscientising them about the
prevalence of new forms of treatment to treat victims of mass violence that there can be
any sustained basis for treatment of victims.
(vi) To educate more NGO’s about the prevalence of PTSD and launch
rehabilitation campaigns to treat victims of torture and trauma caused by mass violence
In the ultimate analysis what is required is much more sustained discussion
amongst various professionals whose work brings them into contact with victims of mass
violence through which alone the issue can be studied and understood much better
Community participation and structures need to be strenghtened which can happen only
with greater campaigning to make people aware that the problem is not that if individuals
who have a mental problem1 but that they are unfortunaten victims of an extremely
harmful and debilitating process.
Epilogue
At the personal level, the process of writing this paper has helped in crystallising
the resolve to launch a comprehensive study of the health problems of victims and
survivors of mass caste and communal violence in Tamil Nadu state. Hopefully by the time
the next similar conference is held there would be a more data-based paper to share with
other concerned people across the country, and indeed the world It is through this shared
concern, that this writer believes, that we can provide meaningful alternatives in a world
becoming more and more individualised, selfish and impersonal. The shared concern is at
the same time a common strength while also being the basis of sustaining our endeavour
to make the world a better place to live
.1)
11
Acknowledgements
This paper owes much to two very concerned doctors, who opened my eyes,
literally speaking, to the prevalence of PTSD They are Dr Yonas Geda of the Mayo
Institute, USA, who was himself a torture victim and jailed for ovei 7 years in Ethiopia,
and Dr Mathiharan from the Forensic Science Department, Chennai Medical College,
Chennai who guided me through the subject and patiently explained every doubt There
are two other doctors whose prompting pushed me to put on paper my experiences and
thoughts on ther subject Dr Madhukar Pai of the Sundaram Medical Foundation w as the
one who informed me and motivated me to write Dr Amar Jasani readily agreed to
include my paper as part of the proceedings Finally my wife, and fellow advocate and
human rights activist, Nagasaila, critically edited my confused writings and added many
relevant aspects especially on the subject of state health policy Needless to say the
shortcomings are entirely mine H
Refereneces
MCULLOCH, Malcom, Chris Jones, John Bailey (1995), Post Traumatic Stress
Disorder’ turning the tide without opening the floodgates. Medical Science Law Vol
35 No 4PP 287 - 293
RAMASESHAN, Geeta Treating terrors of torture’ (1998), The Hindu, 19th Xpril,
Sunday magazine
WELLER, Malcolm, P I ,(1985) Crowds, Mobs and Riots’, Medical Science Law Vol
25, No 4PP 295 - 303
Manual HOME STUDY COURSE IN TRAINING FAMILY PHYSICIANS AS
COUNSELLERS FOR TORTURE SURVIORS’ by A K N Sinha, Institute of
continuing Medical and Health Education and Research with support of United Nations
Voluntary Fund for Victims of Torture and Endoresment of International Rehabiliatation
Council for Torture Victims and National Human Rights Commission, India
Dr V Suresh,
General Secretary, PUCL TN & Pondy
32, Kachaleeshwarar Agraharam Street,
Off Armenian Street, Chennai - 600 001
M p 1^/6
Experience of Domestic Violence Against Community Health Volunteers of Urban Slums
By Medha S. S.
Community Education unit
Alert -India.
Background / Context
The control of women’s labour and reproductive role by the family are the common
phenomena of our patriarchal society. Working women are no exception to this; thus the
Community health volunteers too. Community health volunteers are community women, residing in
the same community to which they are supposed to reach out to and enhance their understanding
and participation in health care promotion work. They have genuine concern for their own
community people and their problems. All CHVs are women belonging to lower class and caste
strata of our society.
Like all other women of our society, they have the lowest position in the family structure,
as well as in the community. Their low position in the social hierarchy enhances their
powerlessness and brings domination, sexual assault, beating, physical and psychological
harassment This paper will unfold four different life stories of women CHVs who are undergoing
such experiences. These four stories are taken from among 550 CHVs of N, S and T wards with
whom we are working for last five years. Once, during one of our session on domestic violence,
some of them came forward and narrated their life experiences. Later, with their consent thesfc
stories are been published in our newsletter called ‘SAKHT. I am presenting the same stories to
you in an abridged version.
Shubhanal
Shubhangi was bom in a village. Her father brought her to Mumbai when she was two
years old. She was die first child bom to her parents after five years of their married life. She
was pampered till she had other siblings. Her parents were quite upset when they had thr$e
daughters one after another. Her father was a mill worker. He got her married when she was jbst
fifteen. She had no choice.
She did not know ‘what marriage meant ?’and before she could understand it; she became
pregnant, just within six months of her married life. She gave birth to a baby boy before she
became seventeen. She had a veiy difficult delivery since she was quite young. Within five years
she had another child. After that, within two months her husband lost his job because of a lock up
in the mills.
Shubhangi took initiative and started selling vegetables. It helped them to survi ye.
„
However, during the same time her husband started drinking. He used to come drunk, asking for
money. Whenever she refosed; she was beaten up. This became an every day scene. When hiis
drinking and beatiqg became unbearable then she complained to her in-laws and parents I
ley
tried to counsel! him, however he didn’t change but became worse. He stopped helping her t ith
the business. She had to stop selling vegetables because she was doing it all alone With sn all
children it became very difficult to manage both household chores and vegetable business. 1 bus
resulted in an economic crisis. He started selling her gold ornaments to obtain money for liqi or.
He continued to beat her and illtreat her, just as if she was an animal. Many times he locked the
I
2
‘Kholi’, madeher and the children sit outside for the whole night Once again she complained to
her parents Their answer was ‘So what if he beats you up ? You are a woman. We have given
up our daughter. Now you are dead for us. What can we do ?’.
4 /h i SHe »8tar^d ma”agin8 40 house
children’s education with her part time job as
danhelper etc. During the same time she heard about CHVs wort and she accepted it The first
reason for her acceptance was the Rs.500 honorarium.
nr
Manaal
...
is a second child of her parents. She has an elder sister and two younger brothers.
She liked playing a lot However, when she started menstruating and her mother stopped her from
going out She was kept at home all the time to do household chores.
Her parents got her married without taking her consent They didn’t enquire properly about
the boy and she got mamed to a man who was an alcoholic and gambler without a job. He lied to
her parents about his occupation. After marriage, her parents washed their hands off her and her
fate was sealed.
She got pregnant during the first year of her marriage, that also without her consent She
gave a birth to a baby girl. At a same time there was lot of pressure on her to move out of house.
Since it was her ( husband’s brother ) brother in-laws house they were not ready to share the
space. With the help of her parents she bougjit one room by taking a bank loan. Ulis brought on an
added tension of repaying the bank in instalments. Also she had to return her husband’s gambling
debts. Everyday, she had to deal with people who came home asking for their money. Somehow
she returned all their money and warned them to stop lending money to her husband. She
accomplished all this by taking up a job in a factory and leaving her child at the mothers place.
In the mean time, she got pregnant, again without her consent She gave birth to a baby boy
and had to stop working outside the house. After 3, 4 years she enquired at different places for a
job prospects and found out about CHVs training and enrolled herself for the same. Since that time
she has been working as a CHV for various organisations. Because of her good work she started
receiving respect from community people. Her husband started feeling jealous of her. She
developed lot of contacts with different people. She always got selected for various training. Her
husband started feeling insecure and envious. He started doubting her loyalty to him. Many times
this used to turn in to a quarrel, fighting, arguments and beating. At a same time he was not
working regularly. For over six months of the year he used to sit at home. So she had no
alternative but to fight, receive beating and work A sexual relationship was demanded frequently
by her husband inspite of her unwillingness for the same.
I
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Suchtta
Suchitawasbominabigfamily. She has four sisters and one brother. She had a thirst for
education, but her father did not allowed her to study beyond mafric. Her parents got her married
when she was seventeen. She had a first child during the first year ofher marriage. Since she was
too young, anaemic and no proper care was taken during deliveiy, the child died immediately after
birth. Within one year she had a second child. Two years later she had her a third child. She had
to bare unwanted children. Her husband never bothered to ask her, ‘whether she wanted to have
children’. She was supposed to have sexual relationship with him every night, even if she was not
interested.
She had worked in a garment factory before her marriage. From which she had saved
money for herself After her marriage, when her parents stopped her sister’s education she came
forward and helped her to do nursing. Now her sister is working in Rajawadi hospital as a staff
nurse.
When her youngest child was one and half year old, she looked for some part time job to
sqjplement family income. She came to know about CHV’s work. She went for a tubectomy
operation and was asked to join on the same day. She gave up tubectomy operation and joined her
duty.
Earlier accepting her secondary role and physical and sexual abuse of her body, was a way
of line. But when she attended Alert India’s training, she was in tears during the session on mental
health. She said, ‘why should I submit myself to my husband? He goes out to other women.
