Righting Sexual Wrongs: Personhood, Sex and Intent in a Former South African Bantustan

Righting Sexual Wrongs examines how survivors of sexual violence seek assistance under a racialized system of legal pluralism in the town of Thohoyandou in northeastern South Africa. Over 22 months of ethnographic fieldwork, I charted itineraries of justice through a variety of sites: a criminal court, trauma clinics, family gatherings, the homes of “traditional healers,” churches, social media and others. I also participated in the daily rhythms of a beauty salon where conversations about sex, love and crime were common. This dissertation argues that sexual harm inhabits survivors in numerous ways, a multiplicity that cannot be reduced to the criminal definition of rape. Survivors did not necessarily talk about injury in terms of force, coercion or consent – ways of reckoning sexual harm invested in liberal ideals of autonomy and freedom-as-separation. Instead, the harm of sexual wrongdoing was spoken of in terms of economic precarity, infidelity, pathological exposure, and the disembodied violence of witchcraft. These understandings of sexual harm were shaped by practices of remedy and restitution, but in ways that challenge spatialized theories of legal pluralism. The larger context of this study is a post-apartheid South Africa simultaneously grappling with a “rape crisis” and the legal legacy of settler colonialism. Under British indirect rule and then apartheid, ethnic bantustans (“homelands”) held captive Africans subject to a reified form of “customary law.” The policing and prosecution of rape was only ever partial for non-white populations. Today, human rights advocates and policymakers worry that the legacy of this history is popular misrecognition of the problem of sexual violence. This misrecognition is understood to happen at the institutional level, where complaints go unregistered by service providers, but also at the level of individuals, who understand sex as an entitlement owed to men. The result has been a turn to criminal justice materialized in legal, psycho-social, and medical procedures that unevenly affect survivors, accused persons and their respective loved ones. Complicating these efforts at criminalization is the post-apartheid persistence of legal pluralism, as new forms of insecurity have given way to privatized policing and parliamentarians work to legislatively reinstitute the judicial authority of chiefs and kings. Righting Sexual Wrongs contributes to pressing debates about justice and inequality, debates with a global scope. Ours is a moment when disparate political movements are coalescing around punitive legal reforms in the name of women’s rights. At the same time, demands for criminal justice reform and even prison abolition have become increasingly urgent. Sexual offences are uniquely resistant to such reforms, in part because of how rape is universalized as “a fate worse than death.” The programmatic insistence on the crime of rape as the only way to experience sexual harm justifies state violence that manifests in policing, prosecution and punishment, but also in medical care and counseling for victims. This state violence strikes along existing lines of inequality. In South Africa, it targets ethnic subjects, HIV-positive black men, and poor and working class people. By highlighting the multiple forms sexual wrongdoing takes, this dissertation endorses a structural framing of gender-based violence. In so doing, it rejects a path to justice through personal accountability and punishment, proposing a course to a world without sexual violence through shared responsibility, mutuality and obligation.PHDAnthropologyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/162841/1/srupcic_1.pd

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research