Institutional Abuse is violence practiced in institutions that render public services such as hospitals, clinics, schools, police stations, and the courts. It is done by people who are supposed to protect women victimized by violence and treat them kindly, preventing and repairing damage that they may have suffered.

Institutional Abuse: Cases of Human Rights violations in the area of maternal and neonatal health care in the state of Rio de Janeiro.

* Laura Mury

 This article focuses on the lives of some women from Nova Friburgo and Cabo Frio, two towns in the state of Rio de Janeiro, who were victims of institutional abuse, which resulted in physical and emotional damage to both the women and their babies. It also examines the indifference shown by the health care agencies, public institutions, and workers that violate basic human rights.

 Ser Mulher – Centro de Estudos e Ação da Mulher Urbana e Rural (Center for Studies and Action for Urban and Rural Women) – is a private, non-profit agency. The feminist agency promotes health, new reproductive technologies, bio-ethics, and citizenship programs, such as the Programa Crisálida, which focuses on the development of female community leaders. The citizenship program targets human rights and violence[1] against women, through concentrated efforts implemented to create a more just society in terms of gender relations.

Conceptual framework

 The debate about Institutional Abuse is directly related to Human Rights both theoretically and practically. It is still not well publicized among several levels of the Brazilian society, including the users and professionals of several public or private service areas. The Ministry of Health defines Institutional Abuse as “the violence perpetrated by public services, either through action or inaction. It comprises a whole range of actions, from the lack of access to bad quality of services dispensed. It includes abuses committed due to the inequality of relationships between customers and institution employees to a narrower concept of intentional physical harm.” Abuse can take several forms:

 Being forced to move from one service agency to another before receiving services sought; professionals’ lack of time and attention to users of services; coldness, aggressiveness, indifference, and neglect; mistreatment of users due to discrimination related to genetic defects, mental health, race, age, sexual identity, gender, physical handicap or mental disease; violation of reproductive rights (discrimination against women who are having an abortion, acceleration of childbirth to liberate hospital beds, prejudice against HIV-positive women, especially when they are pregnant or want to become pregnant); discounting common sense knowledge gained by patients through life experiences in favor of scientific knowledge; physical abuse, denying needs or rights to patients; prohibiting the presence of family members or allowing visits only with restrictions or during strict hours; being critical of (or impatient with) those expressing pain or despair, instead of listening to them silently, supplying information, or providing a secure environment to calm the patient down during confinement in hospitals; making incorrect diagnoses, along with prescribing ineffective or inappropriate medication, which could mask or conceal the effects of the abuse. [i]

 Institutional Abuse is violence practiced in institutions that render public services such as hospitals, clinics, schools, police stations, and the courts. It is done by people who are supposed to protect women victimized by violence and treat them kindly, preventing and repairing damage that they may have suffered. [ii]

 The following are considered rights that patients have in terms of health services: a) a preliminary diagnosis b) a confirmed diagnosis; c) required tests; d) treatment procedures; e) information about the risks, benefits and discomfort of the diagnosis and treatment proposed; f) expected length of treatment; g) in case of invasive diagnostics/therapy, information on whether anesthesia is necessary, and if so, the type and instruments used, the parts of the body affected, the risks and the side effects of the anesthetic along with the duration of the procedure; h) tests and procedures to be used; i) purpose of any lab test required; j) diagnosis and therapeutics alternatives available in the this and other health care units; and l) any other information deemed necessary[iii].

 The content of this article will be limited to what is commonly known as institutional abuse directed specifically to abuse on women committed by public or private services institutions.

Human Rights Violations: The Cases of Cabo Frio (RJ) and Nova Friburgo (RJ).

 Based on the above, we present below the cases from Cabo Frio and Nova Friburgo, in the state of Rio de Janeiro.[2]

 CLIPEL, in Cabo Frio, RJ, is an outsourced clinic previously located within Hospital Santa Izabel (Santa Izabel Hospital), a philanthropic organization. CLIPEL treated SUS, health plans and self-funded hospital patients. Currently, it has its own location, but uses the same physicians as the above-mentioned hospital, and, until a few months ago, accepted patients affiliated with the UNIMED health plan.