Drinks. Gambles. I am the one who takes care of the family and I manage all the expenses. What
right does he has to come and beat me ? He ask for sex every day. And he gave me this
reproductive tract infection. Now he is not even ready to treat himself’ We gave her space and
time to vent out her emotion. This really helped in bringing out all her suppressed feeling of many
years. Then she was calm. She decided to be firm. She made a decision to tell her husband to
treat himself medically. She has decided not to suffer with RTIs.
Conclusion ■
There are many other Shubhangi’s and Mangal’s in our area. These are the facts of life.
Women are not allowed to play, study or develop their own interests in any field. They are
married by their father just before they finish their childhood. Within one year of their marriage
they all have children, when they are still adolescents. They donot even know how to look after a
child.
When they all come together and speak about their past it is amazing. So much of energy
they have. Besides all the torture they struggle, survive, run the families on their own income and
manage to find time for themselves during the period of trainings. The sad part is we all from
Alert-India reached out to them when they are in their thirties and forties. Untill then they had
accepted this subjugation as a part of their life and as the role of ‘wife’. Unwillingly submitted
their body, their mind to their husbands, and tolerated their alcoholism, gambling. Remained
ftithfiil to their husbands though so many of them brought home STDs and RTIs
However, it is better to be late than never. We are confident that, they will help their
daughters to be independent, self supporting, self respecting and assertive women.
"An Overview of Legislation and Guidelines for U.S.A. Health
Professionals in the Reporting on Domestic Violence."
Paper prepared for Conference on Preventing Violence, Caring for
Survivors: Role of Health Profession and Services in Violence’
Mumbai, India
November 28-30, 1998
Helen E. Sheehan, Ph.D.
Associate Professor, Dept, of Sociology/Anthropology
St. John's University, 8000 Utopia Parkway
Jamaica, NY 11439
Introduction
In the United States f
types was
identified not
by the late
1980s,
violence of
a matter of concern
just as
for
all
law
enforcement, but also as a public health issue-- "an epidemic of
violence."
As a result.
studies of the causes and effects of
violence,
reporting and tracking of violent incidents by legal
agencies
and
professional
hospitals,
and
organizations
statements
have
on
increased
violence by
during
the
health
past
10
years. In this paper. I intend to focus on one aspect of violent
behavior in the U.S.,
family and domestic violence.
This paper
will define family and domestic violence,
identify the persons
affected by it.
in
and highlight some issues
respect to reporting on domestic violence.
legislation with
The guidelines that
health professionals follow in identifying victims of domestic/
family violence incidents will be outlined.
Domestic Violence
History in the US
In
American
society,
with
social,
traditions that value independence.
religious
molding,
place
the marital relationship, the family.
arenas
in
legal
individualism, privacy,
property
the
and
which
domestic
violence
and
take
and the home
have been viewed as places where the state did not have the right
to intervene.
In traditional Christian marriage vows. the wife
agrees "to obey" her husband, the wife was viewed as property; in
1
rearing,
child
"children were
to
be
seen
and
not
parents were told "spare the rod and spoil the child";
of privacy,
"a man' s
home is his castle."
and
heard,"
in terms
Wives and children
were viewed as dependents, bound to obey the father and head of
the household.
With such sentiments and traditions.
justifica
tion for physical means of punishment to insure proper behavior
and obedience, was easily reached.
The concept of family and domestic violence in the US,
defined
presently
and
interpreted,
professional
recognition only
efforts
cope
to
shelters/homes
with
for
during
domestic
battered
has
the
violence
women,
reached
last
25
public
years.
included
developing
as
and
Early
opening
of
profiles
of
characteristics of batters, and dispelling of myths about family
violence (husbands don't do such things to their wives; if he did,
"she deserved it," etc.)
Prior
to
the
1960s
and
1970s,
reluctance
to
intrude
into
family life, had resulted in limited and inconsistent use of laws
and remedies against violence that applied in other,
non-family
situations.
Definitions and Types
Domestic
and
family
violence
pattern of abusive behaviors,
“is
defined
as
a
systematic
occurring over a period of time.
that may become more frequent and
severe and are done
for the
purpose of control, domination. and/or coercion”1
Three types of domestic and family violence have been identified
2
in
the
US
spousal/partner
and elder abuse.
sexual),
developed
with
respect
child
abuse,
In the US,
to
(physical
and
certain distinctions have
reporting
and health professionals.
organizations
abuse
abuse
of
by
health
These distinctions
fall
into the categories of mandatory (required) reporting versus non
mandatory reporting.
For
cases
child
of
abuse
and
elder
abuse.
of
reporting
injuries by health professionals and agencies is mandatory.
The
rationale in these cases is that the child. who is underage
is
not
the
competent
decision
to understand
to
professional
report;
individuals who,
also
made,
it
has
is
first
happened or
the
to make
responsibility
encounter and
of
the
identify
the
For the elderly, assumption of incompetence
abuse to report it.
is
hence.
what
usually based
on
identification of physical
and
In the case of spousal abuse, assumptions of
mental infirmities.
competence on the part of the adult (usually the wife, since women
are
more
likely
interpretations
in
to
be
law
decision to report the
victims
that
abuse.
men)
lead
to
should
make
the
health professional is
not
abuse
of
the
adult
The
than
victim
penalized for reporting the abuse; on the contrary. he/she can be
penalized for not reporting child and elder abuse cases.
Problems in Identifying Cases of Abuse
In the US, there are now guidelines available for identifying
cases
of
abuse based
on physical
and
psychological evidence.
However, the complexity of factors involved in abuse, the location
and manner in which cases may come to the attention of health care
3
professionals, the intricacies of treating the victim, the ethical
questions in sorting out problems of competency of the victim. and
the requirements of legal reports and possible court appearances
demand extraordinary commitment from medical personnel to become
involved in these cases.
For example, victims may arrive in an
emergency room suffering from severe trauma from a beating or may
visit a doctor’s office with a minor bruise or burn, yet both may
be victims of violence. The victim may deny the abuse, especially
if the perpetrator brings them for treatment and denies harming
the
individual.
In
the
case
of
an
elderly
their
person.
dependency on their son or daughter for day to day care, may make
them fearful to acknowledge abuse.
Middle and upper class victims
of violence may deny their victimization to the family physician
who may also be a family friend. Cases of child abuse often prove
complicated to document since the child may be too young to speak
or to accurately describe what happened.
added paperwork;
Legal reports require
court appearances to testify about abuse cases
require time.
Guidelines for Identifying Victims of Family and Domestic Violence
Efforts to standardize guidelines to identify abuse victims
have
taken
utilized
hospitals.
place
by
over the past
individual
health
as
years
leading
practitioners,
to protocols
clinics.
and
Specialty professional organizations (such as those of
pediatricians and geriatricians).
(such
25
the * American
national medical organizations
Medical
Association)
and
health
4
administrative
bodies
(such
the
as
Joint
Commission
on
Accreditation of Health care Organization (JCAHO) as well as state
level departments of health and family services have all developed
guidance for spousalr child and elderly abuse identification and
reporting.
The emphasis in
the recommendations is on the health
care organization providing a multi-disciplinary approach to the
identification, treatment and follow-up of suspected abuse cases.
Everyone in the health care organization from the admitting clerk
through the treating physician and nurse to the social worker are
(See Appendix A for
viewed as key players in the complex process.
guidelines for identifying physical and other signs of abuse of
the adult victim and the elderly victim).
While advances have been made in identifying and verifying
experts argue that agreement
signs of spousal and child abuse,
about and understanding about elder abuse is
just developing.
2
“Granny-bashing" as it is often called is hard to identify because
the elderly, often in a frail physical state and a confused mental
state, may well be expected to fall and fracture a leg or hip;
yet, the fall and fracture could also be the outcome of physical
abuse. Likewise, claims of money or valuables being stolen could
be
attributed
to mental
confusion
behavior of a caregiver.
Hence,
rather
than
to
exploitative
the need to question both the
elderly person and his/her caregivers to determine the context of
the incident is emphasized.
5
Legislation regarding Domestic and Family Violence
United
the
In
requirements
States,
States
by
injury
for
reporting originated in the need to identify suspected criminals
who might be at a health care facility for treatment for an injury
suffered in connection with a criminal act such as a robbery, or
a knife or a gun,
someone injured by a specific type of weapon
for example.3
As the social pressure for appropriate treatment
and referral of domestic violence
these injury reporting
grew,
as well.
laws became the umbrella for domestic violence cases
However, concerns about the differing needs of domestic violence
victims from those of persons suffering from injuries from other
causes have led to re-evaluation of reporting requirements.
In domestic violence cases, there is concern for privacy and
protection of the victim; in the US as well there is concern for
The US Congress,
privacy of medical information for all patients.
therefore,
drew
up
model
legislation
(the
Information Act) “to provide uniform laws.
Uniform
rules,
Healthcare
and procedures
-4
governing the use and disclosure of health care information.
