Thursday, April 26, 2007

The HIV trial in Libya, part 5: Discussing unintentional infection

This is continued from part 4 ( The end of the sequel will be devoted to the Libyans' attitudes towards the HIV case.
Although it is impossible to perform a real opinion poll in Libya, it is clear that most Libyans believe the accused in the HIV trial are guilty. This is reported by all foreign journalists and by the Libyans themselves. However, I think this seemingly homogenous public opinion is in fact divided into at least three distinct groups. Let me first address those Libyans who believe only in unintentional infection. (I don't understand why they are so confident that the police, even if wrong about the intentional infection, have found the right people; after all, inquisitional type justice systems like the one in Libya are known to routinely indict the wrong people even in very simple criminal cases. But let's not dig into this issue.)
The Libyan prosecutors, showing what Butler called stubborn idiocy, keep considering intentional spreading of HIV as the only hypothesis able to explain the epidemic in Benghazi. However, some ordinary Libyans, while believing that the police caught the right people, have come to the conclusion that the crime has most likely been of negligence. Two years ago, Highlander wrote, "I don’t want to believe that the Bulgarians could have deliberately given AIDS to Libyan kids" ( I'll try now to present the opinion of these Libyans.
"Let them acquit he lady who has never worked at the El-Fateh hospital, but I want the others punished. And, while I don't believe they acted intentionally, I don't mind them being sentenced as if they did, because the punishments for negligence are a joke, compared to what happened to the children. Even if you are right that they were picked randomly among scores of nurses and doctors doing absolutely the same things, they were caught and I want them sentenced. The Romanians may be happy to have a legion of infected babies and nobody punished - I am not. You described yourself how careless and good-for-nothing health workers spread HIV to every corner of Africa! I am sure this happened because nobody was ever held responsible. If several people are punished, hopefully the others will be more careful next time. Like Mark Twain, I think it is better to have one or a few innocent persons suffering than five hundred."
This viewpoint deserves respect, especially if free of the revengeful "I want somebody punished" attitude which too easily degrades into "I want anybody punished". The preventive, deterring role of the punishment, while somewhat unfair to the defendant in question, is a cornerstone of any justice system. However, will the guilty verdicts have preventive role? Will they send the right message to medics working in Libya?
No, they won't. First, if you don't prosecute people for violating safety rules, you cannot expect the sentence to force others to observe these rules. Second, prosecuting only foreigners will not encourage Libyan health workers to improve their work standards. Moreover, it will not have this effect even on foreign medics, because they know that if the Q-man needs them as scapegoats, he will get them, no matter how precisely they are working. Third, most important, all of the accused except Dr. Hajuj are nurses. As I commented once on Highlander's blog, "if there is something wrong in a hospital, it is the doctors' responsibility, not the nurses'. Doctors are better educated, paid and empowered than the nurses and have to supervise them." (
Let's imagine that back in 1997-98, a nurse had told her patients' parents, "Your child will need intravenous injections, so please leave him here and find and bring at least 5 sealed needles, because the ones we have are non-sterile and unsafe." Would the parents be grateful? Some would, but most would react by going around the hospital asking questions and complaining and the nurse would quickly go into trouble. Or imagine that during a break some nurses and doctors are making coffee, a nurse comes and removes the coffee from the heating plate in order to boil needles and syringes. "I want to be sure that these are sterile and won't contaminate our patients." Would her superiors praise her and her colleagues be inspired to follow her example? No, their reaction would be, "Who do you think you are?". And most normal people have very strong herd mentality and sense of hierarchy. They'll prefer to risk infecting others and themselves with a deadly disease rather than confronting the who-do-you-think-you-are attitude. Then, who could hope that the risk to be arrested and sentenced will scare them enough to overcome this mentality?
Let me also quote from the remarkable essay Silence kills by J. Grenny ( "The recent deaths of Jessica Santillan... and Jeanella Aranda..., resulting from carelessly mismatched blood types during organ transplants, illustrate the tragic results of silence... People who should have been aware of the blood-type mismatches simply said nothing rather than challenge doctors to follow the standard double-checking procedures... Why nurses and fellow doctors did not hold each other accountable for existing policies that already required cross-checks to ensure the accuracy of blood types? The answer, unfortunately, is that most health care workers operate in a culture in which silence is the preferred response when physicians violate protocols... The tragedy, of course, extends far beyond Jessica Santillan and Jeanella Aranda. A culture in which health care workers fail to hold each other accountable contributes to some two million hospital-induced infections each year and results in tens of thousands of unnecessary patient deaths. For instance, a federal Centers for Disease Control and Prevention (CDC) study found that health care professionals wash their hands about half the number of times that policies require – a key factor in the spread of hospital-borne infections. The study probed whether redesigning the care environment through... more sinks available would help doctors and nurses to wash their hands when they should. The answer? It didn’t. What mattered most was whether or not the senior doctor washed his or her hands. Period. When the lead person set a bad example, not only did nurses, residents, and others not speak up, they fell in line – and failed to wash their hands as well."
Let's repeat: the key person was "the senior doctor". What happened to the senior doctors at the El-Fateh hospital who let the hygiene deteriorate to medieval standards? They were acquitted and cleared and can roam freely in their luxury cars, while five nurses and an ordinary doctor are hanging on death row. What message will this send to senior doctors of other Libyan hospitals?
To conclude: I think that even if Dr. Hajuj and four of the Bulgarian nurses have unintentionally contributed to the AIDS epidemic, their role has been quite a minor one, while those truly responsible got away with it. Punishing the "Tripoli six" will not give justice to the infected children. Neither will it help to prevent similar tragedies in the future or bring any good to the Libyan health care. We know from history that too many communities, when facing the onslaught of a deadly infectious disease, have reacted by losing their humaneness and doing irrational acts that could only worsen the situation. It is up to the Libyans whether to do the same or to show the reason and compassion that we hoped would characterize our age.


Simon said...

Yes, we should pay more attention to HIV positive people in Africa. Thanks for posting this article. You may post this in this HIV blog.

programmer craig said...

Wow... I noticed while tracking back through all those old links (yours and the ones highlander had in the posts you linked to) how much H has changed her stance on this. She used to talk like she was ready to hand the nurses with her own hands.

Unfortunately, it seems from reading other Libyan blogs in recent months that most Libyans are more interested in seeing somebody punished (whether or not they are responsible) than for having justice done. And if I hear the plight of the children being used to justify guilty verdicts against people who are probably completely innocent (as if there is some kind of perverse logic where that makes sense) I'm going to scream.

Here's an idea for all Libyan who want blind "justice" - grab an AK-47 and go to the hospitals where those infections occurred and execute every doctor you can find. And when you are done with that, go to the court where these trails were conducted, and execute every judge and every lawyer you can find. At least some of the people you have just killed will have been guilty. Of something. And justice will have been "served".

Maya M said...

Thanks for the comments.
Programmer Craig, I also see mixed tendencies among Libyans, those who trust the international experts and use critical thinking make me feel better. Possibly if we keep saying what is true, according to our best knowledge and belief, this will make a difference one day.