‘The victims were there and they were asking for my help’

When she was a medical student at the University of Colombo, no one spoke of child abuse. “It was simply not a problem that people had recognized,” says the newly inducted President of the Sri Lanka College of Paediatricians, Dr. Asvini Fernando. Now things have changed to such an extent that she has chosen to put forward child protection as her main area of focus in the year ahead.

It was during a period of seven years during which Dr. Asvini worked and trained in the UK that she was made aware of the issue of child maltreatment. “I would proudly tell my colleagues that this sort of thing did not happen where I came from.” She shakes her head. When I got back, I realized that I was wrong. The victims were there; and they were asking for my help.”

Dr. Fernando addressing the gathering at her induction on Saturday, November 19

Her eyes cloud over slightly as she recounts her first encounter with a victim of child abuse in the UK. Despite knowing from a young age that she wanted to be a doctor and knowing, quite early into her medical career, that paediatrics was her chosen field, this was the defining moment in Dr. Asvini’s life as a doctor. In the 19 years since she returned from the UK, her work as a doctor has involved a balance between treating the common, everyday diseases and working closely with hundreds of children who have been subject to abuse in some form- whether physical or emotional.

Years of medical training enables Dr. Asvini to focus on the problem at hand without letting her emotions get the better of her. “It is very emotionally draining though,” she says, recalling countless instances when she would hold back tears in front of her patients and then cry on arriving home later in the day. “The saddest thing is that in almost every case you see the same story at play. The perpetrator is always a known, trusted adult- a father, a grandfather, an uncle or a neighbour. And you cannot help but ask, ‘Why?’ When a foreign tourist is caught exploiting a child it makes headlines, but domestic violence is what is most common. This is the issue we deal with; the one that seems the most difficult to eradicate.”

Beginning her work with victims of child abuse in the Karapitiya Hospital in Galle and continuing it at the Teaching Hospital in Ragama, Dr. Asvini had to face several structural challenges. Since child abuse was barely recognized at the time, there had been no formal structure or guidelines in place for the management of the problem. “So we had to spend a considerable amount of time formulating a structure which would streamline the process of treating the child and of dealing with the authorities in providing a safer environment for the child.”

The structure devised involved a multidisciplinary approach to the problem. “We would bring in Judicial Medical Officers, also known as Forensic Pathologists, surgeons or orthopaedic surgeons depending on the situation, obstetricians and gynaecologists in cases of sexual abuse, and psychiatrists. We would all be involved in treating the child; and if we came to the conclusion that the child had been abused, we would bring in the relevant authorities- the police, the Department of Probation and Childcare, and several other stakeholders- the child’s parents, teachers and principals if necessary; and a case conference would be conducted where we would determine what course of action would be taken.”

“There are several factors to consider,” she continues. “If the perpetrator is a member of the family and the child is to be sent home, this would only be done with supervision. In cases where it is not possible for the child to continue living with his/ her family we would try as much as possible to find a responsible adult in the extended family to be a guardian, as it is unfair to unnecessarily subject the child to the added trauma of being separated from family.”

Dr. Asvini comments on her disappointment at the flaws of the system in which the authorities have little or no motivation in considering the best interests of the child and ensuring that the victim does not continue to be victimized.

To start with, the hapless victims are compelled to remain in a bustling paediatric ward after the initial course of treatment while the lengthy process of court cases takes place and the child’s future is determined. “This is not conducive to healing,” says Dr. Asvini.

“The hospital-based system simply does not work- what we need is a community-based system where the children are placed in a more pleasant environment once the short term treatment is completed.”Despite several attempts to make this happen however, paediatricians are faced with the challenge being compelled to leave victims in their busy paediatric wards with other patients.

“I have said this many times- that the authorities do not seem to have the will to change the system. Maybe they do not understand the magnitude of this problem. Why was I seeing these children and identifying their problem? Because I saw them in the UK and recognized the victims. Why had we not seen the problem before? Because we were not aware of it even though it did exist. But now that the problem is all too evident, things have to change.’

The outcome of Dr. Asvini’s extensive research provides some alarming statistics. 60% of victims are those of sexual abuse; 27.4% are victims of physical abuse; 14.1% are victims of neglect. Many of these victims have suffered an onslaught of more than one form of abuse.

Whatever the form of abuse, it is clear from the research that its impact casts a shadow of a lifetime. “The impact manifests itself differently from victim to victim,” explains Dr. Asvini, “but the psychological scars remain. This is why the principle of long term following up has to be adhered to. But this is easier said than done because of the stigma that remains. While some return for treatment, many do not- some of them fail to respond to our letters, with some of them being returned unopened.”

It is the stigma it seems, which remains one of the biggest impediments to the rehabilitation of a victim of child abuse. Dr. Asvini recalls several instances in which principals have been reluctant to accept victims of sexual abuse on the grounds that they may be a negative influence on their peers. “It is unfair, and completely against policy,” declares Dr. Asvini protesting against the all too common tendency to treat the victim as an offender. “There have even been cases where the perpetrator is a teacher, and the principal defends the accused, stating that he/she is one of the school’s best teachers. In such cases we are sometimes compelled to send the child to another school, where the principal is made to understand the child’s plight and cooperate accordingly.”

Over the coming year, Dr. Asvini’s work as President of the College of Paediatricians will take place under the comprehensive theme of ‘Developing Pathways to a Safer Childhood’. The theme carries three main focus points- Creating Safe Communities for Children, Optimizing Child Nutrition and Rational Management of Infectious Diseases.

“Our aim is to work closely with several institutions including schools in creating awareness- the main problem is a lack of awareness and sensitization. The Canadian Red Cross has agreed to conduct a series of ‘Be Safe’ programmes in schools, and we are confident that these will be effective,” she says.
The Be Safe programmes promise to target several areas- apart from basic health education schoolchildren will also be made aware of how to stay safe, and encouraged to report any incidents of abuse. “The workshops will also have a focus on sex education- an aspect of education which is often glossed over in the current syllabus. Hopefully at the end of the programmes schoolchildren will be more informed and alert, and we would be able to minimize instances of abuse,” comments Dr. Asvini.
Maintaining that while treatment is necessary, it is equally important to work towards the prevention of abuse she says, “The structure we have in mind is not difficult to implement. It is all very practical, where we get as many stakeholders involved as possible. There are community workers who are already in place; they just need to start working together better. So if the project is successful in its early stages we should be able to see effective country-wide expansion.”

Aware of the challenges which lie before her and the 400 member College of Paediatricians, Dr. Asvini remains passionate about her cause. “If you genuinely care,” she says, “you will not go wrong- you will be disciplined, punctual, and honest. Those are the principles on which I strive to work as a doctor. The road ahead will not be easy- the theme of Developing Pathways to a Safer Childhood will take a lot of hard work to implement; but if I can at least forge inroads into those pathways to start with, I will know that I have achieved something.”