Disclosure of patient information may be made to federal,
state,
or local law enforcement authorities if required by law (injury
to overcome the
reporting laws require such disclosure).
multiple
concerns
about
the
adult
victim of
domestic
violence
(including need for privacy and protection from fear of reprisal
from the perpetrator)
obtain
way.
health care professionals
the victim's/patient’s consent
legal
requirements
are
met
but
are
advised to
for disclosure.
the
confidence
In this
of
the
6
patient/victim in
the
health
care
and
legal
procedures
can
be
maintained.
7
Conclusion
As
with many
resolution
of
professionals,
issues
these
in modern
issues
often
society,
falls
the
under
handling
and
purview
of
the
especially those in medicine and law.
Cases of
violence in the family, once viewed as a private family concern
in
the
U.S. ,
providers.
are
now
regularly
monitored
physical
families,
the
and
need
psychological
consequences
for
and
effective
health care professional.
is
most
frequently
and development of the medical.
the
care
health
care
the
for
medical
It is clear that the
first
and
most
trustworthy
Hence, clear comprehension
legal, and ethical requirements
professional
violence is called for.
abuse
although perhaps reluctant to take on
individual the victim may encounter.
of
of
compassionate
treatment and legal resolution has grown.
role.
health
Over the past 25 years, with growing awareness of the
serious
the
by
role
in
family
and
domestic
Each society will have to develop the
regulatory framework in which medical care for these victims can
be
provided.
In
this
paper.
selected
highlights
in
these
developments in the U.S. have been presented.
Schornstein, S.L. Domestic Violence and Health Care: What
every Professional needs to know. Sage Publications, 1997, 1.
2 Lachs, Lecture on elder Abuse, * Emerging Issues in Mental
Health of Older Adults, St. John's University, October 23,
1998.
3 Schornstein, 102
4 Schornstein, 105
8
Appendix A (Source:
State of New Jersey, Department of Community
Affairs r Division on Women, Domestic Violence Prevention Program:
Domestic Violence:
A Guide for Health Care professionals” March
1990)
1.
Guidelines for Identifying Adult Victims of Domestic Violence
A) Patient admits to physical abuse.
B) Patient
presents
fractures
or
healing.
Common
victims
are
genitalia.
with
unexplained
multiple
injuries
sites
face.
of
head.
bruises r
in
lacerations,
various
injury
for
chest,
breasts,
stages
domestic
of
violence
abdomen
and
Pregnant victims typically show injuries to the
breasts, abdomen, and genitalia.
C) Extent or type of injury is inconsistent with explanation
patient gives.
D) Substantial
delay
occurs
between
time
of
injury
and
presentation for treatment.
E) Patient
manner
describes
the
in
a
hesitant,
circumstances
embarrassed
surrounding
or
the
evasive
alleged
-accident".
F) Patient
services.
repeatedly uses
Medical
emergency
history
contains
remarks
previous
injuries were of
by
nurse
room
reveals
or
many
physician
suspicious
other medical
-accidents"
indicating
origin.
Note
or
that
that
victims beaten at regular intervals may come to a hospital
9
with psychosomatic or emotional complaints just before they
expect another beating.
G) No substantiating physical evidence supports complaints.
H) Family member or friend accompanies patient and insists on
staying
close
influence
to
the
alcohol
of
patient,
or
appears
or
drugs
to
be
otherwise
under
the
exhibits
suspicious behavior.
I) Untreated old injuries.
J) A history of
prior physical
abuse.
either
as
victim or
witness.
K) Injuries on area of body normally covered by clothing.
L) Injuries consistent with burns, whip-like bruises, etc.
M) Complaints of chronic pain.
N) Psychiatric,
alcohol or drug abuse history in patient
or
spouse.
0) Depression regarding family situation, e.g. not wanting to
return home, fear for safety of children.
P) Previous suicide gestures or attempts.
2.
Guidelines for Identifying Victims of Elderly Abuse
•
Physical
abuse.
which
includes
beating,
burning,
rough
physical handling and sexual abuse;
•
Neglect, which includes both willful and unwillful neglect,
abandonment,
and
confinement.
malnutrition,
starvation.
over
withholding
of
personal
and
This type of abuse is the most common
□ut
under-medicating
medical care.
and
10
often is difficult to detect;
•
Psychological
abuse.
which
includes
verbal
harassment,
threats, enforced physical and emotional isolation. and any
behavior which
causes
fear
in
the
elderly.
This
Df ten
occurs simultaneously with physical abuse and neglect; and
Financial
abuse.
which
includes
withholding
or
stealing
funds and exploitation of personal property.
11
n »19
I
Violence Against Women:
A Public Health Priority
Presentation by Ms. Iris Tetford, WHO Geneva
International conference on
Preventing violence, caring for survivors:
role of health profession and services in violence
Organised by CEHAT,
Mumbai, India
28 - 30 November 1998
WHO 98.11
Violence Against Women:
A Public Health Priority
♦ Beijing Platform for Action, 1995
♦ World Health Resolution (WHA 49.25)
WHO 98.11
Living in violent relationships affects women’s lives at all levels, reducing
their physical health, their self-esteem, their capacity to care for their
children and their ability to work, to name but a few. Women’s
organizations’ knowing this, have worked for more than two decades to
place the topic firmly on the international agenda, both as a human rights
and as a public health issue.
In 1996, the World Health Assembly endorsed the Beijing Platform for
Action. In Resolution WHA 49.25, WHO initiated its activities by
declaring violence a public health priority and calls for a science-based plan
of action for the prevention of violence.
The Beijing Platform for Action states that "The absence of adequate sexdisaggregated data and statistics on the incidence of violence make the
elaboration of programmes and monitoring of changes difficult" (para 120).
Moreover, it recommends, among other things, the promotion of “research
and data collection on the prevalence of different forms of violence against
women, especially domestic violence, and research into the causes, the
nature and the consequences of violence against women and the
effectiveness of measures implemented to prevent and redress violence
against women" (para 129 a).
iXo
-
s
2
j
Violence Against Women:
A Public Health Priority
The problem
♦ 20-50% of women worldwide report being beaten by an intimate partner
♦ Major impact on:
» women's physical and mental health
» infant and children's health
» health services
♦ Measurement and methodological issues
» crime statistics widely underestimate true incidence
» no standard definition
» few validated instruments for assessing the problem cross-culturally
WHO 98.11
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
3
Violence Against Women:
A Public Health Priority
Objectives
♦ Increase knowledge
♦ Identify prevention and intervention strategies
♦ Improve health workers’ capacity
♦ Support the formulation of anti-violence policies
♦ Advocacy
WHO 98.11
WHO aims to decrease morbidity and mortality among women who have
been abused and to identify feasible, appropriate and effective strategies to
prevent VAW.
The specific objectives are to :
♦ Increase knowledge about violence against women, sharing this
information with policy makers and health providers
♦ Identify feasible, appropriate and effective prevention and intervention
strategies that can reduce violence against women
♦ Improve the capacity of health workers to identify and respond to women
suffering mental and physical abuse
♦ Support the formulation of anti-violence policies by national governments
♦ Serve as an advocate for greater recognition of the problem
4
Violence Against Women:
A Priority Health Issue
Activities
WHO Consultation on Violence Against Women
♦ Research and development
» Multi-country study
♦ Information and advocacy
» Database
»Information pack
♦ Norms and standards
WHO 98.11
In February 1996, WHO organised the first WHO Consultation on VAW.
The meeting brought together researchers, service providers and women’s
health advocates, as well as staff from several WHO programmes. It
reviewed existing information concerning the magnitude of the problem,
health care interventions, and ongoing research initiatives; identified gaps
and made recommendations to WHO. Recommendations made to WHO
provided guidance on priority areas and have been the basis for the Plan of
Action on VAW.
Research and development
Multi-country study on women’s health and domestic violence
Manual on research methodologies
Statement on ethical and safety recommendations
Information and advocacy
Data base on violence against women and health
VAW Information Pack
WHO/FIGO Workshop “Eliminating VAW: In search of solutions”
Norms and standards
Review interventions and development and testing of new ones for
the prevention of VAW and management of its health consequences
5
Multi-country Study on Women’s Health and
Domestic Violence Against Women
Objectives
♦ Obtain reliable estimates of prevalence
♦ Document health consequences
♦ Identify risk and protective factors
♦ Explore strategies used by women who experience
domestic violence
WHO 98.11
Our largest project on violence is a multi-country study on prevalence,
health consequences and risk and protective factors for domestic violence
against women. The study will initially take place in five countries. In each
country, a cross-sectional survey of 3,000 women from the largest urban
centre and one province with urban and rural population will be used to
obtain detailed information on:
• the prevalence and frequency of different forms of VAW (physical, sexual
and emotional)
• the health consequences of violence, including the measurement of mental
distress, reproductive health problems and use of services
• risk and protective factors at the individual, household and community
level, and
• the strategies used by women in violent relationships to end or minimise
violence, the health and other support received and where they would have
liked to get more help.
This quantitative information will be supplemented by qualitative research
involving men and women.