 During the 10-month period investigated by the families who  were victims of abuse, dozens of babies were hospitalized in the neonatal intensive care unit of CLIPEL. 82 such babies died, most of them due to very virulent bacterial infections.

 The immunological systems of prematurely-born babies are not completely developed, which makes them easy victims of opportunistic bacteria that attack their bodies when invasive methods of treatment are used, or, more commonly, through the skin. The main transmission means is nurses or physicians’s lack of appropriate hygiene (unwashed hands). CLIPEL’s physicians, although aware of the situation, did not denounce the clinic to authorities nor were informed families about the contamination in the Neonatal ICU during this 10-month period.

 Families belonging to the poorer segment of CLIPEL’s patients were easily convinced that the infections, followed by long hospitalizations that ended with the death of the patients, were inevitable.

 In September 1996, civil engineer César A. N. Eboli, and the sculptor Marcela B. Granzella were suspicious of the unconvincing explanations given about the death of their son on his sixth day of hospitalization.

 Nicolas had been born without any problems, and, according to the physicians, had been hospitalized for only a few hours to receive oxygen. After some hours, however, the parents were informed that Nicolas had a mild, routine infection and, although no clear diagnosis had been made, he should remain hospitalized for a couple of days. The general appearance of the baby was good and the physicians said that the parents would be able to take him home within a short while.

 At the end of the fifth day, one of the physicians informed the family that the baby was in serious condition. The next night, the baby died due to pulmonary hemorrhaging, after inhaling blood for more than two hours.

 The baby’s mother was told that she had been the primary carrier of a uterine infection, had transmitted it to the child during childbirth, and that this was the cause of the baby’s death. This fact was denied by the gynecologist who had assisted the mother through childbirth.

 The parents were denied access to the baby’s medical records[3], for “ethical reasons.” They then requested the lab results of an antibiogram, and learned about the presence of the deadly bacteria Klebsiella Pneumoniae. All other blood tests that had been made with the baby confirmed the presence of this bacteria.

 Marcela and other mothers whose children had died suspiciously in that hospital joined together and demanded access to all of the antibiogram lab tests. All of the serum cultures of deceased babies confirmed the presence of the same bacteria.

 On December 17, 1996, the mothers filed a formal complaint with the Secretaria de Saúde (Secretary of Health) of Rio de Janeiro. Their complaint was ignored by this agency.

 In April, 1997, the case was sent to the Ministério Público (District Attorney’s Office) of Cabo Fio, which resulted in a police inquest and the filing of a public civil action.

 The inquest dragged on for more than two years and in January, 2000, the District Attorney’s office of Cabo Frio charged the physicians of CLIPEL with involuntary manslaughter, claiming that they were responsible for the deaths of 52 babies due to hospital infections.

 In order to face the economic, corporate, and political powers, the mothers of the babies formed the Associação de Mães de Cabo Frio.

 As a result of the persistence, systematic research and analysis done by mothers, relatives, and other professionals trying to bring the case to justice, it was discovered that physicians routinely hospitalized the babies without isolating them from babies who already were infected. Nurses handled the babies without using gloves or hats. Visitors handling the babies were given used clothing.

 The judge assigned to the case considered the accused not-guilty of all charges, even though he was aware of the following evidence: 82 babies dead in a 10 month period; 90% of the babies infected following hospitalization; 92 hemoculture tests positive for the bacteria typical of hospital infections; babies who were infected three consecutive times; mortality rates well above the mean; records registering systemic infection of all babies hospitalized who died or were discharged; CLIPEL had no record of any inspection by the Commission of Infectious Diseases; omitting the deaths and the infections from authorities and victims’ families; hiding records to be used in the investigation; telling lies and incurring in contradictions in regard to the hospitalizations when talking to the investigators; falsifying death statistics given to the investigators. Even when presented with this irrefutable evidence, the judge declared the accused innocent. [iv].

