While interviewing patients, family members and healthcare professionals for my research in Nigeria, I interviewed a 70-year-old woman who has been wheelchair-bound for almost 13 years after having a stroke. Her older son lives outside of Nigeria and she currently lives in her own house with her youngest son and daughter-in-law. The vulnerable woman narrated stories of abuse, neglect and undignified maltreatment from her son including taking over her properties and money, verbal abuses and being locked-up inside the house without any support on some occasions. The woman explained the difficulty of discussing these concerns with the seemingly overburdened doctors and nurses at the clinic which she attends every 6 months. She responded that I am the only person who has asked about her welfare beyond her immediate physical health needs; hence she did not see the need to discuss this with anyone else. I was distraught. The woman has been suffering in silence with no support or help.
‘We care for our elderly within the family and not in institutions’, I am often told by Africans who live in Europe. However, the enmeshed family system in Nigeria and many African cultures are evolving rapidly with mass urban migration of working-age adults leaving older relatives alone at home in the care of other relatives or carers. Caring for an older adult with multimorbidity can be extremely demanding on carers – physically, emotionally and socially. Our cultural values emphasise respect and care for the elderly, but this is not always so within all families. Nevertheless, these cultural values mean that we remain blind to the plights of vulnerable individuals and unable to comprehend that family abuse and maltreatment can occur. Even when such is observed, we expect the family to handle it among themselves. This means that except for children, there are seldom laws, structures or policies in place to ensure other vulnerable individuals (elderly, people with disabilities) are protected from all forms of abuse.
In keeping with my ethical guidance, I reported my observations and need for action to one of the doctors and nurses I was working with. However, it seems they were unsure of why I was reporting this to them and what I expected them to do. They considered this the responsibility of the family to care for and protect their vulnerable ones. Apart from the ethical research requirement of reporting this, the need for the safeguarding of vulnerable individuals is not prioritised within our healthcare system in Nigeria and it is not clear whose roles and responsibilities it is when abuse of vulnerable individuals are discovered within the health system.
Safeguarding of vulnerable individuals is not yet a priority in research in Africa. Many vulnerable adults are escaping through the policy gaps in our African health systems unnoticed. There is a need to understand factors contributing to family abuse of vulnerable individuals, including how to identify these individuals during episodes of clinical contacts and understanding healthcare worker perceptions about their role and responsibility in safeguarding and protecting against vulnerability.
Also, there is a need to develop policies, guidelines and frameworks to guide healthcare professionals working within the Nigerian health systems in this regard. For example, the Nursing and Midwifery Council of Nigeria’s code of professional conduct for nurses, highlighted that the nurse must protect the public against danger or harmful agents. In addition, the Medical and Dental Council of Nigeria’s code of medical practice in Nigeria highlighted that professional negligence constitutes among other things; failure to do anything that ought reasonably to have been done under any circumstance for the good of the patient. These are unspecific statements within the code of ethics which require proper interpretation and guidance for nurses and medical doctors to understand that abuse, neglect and maltreatment also constitute a danger to their vulnerable patients and must be reasonably acted upon to safeguard and protect patients.
However, even when healthcare professionals are aware of their responsibilities, they can only do so much in identifying vulnerable individuals who are being abused or maltreated. Another important point is how to ensure that identified cases of maltreatment are protected. As there is little to no state funding for social care to protect these individuals, who will fund the care of such individuals when they are identified as needing protection? The vulnerable ones are here too. They are invisible to the professionals who should protect them; the health system is not positioned to safeguard them and they are stuck with their abusive families/carers begging to be noticed and supported.
About the author
Oladayo Afolabi is a PhD student at the Cicely Saunders Institute of Palliative care, policy and rehabilitation, King’s College London funded by the King’s International Postgraduate Research Scholarship. A registered nurse in Nigeria and the UK, his research focuses on developing and testing the feasibility of an intervention to integrate palliative care for patients with serious life-limiting illnesses within the primary healthcare level in Nigeria.