6
I
Multi-country Study on Women’s Health and
Domestic Violence Against Women
I
I
I
Corollary objectives
♦ Develop and test new instruments
♦ Increase national capacity among
researchers and women’s organizations
♦ Increase sensitivity
WHO 98.11
I
I
I
WHD is also committed to achieving other objectives through this study:
• development and testing new instruments for measuring violence crossculturally
• increasing national capacity and collaboration among researchers and
women’s organizations working on violence, and
I
• increasing sensitivity and responsiveness to violence among researchers,
policy makers and health providers.
I
I
I
I
I
I
I
I
I
I
I
I
I
7
Multi-country Study on Women’s Health and
Domestic Violence Against Women
Risk and protective factors
Larger society
Immediate social
context
Immediate family
context
Individuals
involved
WHO 98.11
The study uses as its framework what is called “an ecological model of
violence”. Rather than focusing on individual causal factors it will look at
risk and protective factors in multi level analysis.
Risk and protective factors
Individual
- witnessing marital violence as a child
- being abused in childhood
- absent or rejecting father
Community
- levels of unemployment or crirr.e
- isolation of women in the family
- availability of services
Family
- male dominance in the family
- male control of wealth in the family
- use of alcohol
Society
- norms around male dominance
- approval of physical
chastisement
- male entitlement over women
8
I
Multi-country Study on Women’s Health and
Domestic Violence Against Women
I
I
Country selection criteria
♦ absence of existing population-based data
♦ strong potential partners
♦ receptive policy environment
♦ absence of recent war-related conflict
♦ regional representation
WHO 98.11
I
With the WHO Regional Offices, we have selected countries which meet
the following criteria:
• Absence of existing population-based data
• Presence of strong potential partners known to WHO
• A receptive policy environment that is open to taking up the issue
• Absence of recent war-related conflict
• Regional representation
To date, Brazil, Thailand and Peru are committed to the research. WHO is
currently negotiating to include Namibia early in the new year. Japan and
Italy expressed an interest in joining the study which coincided with a
recommendation from the Steering Committee to include an industrialised
country, so they may also be included, although with some special cost
sharing arrangements. Other countries that have shown interest and will be
considered for a second phase of the study.
I
I
There has been enormous interest in the study and other countries may use
the protocol which will be available by mid 1999, without necessarily being
part of the WHO study.
In this regard, discussions are ongoing with WHO’s Pan American offices in
Central America, and WHO’s European offices in Tajikistan and UNFPA in
Fiji and South Pacific Islands.
9
Other Research Activities
♦ Manual on research methodologies
♦ Statement on ethical and safety
recommendations
WHO 98.11
♦ Manual on research methodologies for the study of violence against
women.
I
As attention and concern around VAW has mounted, more researchers have
become interested in pursuing work in this field. This new-found interest,
while positive, leaves substantial room for costly methodological mistakes,
ethical breaches and other actions that may put women at risk of harm.
There is a need for practical and ethical guidance on how to conduct such
research. WHO is supporting the development of a manual by the Centre
for Health and Gender Equity (CHANGE) and International Research
Network on Violence against Women (IRNVAW).
As an interim measure, the Technical Advisory Group and the Steering
Committee of the WHO Multi-Country Study have prepared research
guidelines which will be issued by WHO. These guidelines will be
available by mid 1999.
^Statement on ethical safety recommendations
Research on domestic VAW raises important ethical, safety, methodological
and interviewer training issues, but experience shows that:
• it can be conducted with full respect of ethical and safety considerations:
• when interviewed in a sensitive and non-judgmental manner in an
appropriate setting, many women will discuss their experiences of violence
10
The following are examples of actions that will help ensure that women are not
put at risk during the process of data collection:
• Ensuring confidentiality is essential to women’s safety and data quality, and
can be addressed by instructing interviewers about the importance of
maintaining confidentiality, and sufficiently aggregating or modifying data and
case study findings to ensure the sources of information cannot be identified.
• Safety of the respondents and the research team is paramount, and can be
maintained through measures such as considering interviewer safety and
ensuring that interviews are only conducted in a private setting.
Database on Violence Against Women
and Women’s Health
♦ 1400 documents on various aspects of violence
against women
♦ 400 documents on FGM
♦ Statistical data from 40 countries
♦ Essential information on subject matter and
country
WHO 98.11
Existing data, while increasing, are still scattered. It is difficult to compare
since studies use different definitions of violence against women and are
often measuring different things. However, they signal a major problem
when looked at together. In parallel to our research efforts, WHO has set up
a database to collect information, from across the globe, on the prevalence
and health consequences of domestic violence, rape and sexual assualt. This
includes hard to access unpublished data and now has over 1400 entries for
future use to calculate estimates as in the case of maternal mortality.
1400 documents on various aspects of violence against women
400 documents on FGM
Statistical data from 40 countries is nearing completion. The release of data
is scheduled for the first months of 1999
Documents are reviewed to extract essential information on statistics,
subject matter and country
11
WHO has been requested to contribute data to several advocacy documents
by various NGOs. The database has supported many conferences. For
example, we are currently working with the South East Asia Regional
Officeto provide information for a background document for their upcoming
Regional meeting on violence against women. As well, in 1996,
information from the database was used to support the advocacy document
Violence against women: a priority health issue, produced by WHO, HQ.
UNIFEM has established the Trust Fund to support actions to eliminate
violence against women. The Fund is a grant making body supporting
locally based interventions. The Trust Fund has established a Learning
Component, funded by the MacArthur Foundation. WHO is collaborating
with UNIFEM’s Learning Component to create a manual of best practices
for health care.
WHO Database on Violence Against
Women
Dissemination of information
♦ WHO Website
http: //www .who. int/frh-whd
♦ POPLINE
http://www.j huccp. org/popinfr 1. stm
♦ Wistat
♦ Printed format
WHO 98.11
e
The WHO Website contains bibliographic listings of database documents and
includes a list of the countries and subjects discussed. When statistical analyses
have been finalised, these will also appear on theWebsite.
jv
.
V
The existence of WHO’s extensive database has prompted numerous requests for
copies of many key documents. Because of copyright regulations, WHO is
unable to provide this service. WHO is now working with POPLINE
(POPulation information onLINE), a USAID funded library service, to provide
full texts of many key documents to developing countries.
This information is available on the Internet and on CD-ROM and is free of
charge to developing countries.
The United Nations Statistics Division will include prevalence data in the
Women’s Indicators and Statistics CD-ROM (Wistat). This upcoming fourth
edition of Wistat, to be released in 1999, will be the first to include data on
violence against women.
Printed format Occasional papers are planned for the new year.
POPLINE, 111 Market Place, Suite 310, Baltimore, MD 21202-4024, USA.
Phone: (410) 659.6300; Fax: (410) 659.6266; E-mail: popline@jhuccp.org.,
Internet: http://www.jhuccp.org/popinfrl .stm.
12
Multi-country Study on Women’s Health and
Domestic Violence Against Women
♦ Major contributions of the study will be:
- methodology for measuring violence against women
- a reliable pool of representative data
- identification of areas for possible interventions
growing awareness of the problem nationally and locally
local research capacity
WHO 98.11
The project is complex and innovative in its design, scope and way of
working. To summarise, major contributions of this study will be:
•the development of a methodology for measuring violence against women
cross-culturally;
• a more extensive pool of representative data to begin calculating some
measure of the impact or burden of violence on women's health;
• identification of areas for possible interventions;
• increased awareness of the problems nationally and locally; and
• strengthened local research capacity and collaboration among researchers
and NGOs and governments.
13
Violence Against Women
General Report
Data Characteristics
Region Country
Year
or Area
Sample
Sample
Size
Group
Sampling
Method
Measure
Health Statistics
Location of
Violence
Relationship of
Study
Occured
aggressor
Physical
Typ«
to victim________
Broad
Dal
Savor •
Sexual
Broad Rap*
Del
Psyc
PhyV
Sanjal
Phys/
Psych
SOUTH-EAST
ASIA
BANGLADESH
National
1992
1225
W cur married
RS
lot, pers n conf
community
ever
husband
47.0
Samples from v
National
1992
1225 W cur m, <50
RS
Int, pers n conf
community
past 12 months
husband
19.0
Samples from v
May be under e
INDIA
3 Southern villages
1997P
183 W, 15 ♦
AS
Int, pens conf
household
in cur marriage
husband
22 0
Mumbai (Bombay)
1995-1997
65
W cur married
NS
Int. pers conf
community
in cur marriage
husband
49 2
considered "abu
Rural
1993-1994
1842
W cur married
NS
Int. pers n conf
household
in cur marriage
husband
40.0
Tamil Nadu
1993-1994
983
W cur married
NS
Int pers n conf
community
in cur marriage
husband
37.0
W cur married
NS
Int pers n conf
two villages
in any relation
husband
V married
RP
Int pers n conf
community
in cur marriage
husband
W cur married
NS
Int, pers n conf
household
m cur marriage
husband
Uttar Pradesh
1996
98
i Utter Pradesh
1996
6926
;Utter Pradesh
1993-1994
850
Bangkok
1994
619
M married
RP
Int, pers n conf
household
in cur marriage
Bangkok
1994
619
W cur married
RP
Int, pers n conf
household
in cur marriage
On average, ea
68 0
28.0
30.1
44 7
On average, ea
husband
19 5
Researchers In
husband
20.0
Researchers in
THAILAND
3^^
• Rape category inctades forced sex, sexual coercion, attempted rape.