 Case of Medical Negligence in Nova Friburgo- In 2003, after not having received any attention from public agencies, three mothers joined together in Nova Friburgo to denounce publically the occurrence of torture, negligence, and mistreatment by physicians. They allege that, since 1984, more than 15 mothers and children had being the victims of torture and inhumane treatment by a certain doctor in the maternity wing and various other clinics within the municipality of Nova Friburgo. The majority of these mothers was poor, and lacked the time, money, or transportation necessary to pursue legal action. Most of them were single parents and unemployed. The following paragraphs present one of these cases, in which the parents of one of the children are seeking justice in order to prevent others from suffering the same mistreatment that has already destroyed many lives.  

 Here is the story of one of the mothers, Janaína:

 “On August 21, 2000, my water broke at 1:00 A.M. and I went to the maternity wing at the hospital. I arrived 1:30 A.M. and was examined by the doctor in-charge and sent to the pre-labor section of the wing. Although I had contractions for several hours, everything was under control, and my pre-labor care was very good. In the morning, a new set of physicians came to start their rounds, and, from the start, Dr Edna Bartholomeu Mendes treated me very arrogantly. When she touched me during her preliminary exam, she hurt me. When I complained about it, she said that she had 30 years of medical experience and knew what she was doing. I became very anxious and began to cry copiously, as I was about to have my first child. She then declared that my water had not really broken and started trying to break it. But my water had actually broken at home eight hours before. Even though I was in the pre-labor room, she instructed me to push, so that the baby came out. I did so unsuccessfully. She then gave me an injection to increase the rate of the contractions, but this also did not work. She became irritated and told me that I wasn’t doing my part in the process. She then pulled me off the bed and instructed me to walk to the surgical center I began to cry and said that I didn’t want it anymore, meaning (that I did not want) natural childbirth. To this she ironically remarked that I had had 9 months to abort the baby. While this was taking place, I (mentioned) that I wasn’t feeling (any contractions), but she treated me like I was being overly dramatic. My son was already suffering, but she never listened to his heartbeats and she continued to tell me to push. In addition, she swore at me and criticized me, saying that I was not pushing correctly. I started to feel short of breath and then they gave me oxygen, but I lost consciousness. When I regained consciousness, she spoke rudely to me, saying that my contractions were taking too long. She continued to wait (and did not do anything). In the end, my son was stuck for an hour and I am certain that he was pulled out with forceps, although my medical records do not say so. I say this because he has a scar on his head and I felt a jolt. When I asked whether my son was all right, she said that he should not have spent that much time inside my womb. A nurse tried to calm me down, but I began to cry. To this, she said that she would only take out the placenta if I stopped crying. Later on, when I went to the recovery room, I was unable to move and felt like I was paralyzed. I then found out that my son had been born with cerebral anorexia caused by asphyxia. He had to remain in an induced coma for 35 days, to prevent further injury.

 “After being examined by Dr. Edna, I heard her say that I should beg to God to let my son live, because I had not done my part during childbirth. I then became depressed and started to feel guilty. Later I talked to a psychologist and she comforted me and I began to see that the fault was not mine. My son was stuck for too long (during child birth) and could not get enough oxygen to his brain. The doctor should have done a c-section, as he was too large (3.9 kg and 51 cm).

  “I was called by the director of the maternity to tell my story and (Dr. Edna) ended up being fired, because 15 days before she had been negligent during another childbirth. While I was still hospitalized, I was examined by a doctor and then filed a claim with the District Attorney’s office. My husband and I are waiting for justice to be served. I think it is absurd that they kept such a negligent professional for so long in the natal care unit. I also filed another claim against the City. I spent 6 years trying to get pregnant and when it finally was time for my childbirth, I was treated with such negligence by this doctor. My son has a very serious case of cerebral palsy and had to get a tracheotomy in order to breathe. He is fed through a tube, because he cannot swallow and suffers from convulsions, among other problems. We have very high medical expenses and I had to leave my job as an office assistant to spend all my time taking care of him. When he started to be treated, at APAE, I heard about several other cases alleging negligence on the part of this doctor. I decided to get in contact with the other mother to join forces in order to pursue justice. 