Domestic Violence Against Women:
Norms and standards
♦ Meeting on role of health sector
♦ Documentation of interventions
♦ Systematic review of interventions
WHO 98.11.
•Meeting on the role of the health sector in VAW
A one-doy meeting to review different country experiences with
< health care sector interventions to address VAW was organized as
(X^a satellite meeting to the WHO/FIGO Workshop on "Eliminating
I Violence Against Women: In Search of Solutions", July 1997. The
purpose of the meeting to brainstorm on key issues the WHO should
address in relation to health sector for resource poor settings.
"Notes of a meeting on the role of the health sector in VAW" is
available from WHO. The meeting recommended the following:
OWHO should develop guidance to help health policy makers'
decisions on programme development: what types of interventions
are appropriate for different levels of health services and what must
be in place to ensure the safety of women and health workers,
among other things. (WHO will convene a working group of experts
to help elaborate this document. A review paper is already under
preparation for this meeting.)
OWHO should facilitate the development of a manual for training
health at different levels of the health system. As a first step, it was
suggested to bring together experts from complementary
disciplines to review existing training. Each participant would
review the materials available in her/his field and bring examples of
the best curricula to a meeting.
♦ Meeting on the role of the health sector in VAW.
A one-day meeting to review different country experiences with health care
sector interventions to address VAW was organized as a satellite meeting to
the WHO/FIGO Workshop on "Eliminating Violence Against Women: In
Search of Solutions", July 1997. The purpose of the meeting to brainstorm on
key issues the WHO should address in relation to health sector for resource
poor settings. A summary of the meeting "Notes of a meeting on the role of
the health sector in VAW" is available from WHO. The meeting produced the
following recommendations:
o WHO should develop guidance to help health policy makers' decisions
on programme development: what types of interventions are appropriate
for different levels of health services and what must be in place to ensure
the safety of women and health workers, among other things. (WHO will
convene a working group of experts to help elaborate this document. A
review paper is already under preparation for this meeting.)
o WHO should facilitate the development of a manual for training health at
different levels of the health system. As a first step, it was suggested to
bring together experts from complementary disciplines to review existing
training. Each participant would review the materials available in her/his
field and bring examples of the best curricula to a meeting.
Documentation of existing interventions
Presently there is little documentation of the limited number of interventions
that are being tried in developing countries for the prevention of VAW and
for improving the identification and management by the health sector of
women who experience violence. Often it is the most innovative groups who
are least likely to have the time, funds or technical expertise to document
their work. There is a need to invest in documenting these experiences so
that other groups can benefit from this experience as they venture into this
nascent field.
♦
WHO had been planning to set up a small-grants fund to support NGOs and
others to document their interventions and the lessons learned and to fund a
small number of research and demonstration projects. However, the United
Nations Development Fund for Women (UNIFEM) has set up the Trust Fund
in Support of Actions to Eliminate Violence Against Women. Rather than
starting a separate fund, WHO will collaborate with UNIFEM to fulfill its
documentation plans.
♦ Review papers on interventions
Two review papers are under preparation on interventions for primary
prevention of VAW and on health sector interventions. The aim is to review
the published literature to identify those interventions that have been
evaluated and shown to be effective and those that look promising but have
not yet been evaluated, and develop ideas for intervention research in this
area. This work will be developed throughout 1998/1999.
3
♦ Sexual coercion and adolescent health
UNDP/UNFPA/WHO/WORLD BANK Special Programme of Research, Development and Research
Training in Human Reproduction (HRP)
The sexual and reproductive health of adolescents, the choices they make, the constraints they face, their
needs and perspectives, and the scope of available services are critical elements in the design of effective
strategies and interventions that respond to their needs in ways they find acceptable; in providing inputs
for advocacy and planning; and in improving their health, and ensuring informed and responsible choice.
In March 1998, HRP launched a new research initiative on adolescent sexual and reproductive health.
Questions to be addressed include sexual coercion of and violence against adolescents.5?' A Call for
proposals or concept papers on this issue was widely distributed to developing country. Investigators
from 48 developing countries submitted over 240 research ideas, including several on sexual coercion.
Submissions were peer reviewed by a Scientific Review Committee of international experts, Four
proposals were approved, and 67 other proposals and concept papers were invited to be developed into
full proposals. About 10 of these relate to sexual coercion. Next spring, the Scientific Review
Committee will review all fully developed proposals.
* Other research questions include, among female and male, married and unmarried adolescents: what
kinds of gender roles and life skills do they display in negotiating good health outcomes? How do
family attitudes support or obstruct their health? How are adolescent sexual partnerships formedr How
vulnerable are sexually active adolescents to unplanned pregnancy, sexual coercion, and disease? How
do they deal with the dual risks of unwanted pregnancy and sexually transmitted infections? What are
the risks pregnant adolescents take in terminating unplanned pregnancies, or, in carrying a pregnancy to
term? What constraints do they face in accessing services? How responsive are health providers to the
needs of youth? What is the impact of programmes and interventions designed to improve adolescent
sexual and reproductive health?
In closing
In the three years since Beijing, WHO has accomplished a lot in its efforts against
violence against women. We have initiated a major multi country study, produced an
information package that has been translated into four languages, and implemented an
international database producing statistics from around the globe and providing full
text of key documents to developing countries. We have provided information and
data to many NGOs, governments and UN agencies and collaborated in many areas.
WHO looks forward to building on this work and continuing the work to eliminate
violence against women.
Thank you
Some Other
Violence Activities at WHO
♦ Interventions in post conflict situations
♦ Identifying interventions for adolescent
boys
♦ Sexual coercion and adolescent health
WHO 98.11
Interventions in post conflict situations:
In Rwanda, rape and other forms of gender-based and sexual violence
against women, adolescents and girls have been used as weapons of ethnic
cleansing. The Division of Emergency and Humanitarian Action (EHA) has
initiated a project addressing the needs of women and girls affected by
violence in Rwanda.
The main objectives of the project are:
•to improve the accessibility of health services for women affected
by violence, by training health workers; and
•to establish a national network of health and psychosocial
assistance for women affected by violence.
An orientation workshop was held in Kigali, February 1997. This provided
guidance to the development of training modules for health workers to help
manage and care for women affected by violence in conflict and post
conflict situations. Modules on counselling women who suffer violence
were also developed and validated in Rwanda and Burundi. All material has
been developed in French, as there is an evident lack of documentation on
the subject in this language. They will be used in other countries in conflict
or post conflict situations.
18
♦ Identifying interventions for adolescent boys
Identifying interventions for adolescent boys to promote more gender equal
relationships and reduce unsafe sex including sexual abuse and violence
A WHO-commissioned review of the health needs of adolescent boys
indicated that many programmes working in adolescent health, adolescent
reproductive health and violence prevention had yet to fully explore the role
of gender socialisation, particularly male socialisation, for their
programmes. The study found that programmes sometimes attempt to
involve young men and then give up when they do not show up. To be sure,
the obstacles to reaching young men, discussing deep-seated gender
socialisation issues, and questioning what it means to be a man are
complicated. Nonetheless, this limited experience suggests that it is
possible to reach young men, and that many of the health problems young
men face, which are often considered beyond our reach, are preventable.
The project entails a review of the literature and a survey of organisations
currently working on the issue.
Review of literature on programmes targeting adolescent boys in both
industrialised and non-industrialised countries. The review is under review
by internal and external experts.
Organisations that have implemented programmes for boys, throughout the
world are being surveyed. From these questionnaires, WHO hopes to distil
lessons learned from the experiences gained within these projects. The
surveys are currently underway in all the regions and their preliminary
results are expected by the end of 1998.
A technical consultation is planned for early 1999 to discuss the findings
and implications for the work of WHO and other organisations.
19
Hp If-
I
CENTRE FOR ENQUIRY INTO HEALTH AND ALLIED THEMES
INTERNATIONAL CONFERENCE
PREVENTING VIOLENCE, CARING FOR SURVIVORS
DOMESTIC VIOLENCE : A HEALTH CARE ISSUE?
Domestic violence is a major medical and social issue. However, few guidelines for health
professionals have been produced on the topic. Earlier this year, the British Medical Association,
the professional organisation representing all United Kingdom doctors, therefore published a
report entitled Domestic violence: a health care issue?,’ in response to a motion passed at the
BMA’s 1996 Annual Representative Meeting, so as to encourage all health professionals to raise
their awareness of the problem, and to develop strategies to identify and reduce the injuries
caused. The report concentrates on all types of abuse between sexual partners, and does not
consider in detail other aspects of family violence, including child abuse. The BMA is thus
acting in the spirit of the 1996 World Medical Association declaration on family violence, which
recommended that national medical associations should encourage and facilitate research to
understand the prevalence, risk factors, outcomes and optimal care for those who h^ve
experienced family violence, and identified doctors' important role in prevention and treatment.2
The term domestic violence refers to physical, sexual or emotional violence by an adult
perpetrator, directed towards an adult victim, within a close relationship. Most often, the
violence will be by a man, on his wife, ex-wife, female partner or ex-partner. The term includes
criminal and non-criminal behaviour, and the perpetrator uses that behaviour to maintain control
and power over the other person.3
Domestic violence inlcludes such examples of physical violence as sleep deprivation, starvation,
biting, bruising, burning, choking, hitting, kicking, knifing, punching, scalding, scratching,
slapping, strangling, and even murder. Sexual abuse and assault includes forced vaginal, anal
and oral sex, urination on the woman, sexual assault using objects, forced mimicking of or
participation in pornography, forced tying up, and enforced prostitution. Psychological abuse
includes verbal abuse, criticism, humiliation and degradation, threats, forcing the woman to
undertake menial or trivial tasks, extreme jealousy and possessiveness, isolation from family,
friends and work, financial deprivation, destruction of personal belongings, and making the
woman think she is going mad.
Domestic violence affects a significant proportion of the population at some time in their lives.
It accounts for a quarter of all violent crimes in England and Wales.4 It is a serious crime which
has a substiantial impact upon the health and welfare of adults and children. Some one in four
women experience domestic violence, yet only about 25 per cent of all incidents are reported to
the police.5 Domestic violence is the least likely violent crime to come to the attention of the
police or the criminal justice system.4 Sixty nine per cent of domestic violence incidents result
in injury - more than for any other violent crime.4 It is usually repeated, and often escalates, over
many years.6 Only some 30 per cent of women seek help soon after an attack.7 Women are often
at greater risk of violence on separation,8 and a father's continued contact with children after
separation or divorce may provide a particular flashpoint for further violence.9
Many reasons have been identified for why individuals experiencing domestic violence find this
difficult to report to the police and other agencies, including:
the emotional relationship between victim and perpetrator
the perpetrator's behaviour fluctuating between extremes
fear of reprisals
a tendency to minimise rather than exaggerate the violence, and hide it from
family and friends
pressure from the family or local community to remain in the relationship
worry about the effect on their children, whether they stay or leave
financial dependence on one's partner
not knowing a safe place to go or the sources of help and advice available
a less than helpful response from agencies from which help has been sought
undermining through repeated abuse of a woman's confidence in her ability to
take decisions and act.10
It has been argued that domestic violence to men by women occurs as frequently as violence to
women by men, and it may be that men are even more likely to conceal domestic violence
against them than are women, but evidence is lacking and more research is needed. Currently
available data show a clear gender pattern, with the majority of domestic violence perpetrators
being adult males, and most victims female.4,11
Various research reports by psychologists have identified common characteristics in the
perpetrators of domestic violence, including holding traditional views about men's position in
the family, pathological jealousy, hostility to women but dependence on the partner, and low
self-esteem.12 However, no studies attempt to compare the behaviour, attitudes and
psychological profiles of abusive and non-abusive men, and it is not possible to identify character
traits which could predict the likelihood of someone becoming an abuser.
The Domestic Abuse Intervention Project in Duluth, Minnesota, USA manages one of the longest
running projects working to change the behaviour of perpetrators, and has developed training
materials for use in reeducative group work. The 'Power and Control' and 'Equality' wheels were
devised by Duluth battered women to help perpetrators to recognise the difference between
controlling, violent behaviour and more egalitarian behaviour. The model of violent behaviour
includes physical and sexual violence, coercion and threats, intimidation, emotional abuse,
isolation, economic abuse, using children, using male privilege, and minimising or denying the
abuse or shifting blame. The model of non-violent behaviour includes showing respect and trust,
giving support, being honest and accountable, negotiating fairly, taking shared responsibility,
having economic partnership and responsible parenting.13
Getting perpetrators to accept their own responsibility is the first objective of most reeducative
anti-violence groups.14 Many perpetrators try to control the medical setting by talking for a
partner, answering all questions directed at her, refusing to allow her to be seen on her own, and
communicating directly with medical staff about their partner's health care in her absence.
Patient advocacy services are particularly important for women who lack language skills.
Some women stay with or return to abusive partners, for a variety of understandable reason^:
the perpetrator not letting her go
fear for her life
feeling that it is all her fault
feeling that there is no way out
isolation from family and friends
feeling of inability to cope independently
concern for the welfare of children
denial of the impact of violence on her own or her children's welfare
stigma and an unsympathetic response from family, friends or service providers
the impact of the violence on the woman's health, so that she is seen as the major
problem and the effects of violence are misinterpreted as the cause
being in love with the perpetrator and hoping he will change
the perpetrator's threats or attempts to commit suicide.15
Battered Women Syndrome 16 is characterised by psychological, emotional and behavioural
deficits arising from chronic, persistent violence. Its central features include learned
helplessness, passivity, paralysis, and a cycle of violence with three phases: build-up, impact, and
contrition and remorse, before the cycle starts again. In its extreme form, a traumatic
pathological attachment may develop between victim and perpetrator. Nonetheless, the majority
of women in violent relationships do leave and separate permanently.17,18,19 It is perhaps mpre
helpful to replace the question as to why battered women do not leave, with a question about who
stops them leaving and why.
Women from minority ethnic groups, especially those for whom English is not their first
language, may find difficulty in accessing refuges, legal and welfare services,20,21 may fear
deportation if their immigration status is insecure,22 and may feel constrained from contacting
the police or social services or separating from their partner by notions of family honour and
shame.9 Access to translators and patient advocates can be particularly important.
Many women who experience domestic violence go undetected - partly because women do not
report, but partly because they are not identified by doctors and other health professionals. Me ny
reasons for this failure on the part of doctors have been suggested, including:
doctors' fears or experiences of exploring the issues of domestic violence
lack of knowledge of community resources
fear of offending the woman and jeopardising the doctor-patient relationship
lack of time
lack of training
lack of control
infrequent patient visits
unresponsiveness of patients to questions
feelings of powerlessness, inability to remedy the situation.
The consequences of domestic violence in terms of the effect on the mental and physical health
of women and children, and the resultant health and social costs, are extensive. Domestic
violence may present in a variety of ways:
physical injury
insomnia
anxiety
depression
drug and alcohol abuse
other mental health problems.
Disclosures of violence require confidentiality, privacy, sensitive questioning and a nonjudgmental attitude. Women may not disclose violence unless they are asked directly.
Identification is the necessary prerequisite to ensuring appropriate care. The BMA has suggested
an action list for health care professionals:
privacy and confidentiality
questioning
respect and validation
assessment and treatment
record keeping and concise documentation
information giving
support and follow up.
The annual report for 1996 of the English Chief Medical Officer, which highlighted domestic
violence as an area for special attention during 1998, states that effective implementation of the
new legislation in Part IV of the Family Law Act will require improved recognition of domestic
violence, further facilities to help, advise and support women who experience domestic violence,
and an effective interface with other agencies, especially social services and the criminal justice
system.23 Current proposals for NHS reform in each of the four countries of the United Kingdom
24,25,26,27,28,29,30 afforj additional opportunities for strategic planning of better integrated care for
patients who experience domestic violence, through for example agreed Health Improvement
Programmes for local populations, long term service agreements with explicit quality standards,
and an emphasis on closer liaison between health and social services, and better inter-agency
coordination.
Health care professionals need to recognise their responsibilities for managing violence against
women, and to realise that they can make a difference. However, these responsibilities are not
those of individuals alone; health care professionals must work within a multidisciplinary and
interagency approach. There is a pressing need too for more research into the effectiveness of
interventions to deal with domestic violence.
Interventions include not only trying to stop the violence, but also validation of the violence,
medical treatment, information giving and support, and facilitating referral. Treatment of the
symptoms of domestic violence is unlikely to be more than palliative, however, so long as the
patient remains in a high risk situation.
The nature of domestic violence means that health professionals assist in a process of
empowerment and self-management by the woman of her own situation. It may take time before
she reaches the point where she is ready to take definitive action, and thus an apparently
unsuccessful interaction with an abused patient may be more successful than initially supposed.31
The BMA's report concludes with twenty one recommendations, in four broad areas:
recommendations concerning national policies, health professionals, education and training, and
research.
In the realm of national policy, the Health Departments are seen as having a role in connecting
existing initatives, informing health care professionals, coordinating the effective use of NHS
resources, increasing the funding and resources devoted to domestic violence, and promoting
inter-agency strategies at local level. Health Authorities' Health Improvement Programmes
should contain inter-agency agreements to provide for the recognition and management of
domestic violence, with continuous monitoring of the frequency of its occurrence and the
effectiveness of solutions.