 So far, I know of 10 similar cases, all caused by the same doctor. I believe that there are many more cases and I ask all the mothers to get in contact with us to tell us their story.”

 Janaína da Silva Mineiro, 26 years old, housewife, mother of Luiz Guilherme da Silva Mineiro, 3 years old[v].

Legal Landmark for the Protection of Women’s Human Rights

 The basic source-value for human rights is the respect for the dignity of a person. Human rights are important determinants to the application and interpretation of the Brazilian Constitution. The basic foundation of the Brazilian State is that the state exists to guarantee and promote the right to dignity of all people. It is as a result of this principle that Section Two of the 1988 Constitution, entitled About Fundamental Rights and Guarantees, establishes a wide range of individual and collective rights. Chapter 1, Article 5, Paragraph 3 states that “nobody will be submitted to torture or any degrading or inhumane treatment”. Section 7 is entitled “About Social Order” and in Chapter 2, Section 2, item 196, the Constitution states that ”Basic health is a right for all, and is the duty of the State to establish social public and economic policies that aim to reduce the risk of illness and to implement fair access to means that promote, protect, and help to regain health.”

 The Convention on the Elimination of All Forms of Discrimination against Women/ CEDAW, promoted by the UN, and ratified in 1984, and the CEDAW’s Optional Protocol, ratified in 2002, Article 12-1, says that states will adopt all measures to end all discrimination against women in the area of medical care in order to guarantee equal access of both men and women to health care, including access to family planning. [...] The states will also guarantee proper care to women who are pregnant, both before and after childbirth, including free assistance when necessary and adequate nutrition during these periods.

 The Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women, known as Convenção de Belém do Pará, and ratified and approved by the Brazilian National Congress in 1995, defines Abuse of Women as “any act or conduct, based on gender, which causes death or physical, sexual or psychological harm or suffering by women, whether in the public or private sphere. In article 4, it states that “Every woman has the right to the recognition, enjoyment, exercise, and protection of all human rights and freedoms embodied in regional and international human rights instruments. These rights include, among others: a) the right to have her life respected; b) the right to have her physical, mental and moral integrity respected; c) the right not to be subjected to torture; d) the right to have the inherent dignity of her person respected and her family protected; e) the right to simple and prompt recourse to a competent court for protection against acts that violate her rights.”

 The Pacto Nacional pela Redução da Mortalidade Materna e Neonatal (National Convention for the Reduction of Maternal and Infant Mortality during Childbirth), announced on May 27, 2004 by the Brazilian Ministry of Health, declared that the high rates of mother and infant mortality in Brazil constitute a serious public problem, affecting unequally the several Brazilian regions. In other words, these rates are higher among the unprivileged social classes, who had less access to social welfare.

 The deaths of mothers and infants are closely related to their non-recognition as a social and political problem, to the lack of recognition of the scope of this problem and to the poor quality of health services provided to women and babies during their pregnancy and the post-childbirth stages.

 Solving the problem of maternal and infant deaths requires the involvement of the various players in society, in order to guarantee the formulation of national policies that will help to address the needs of the local population.

 Some of the strategic actions suggested by the Pacto Nacional pela Redução da Mortalidade Materna e Neonatal during Childbirth are:

 Humanize the process of childbirth, delivery, and legal abortion; set standards for maternity wards and hospitals that are responsible for deliveries, emergency care, and basic women and babies’ health care; prioritize continuous education and qualification of all health professionals involved in obstetrics and neonatal care; support the development of social support for pregnant women and infants at risk; implement and support actions to make people accountable for the care of mothers and infants.  