Social and legal services offering support and help need to be developed and provided, and local
government needs to assist in funding refuges, raising public awareness, assisting in helpline
provision, improving access to safe housing, and providing legal advice and protection. Those
who provide services to the public need to understand the nature, context and pattern of domestic
violence, so as to provide needs-led services which are more accountable to service users.
There needs to be a wider definition of domestic violence in police records, criminal statist ics
and government crime surveys, and the laws on violence and harassment need to be amended so
as better to protect and support those who suffer non-physical domestic violence.
So far as health professionals are concerned, perhaps above all, greater awareness of domestic
violence is required. Professional and representative organisations should develop policies and
guidelines on the identification and management of domestic violence, and should disseminate
guidance via conferences and the production of accessible materials such as briefing papers,
contact lists, posters and booklets. There should be continuing commitment to the
implementation of guidelines, staff training, and regular audit of process, outcomes and rates of
identification.
As doctors, we need to develop a safe and private environment for questioning, and a nonjudgmental and supportive attitude. We also need information about local resources and
initiatives, including refuges, the police domestic violence unit, children's organisations, legal
advice organisations, and support and counselling groups.
An inter-agency approach is helpful, including liaison with voluntary sector agencies, which can
themselves provide training, information on support groups, resources and referral agencies, and
guidance on best policy and practice.
Health professionals also need to be supplied with basic information on the nature and prevalence
of domestic violence and the steps to be taken following disclosure. Education and training
about domestic violence need to be part of undergraduate and specialist training and continuing
professional development. Medical professional bodies themselves need to produce educational
programmes and guidelines, covering such matters as documentation of injuries and the
production of evidence for the courts.
An extended and comprehensive research base is needed, and there needs to be much more
research in a number of areas:
the prevalence, identification and care of women experiencing domestic violence, and the
benefit of screening
the short and long term physical, psychological and social implications of domestic
violence for adults and children
the prevalence of male-reported domestic violence and the circumstances in which it
occurs
doctors' responses to domestic violence in black and ethnic minority families and lesbian
and gay relationships
the relationship between domestic violence and people with disabilities; and
the role of the medical profession in civil and criminal legal proceedings.
A central, accessible database of domestic violence research also needs to be established.
John Chisholm
15-16.11.98
i
British Medical Association. Domestic violence: a health care issue? London: British
Medical Association, 1998.
2
World Medical Association. Declaration on family violence. Adopted by the 48th
General Assembly. South Africa: World Medical Association, 1996.
3
Dobash RE and Dobash R. Violence Against Wives: A Case Against The Patriarchy.
New York: Free Press, 1979.
4
Mayhew P, Mirrlees-Black C, Percy A. The British Crime Survey England and Wales.
Home Office Statistical Bulletin, Issue 19/96. London: Home Office, 1996.
5
Mayhew P, Aye Maung N, Mirrlees-Black C. The British Crime Survey of England and
Wales 1992. Home Office Research Study 132. London: HMSO, 1993.
6
Dobash R, Dobash RE. Women, Violence and Social Change. London: Routledge, 1992.
7
Bewley S, Friend J, Mezey G, eds. Violence Against Women. London: RCOG Press,
1997.
8
Wilson M, Daly M. Homicide. New York: Aldine de Gruyter, 1988.
9
Hester M, Radford L. Domestic Violence and Child Contact Arrangements in England
and Denmark. Bristol: Policy Press, 1996.
10
Home Office and Welsh Office. Domestic Violence: Don't Stand For It: Inter-Agency
Co-ordination To Tackle Domestic Violence. London: Home Office, 1995.
ii
Gelles R, Pedrick-Cornell C. Intimate Violence in Families. London: Sage, 1990.
12
Schornstein S. Domestic Violence And Health Care. London: Sage, 1997.
13
Domestic Abuse Intervention Project. Duluth, Minnesota.
14
Edleson J, Tolman R. Intervention For Men Who Batter. London: Sage, 1992.
15
Glass D. All My Fault: Why Women Don't Leave Abusive Men. London: Virago, 1997.
16
Walker LE. The Battered Woman. New York: Harpers and Row, 1979.
17
Biennia V, Harked G, Nikon J. Leaving Violent Men. Bristol: Women's Aid Federation,
1981.
18
HoofL. Battered Women As Survivors. London: Routledge, 1990.
19
Pahl J. Private Violence and Public Policy. London: Routledge, 1985.
20
Bhatti-Sinclair K. Asian Women and Violence From Male Partners. In: Lupton C,
Gillespie T, eds. Working With Violence. London: Macmillan / British Association of
Social Workers, 1994.
21
Mama A. The Hidden Struggle: Statutory and Voluntary Sector Responses to Viole. nee
Against Black Women in the Home. London: London Race and Housing Unit, 198S.
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Reform. In: Home Affairs Select Committee Report on Domestic Violence. Volume 2:
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Medical Officer of the Department of Health for the Year 1996. London: HMSO, 1997.
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Office, 1998.
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Secretary of State for Scotland. Designed to Care: Renewing the National Health Service
in Scotland. Edinburgh: Stationery Office, 1998.
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Secretary of State for Wales. NHS Wales Putting Patients First. Cardiff: Stationpry
Office, 1998.
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on the Government's proposals for the future of the Health and Personal Social Services
in Northern Ireland. Belfast: Department of Health and Social Services, 1998.
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Secretary of State for Health. Our Healthier Nation: A Contract for Health. London:
Stationery Office, 1998.
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Scottish Office. Working Together for a Healthier Scotland. Edinburgh: Stationery
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Department of Health and Social Services. Well into 2000: A Positive Agenda for Health
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Stevens, KLH. The role of the accident and emergency department. In: Bewley S,
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C:\WPWIN60\WPDOCS\18l I9801.WPD
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The Role of Health Profession and Services
Investigation of Violence Against Women and in
treatment of victims/survivors
Binoo Sen
Member-Secretary
National Commission for Women
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Violence against women is an extremely complex phenomenon,
deeply rooted in gender-based power relations, sexuality, self-identity, ahd
social institutions. Any strategy to eliminate gender violence must therefdre
confront the underlying cultural beliefs and social structures that perpetuate
it. For decades women’s organizations around the world have worked
against gender-based violence through advocacy, victim services, and
consciousness-raising. However, in the light of growing violence against
women,existing interventions need to be redefined.
Frequent incidents of violence restrict gender development. It limits
the range of choices open to women and girls in almost every area of life,
public and private - at home, in .school, in the workplace and in most
community spaces. It limits their choices directly by destroying their health,
disrupting their lives, and narrowing the scope of their activity; and
indirectly by eroding their self-confidence and self-esteem. The wide range
of discriminatory and criminal practices exact incalculable social costs as
well.
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While legislative and judicial activism have constituted the mainstay
of efforts to eliminate discriminatory behaviour, stereotyped roles and
inequality of status, they can never be adequate. Laws alone or judicial
activism cannot bring about enduring changes. The socialization process js
too deep and too entrenched to be tackled through legislation alone. Very
often, enforcement agencies and institutions remain steeped in gender biases.
Further, the biases that restrict women’s mobility and access to resources are
deep rooted in economic and social interests and unequal power
relationships. Patriarchal controls redefine and re-assert themselves cutting
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across barriers of caste and community threatening the realization of a
gender-just society, free from exploitation.
In this context, the role of the family is crucial. While the strength of
the family respect for elders and strong family values are abiding features of
diverse and pluralistic societies cutting across religions, cultures, languages
and castes, the family is also very often the site for discrimination and
subordination, It is here that violence against girls and women reach
alarming proportions. Female foeticide, infanticide, dowry violence and
torture, remain largely invisible and often go unpunished in spite of
Constitutional guarantees and the long arm of the law.
While making preparations to come to Mumbai I came across a
statement in an article I was reading. It describes the helpless situation a
woman invariably finds herself in times of crisis and oppression. “We hs.ve
mouths but we use them only for crying”. An average woman has no choice
in relation to important events in her life, such as, marriage, parenthood,
family planning, participation in community activities and divorce. It is
these kind of women that the medical profession has to provide relief from
shock and pain .
The World Bank in 1994 came out with a Discussion Paper bn
“Violence Against Women - The Hidden Health Burden”. The study has
given a cyclic description of violence perpetuated on women right from the
time of pre-birth till the old age. The life cycle of a women and the kind pf
violence afflicted on her shows that a woman is never free from the grip of
oppression.
Phase
Type of violence present
Pre-birth
Sex-selective abortion battering during pregnancy
(emotional and physical effects on the women; effects on birth
outcome); coerced pregnancy (for example, mass rape in war)
Infancy
Female infanticide; emotional and physical abuse; differential
access to food and medical care for girl infants.
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Girlhood
Child marriage; genital mutilation; sexual abuse by family
members and strangers; differentials access to food and
medical care; child prostitution.
Adolescence Dating and courtship violence (for example, acid
throwing in Bangladesh, date rape in the United States);
economically coerced sex (African secondary school girls
having to take up with “sugar daddies” to afford school fees);
sexual abuse in the workplace; rape; sexual harassment; forced
prostitution; trafficking in women.
Reproductive Abuse of women by intimate male partners; marital rape;
age
dowry abuse and murders; partner homicide; psychological
abuse; sexual abuse in the workplace; sexual harassment; rape;
abuse of women with disabilities.
Elderly
Abuse of widows; elder abuse.
A life-cycle approach to gender-based victimization provides
important insights into the immediate as well as the cumulative effects Df
violence on the lives of women and girls. Violence can occur during any
phase of a woman’s life; many women experience multiple episodes
violence throughout their lives. A life-cycle perspective also reveals thkt
violence experienced in one phase can have long-term effects that predispose
the victim to severe secondary health risks, such as suicide, depression and
substance abuse. Hence, the responsibility of the medical community is not
limited to any particular stage of rehabilitation. It has to remain a
continuous process.
Violence against women is also perpetuated because the development
for women is not planned within a framework of equality. Equality is seen
as a concern of law, and does not consciously inform policy. Policy
approaches target women as dependents rather than as individual^
contributing equally to household survival and well-being.
In understanding the role of health professionals and services in
investigation of violence against women and in treatment of
victims/survivals, it is extremely necessary to understand the basic
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psychology of those persons and people who perpetuate these atrocities.
Given below is an integrated model for Violence Against Women, This
model has been given in the Chapter “Motivations in Violence : Theoretical
Explanations” written by Mr. Ram Ahuja in his Book “Violence Against
Women. The integrated model takes into account the innate and acquired
behaviour within human beings.
The model concentrates on the
psychological analysis of the socio- structural conditions in which human
beings co-exist today. It also co-relates with the social norms and
socialisation process through which human beings co-exist. Studies
personal characteristics of offenders, their interpersonal trials and eva uate
the environmental factors, for it is within the ecological boundaries that
personal dispositions to use violence or commit crime are developed and
crime evoking situations arise.
For health workers and service providers in investigation of violence
against women, it is extremely necessary to concentrate on capacity building.
A system that creates conceptual clarity about the undermining of human
violence in each act of gender violence. In order to succeed to deal witq the
multifaceted dimensions of violence against women, networking at the grass
root, local and national level is a must. According to Vibhuti Patel in her
Article “Campaigns against Gender Violence” (1977-1993) in the Book
“Women Against Violence edited by Shirin Kudchedkar and Sabina AlIssa” In any cultural context, patriarchal control over women’s sexuality,
fertility and labour manifests itself in physical and psychological violence
against the relatively powerless section, namely children, women, ethnic
We need to
minorities, oppressed castes and religious minorities.
contextualise gender violence within this ideological matrix, so that we can
identify the forces with whom we peed to network.
The adjustment of victims after being stigmatized (i.e. raped,
molested, kidnapped, beaten, harassed) to new life and their taking up new
roles involve several phases, although there is much intermeshing of these
phases. Ram Ahuja in his book “Violence Against Women” has identified
the following four phases in female victims adjustment to life after
stigmatization: (I) shock and pain, (ii) removing pain, (iii) avoidance and
humiliation, and (iv) adaptation. Shock and pain depend on nature of crime
committed against here and also on factors like age, education, employment
and emotional attachment. Removing pain depends on support and security.
Avoidance/humiliation depends on family members, kin, friends, arid
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acquaintances. Adaptation depends on religious consolation, accepting
social challenge, neutralization and attachment and identity change.
For health professional and attached service providers it is important
to be sensitised and aware about the dynamics and impact of sexual abtise
and violence. Awareness has also to be there in the political and social
context of violence. On a number of occasions the needs of women are
misunderstood. As a result they tend to be over medicated and over
psychiatrized in treatment. What is needed from health professionals is a
proactive policy that responds to women in distress, takes care of their
health needs and to able to link up between emotional and physical well
being and the deep impact of victimisation as a result of violence being
afflicted on them. Health professionals should understand that the first
requirement of a woman in distress is emotional healing and social
acceptance. This is the first step towards empowerment and the re-birth of
self-esteem and skills within shattered human beings. Sexual harassment pf
patients, mis-diagnosis and maltreatment of women should be avoided at 11
costs.
The National Commission for Women, recently conducted an
investigation into the unfortunate rape of nuns at Jhabua in Madhya
Pradesh. One of the recommendations given to the State Government
concerns the role of doctors in facilitating such kind of investigations.
During the investigations, the Commission found the doctors who conducted
the first medical examination lacking in both sensitivity and competency .
The Commission was concerned that their understanding of the meaning of
“rape” was inconsistent with its Medico-Legal definition. Therefore, the
Commission has proposed to develop a module for doctors conducting
MLC’s to be taught and sensitised by forensic experts, legal practitioners!,
psychologists and gender specialists. The NCW proposes to write to the
Indian Medial Association to incorporate a gender sensitisation module for
doctors in their educational curriculum.
Estimating the health burden of violence against women on a number
of occasions is hampered by the lack of data on the incidence and health
impact of abuse. Crimes statistics are of no use in estimating incidence of
gender-based abuse because crimes are not reported. As the stigma and
ostracism associated with sexual violation is deep, data on rape and abuse is
not easily available.
The medical community should try to integrate
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questions on gender violence into national health surveys and into ongoing
research in such areas as AIDS, sexuality, and family planning. It should
also try to introduce consciousness-raising material and training on the
dynamics of abuse (including culture-bound practices that are harmful) into
the curricula and professional licensing exams for such health care worke rs
as doctors, psychologists, nurses, and midwives. Similar themes should al so
be included in collaboration with NGO’s and Department of Health. The
medical fraternity should also develop sensitivity training for forensic
doctors on violence against women and upgrade skills as to how to collect
and document evidence of assault, sexual abuse and rape.
As we are day by day being drawn in the whirlpool of consumerism,
the mental health consequences of violence are increasing in the form of
anxiety, depression, suicide attempts, sexual dysfunction, somatic health
complaints. Very little awareness and information is available on the impact
of domestic violence and sexual assault on birth outcomes, pregnancy
complications, rates of miscarriage and low birth weight. Professional
counselling from the service providers in the medical profession to counter
such growing ills would integrate the medical community with community
social development.
It is also the responsibility of the medical community to undertake
studies on issues concerning community, such as, AIDS prevention, safe
motherhood, child survival and mobilise support for target free family
planning. It is imperative for the health community to build linkages so thai
effective interventions can be made through self-help support groups anc
voluntary organisations.
Orie of the important recommendations for government action to
combat violence against women in the World Bank discussion paper
mentioned earliei>t^ked of providing financial and technical support to
NGOs that provide services to and perform advocacy on behalf of victims of
violence, especially those working from a feminist perspective. The study
also recommended health professionals to work with women’s NGOs to
develop strategies to expand the availability, of services for victims - from
both governmental and non-governmental sources - including shelters, crisis
centers, legal assistance, counseling, and support groups.
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The recommendation also suggested an action plan to activate the
health professionals. It called for establishing and implementing model
protocols for the early identification and referral of abuse victims in health
care settings, including'emergency rooms and primary care facilities, such
as, family planning and pardnatal clinics. Train staff in counseling,
examining victims, and collecting legal evidence for prosecution.
For the Judicial Department, the study recommended amendment of
laws and regulations, as needed, to allow any licensed health care providi :r
to examine and collect evidence of physical and sexual assault for legal
purposes.
In countries where there has been some reporting of crimes against
women, an increase in the incidence of domestic violence is also indicatedDomestic violence includes, rape, kidnapping and abduction, dowry deaths!,
torture, molestation, sexual harassment, importation of girls, Sati and other
forms of violence.
In 1996, the National Crimes Records Bureau,
Government of India, showed a total of 1,09,259 cases of crimes againsj:
women were reported. The All India Crime rate, i.e., the number of crimes
per lakh population, for crimes against women reported to the police was
estimated at 12.4 at the national level. When put with reference to female
population, the All India Crime rate doubled to nearly 25.7 per lakh female
population. One must also recognise that a vast percentage of crimes against
women go unreported due to the social stigma attached to them. Therefore,
these statistics represent rates of reported crimes against women, while
actual rates may be much higher.
Crimes against women in 1996 reported an overall increase of 5.9%
and 7.5% over respective previous years 1995 and 1994. More specifically,
the incidence of rape cases and dowry death cases during 1996 over 1995,
reported an increase of 7.9% and 8.3% respectively. The number of eveteasing cases reported an increase of 17.7%.
The need to create awareness is immediate. The continuation of the
violation of women’s rights through the use of physical and non-physical
violence prevents women from enjoying their fundamental freedoms and
from participating as full members within their families and societies.
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- Media
RF_MP_11_SUDHA.pdf
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