Fighting for Justice and Solidarity in Defense of Women’s Human Rights  

 The Movimento de Mulheres no Brasil (Women’s Movement in Brazil) has come a long way in the last few decades, contributing significantly to better the status and quality of life of women in Brazil and abroad. They have strived to end the large inequalities existing between genders. The feminist movement has vigorously supported the implementation of fairer public policies that increase the access of women to health care, justice, education, and have contributed to end discrimination and abuse. To implement women’s rights means to guarantee that every person is an active citizen. It is not enough to just sign laws, treaties, or conventions. It is essential to articulate partnerships and networks in order to guarantee that changes will actually occur. Ser Mulher, the Rede Nacional Feminista de Saúde e Direitos Reprodutivos, ADVOCACI, and the Rede Social de Justiça e Direitos Humanos are making facts visible, actively articulating social alliances, and activating legal resources, in a quest for justice and reparation.

 On August 30, 2004, a meeting took place in Cabo Frio between the District Attorney’s office, Ser Mulher, and the Associação das Mães de Cabo Frio, with the purpose of exchanging information about the following actions: action against Ministry of Health, filed October 25^th, 2000; action against the Coordenadoria de Fiscalização Sanitária da Secretaria Estadual de Saúde (Coordinator of the Sanitation in the Health Department of Rio de Janeiro), filed April 22nd, 1997; action against CREMERJ, filed October 25th, 2000; against the nurses, workers, and supervisors of the hospital on October 15^th, 1997. In addition, information was exchanged about the criminal prosecution against the doctors responsible for CLIPEL, whose original verdict favored the clinic, and which was returned to Cabo Frio due a procedural error.

 The District Attorney’s Office informed that the case had been assigned to the special branch of the District Attorney’s Office (Tutela Coletiva de Cabo Frio). A prosecutor in-charge of the case would be available in September. A meeting was set for that month with the Associação de Mães. The criminal action against the responsible doctors at CLIPEL was returned to the Second Circuit Court for judgment, after the procedural error was corrected.

 The District Attorney also said that there could be a second inquiry for the cases of the surviving, provided that the Associação das Mães provided his office with the corresponding evidence.

 In Nova Friburgo, beginning in June 2004, volunteers, interns, and legal help for Ser Mulher identified and visited many of the victims of institutional abuse. In August, the Segunda Promotoria de Justiça de Tutela Coletiva do Núcleo Friburgo established a civil inquiry that is presently collecting depositions from the mothers who have suffered doctors’ mistreatments or negligence. Four mothers have already been deposed and there are other awaiting their turns.

 Janaína, the mother of Luiz Guilherme (the 4-yeard old child who was born with cerebral anorexia because a lack of oxygen during his birth and who presently weighs only 10 kg), filed a lawsuit against the maternity ward, asking for damages, but the action has not being brought to judgment yet, due to a lack of cooperation on the part of doctors in the hospital. All of the doctors who were called refused to carry out an official medical exam (of the boy). At the same time, a complaint was filed with the police concerning the body injuries suffered by the child. This is awaiting investigation.

Conclusions

  The existing laws for protection of women’s human rights referred to in the article satisfy the due process of legal action aimed to bring justice and reparation to the violation of women’s human rights perpetrated by institutions. However, there are few positive outcomes both in terms scope and time. The delay and causes of advance in this area must be constantly evaluated with the purpose of finding effective strategies to promote social change in the areas of health care and human rights in Brazil.

 This article is a contribution to push forward the necessary changes in socio-cultural standards pertaining to violence related to gender, in order to improve the situation of violence against women and institutional abuse.

 Finally, a historical document, the United Nations Millennium Development Goals, approved in September 2000, during the New York Millennium Summit, reflects the concerns of 147 heads of State and 191 countries about eight serious problems existing in the world. Among those are to eradicate poverty, to achieve universal primary education, to promote gender equality and to empower women. Goal 4, item 5 is to reduce by 2/3 the rates of infant mortality between 1990 and 2015, and goal 5 is to improve maternal health, especially in the reduction of maternal mortality through the promotion of childbirth assisted by qualified health professionals.

 Bibliography:

* Laura Mury Coordinator of Ser Mulher, a program of Citizenship, Rights, and Violence Against Women Ser Mulher