“I remember well the sting of the shot that sent me to hell that night,” says Wafa Qurawi, a 35-year-old mother. “I felt my body turn into a flaming mass with burns everywhere. I could smell my flesh burning,” she recalls. “I was screaming and writhing in pain. I asked my little boy to turn on the lamp next to my bed, but to my horror he said the lamp was already on.”

“I remember well the sting of the shot that sent me to hell that night,” says Wafa Qurawi, a 35-year-old mother. “I felt my body turn into a flaming mass with burns everywhere. I could smell my flesh burning,” she recalls. “I was screaming and writhing in pain. I asked my little boy to turn on the lamp next to my bed, but to my horror he said the lamp was already on.”

The injection meant to reduce her fever, left Qurawi blind and her body distorted by severe burns. Since June 2014, she has been suffering in silence without knowing what exactly happened and why the injection destroyed her life. A hospital investigation has been inconclusive and neither the hospital nor the doctor has been held accountable.

Qurawi is one of hundreds of victims of medical malpractice in Tunisia. Surgery – general surgery, orthopedic, obstetric, anesthesia and plastic surgery – accounts for the highest proportion of these malpractice cases.

Sixteen deaths in one month

A 2009 report by head of the Tunisian Association for Aid to Victims of Medical Errors (ATAVEM) Issam Amery disclosed alarming figures about medical misconduct at Farhat Hached University Hospital (FHUH) in Sousse, Tunisia’ third largest state. Over the period of one month, out of 1,428 in-patients in all FHUH’s wards, (not including psychiatry, emergency and neonatal wards), 162 patients were victims of at least one medical error and 184 patients were victims of more than one medical error.

The study also showed that 3.1 percent of the victims experienced a physical disability as a result of  medical misconduct or neglect. These medical errors might have led to the death of 16 patients in one month. Before the Tunisian revolution, the  study was hidden and after the revolution,the warnings within  it went unheeded.

Deadly sleep

All of the data points to faulty anesthesia being at the center of most cases. In late 2013 and early 2014, a ‘lethal anesthesia’ scandal shocked the country when eight cases of medical misconduct, with varying degrees of severity, were registered in private and public hospitals. A prominent case was Muhammad Yassin. Born with a blood disorder, Yassin underwent surgery, but inappropriate anesthetization led to brain damage. After the surgery, he could no longer hear, speak or move his limbs.

The Ministry of Health, MoH, has since pulled a problematic anesthetic from the market.

Dirty instruments in a modern hospital

On March 21, 2013, Shiraz Hammami, a 38-year-old bank employee had a gastric bypass – a procedure that reduces the size of the stomach and is relatively simple, lasting as little as one hour – in a renowned hospital in Tunis. The day following the surgery, the doctor allowed her to leave the hospital despite severe stomach pains and a bloated belly.

When Hammami arrived home, she came down with a fever so she was rushed back to the hospital. A second surgery was conducted, but she died. A hospital  investigation revealed that Hammami caught a deadly germ in the operating room due to unsterile surgical instruments, according to her family.

Tragic birth

Sumayya Boushir, in her twenties, went to the private Rawabi Hospital in Bizerte on October 15, 2013 with labor pains. She underwent a Cesarean section and gave birth to twins. Hours later, she experienced severe pain, had abnormal swelling in her belly and developed a fever. She was overcome by persistent nausea.

“My sister kept suffering, but no one responded,” says her brother Salim. “Finally, when she was about to die, she had a second surgery to stitch a hole in her intestines that resulted from the Cesarean section. But the surgery was a failure and my sister died days after the delivery.”

A court order forced the hospital to form a medical committee, which then acknowledged that there had been obvious medical misconduct during the Cesarean section.

Helping victims

The Tunisian Association of Victims’ Compensation for Medical Accidents (ADOSAVIAC) helps victims recover their rights and prove injury afflicted on them due to medical misconduct or neglect. Head of ADOSAVIAC lawyer Sabir Bin Ammar defends victims before competent courts. He is one of a few Tunisian lawyers specializing in medical malpractice.

He founded the ADOSAVIAC a few years ago, after he lost his mother due to a wrong diagnosis. She developed clogged arteries, but her doctor insisted that the frequent pains below her neck were caused by rheumatism. His mother’s case worsened and she eventually died. “The law is still defective in addressing the issue of medical errors, which is growing worse,” says Ammar.

The main purpose of the ADOSAVIAC, says Ammar, is to pressure the government to adopt a ‘liability without fault’ concept— where a defendant is held criminally liable even if criminal intent was not evident— break the relation between cause and effect, and abandon the approach of tasking the victims with providing evidence.

Fund for compensation

Every day, says Ammar, the ADOSAVIAC receives dozens of complaints through phone calls and personal visits. “Every year, we record some 15,000 medical errors of various levels of seriousness in the private and public sectors,” he says. “This number which the MoH seeks to black out reflects the large number of daily complaints and the thousands of lawsuits filed annually, not to mention that some deliberately conceal it, especially in plastic surgery for women to avoid scandal.”

Ammar demands a national fund to compensate victims of medical errors. He underlines that the absence of such a fund has aggravated some cases, leading to death, because families did not have the funds to treat the effects of errors, which is what pushed Ammar to found a cooperative. Besides, litigation procedures may take up to five years before a victim can get compensation. “Doctors in the medical committee stand by other doctors (who are defendants) in outrageous collaborations that violate the rights of victims,” says Ammar. “This is what forced the French state to adopt liability without fault.”

MoH is considering such a fund, according to MoH Inspector General Taha Zeinelabidine.

Murder and extortion

Ammar argues that the state’s compensation is low and inadequate since it does not exceed TND 100,000 (US $48,460) in cases of death. He also claims that extortion is rampant in private hospitals, especially when patients are foreigners.

In one case, according to Ammar, a Libyan patient with a brain tumor underwent surgery in Sukkara Hospital – it was the first time the operation had ever been performed in the hospital. Following the surgery, the patient was almost completely disabled. His family tried to get him out of the hospital and take him to Germany, but the hospital administration refused and performed  another surgery after which time the patient went into a coma for three months before finally dying.

The family was billed for both surgeries and for the patient’s stay during his coma. The hospital administration refused to deliver his body to the family, until the family paid TND 360,000 (US $174,457). Eventually, the family pressed charges against the hospital, accusing it of manslaughter and extortion.

In another incident, according to Ammar, French citizen Michelle Thierry travelled to Tunisia in early 2014 to have liposuction in the Bhera Hospital. A wrong dose of anesthesia led to her death. Later, the doctor admitted her mistake and compensated Thierry’s husband.

Ammar plans to publish in ADOSAVIAC’s next report the names of the hospitals guilty of  unprofessional ethics. ADOSAVIAC has observed recurrent medical errors in five hospitals throughout Tunisia, Ammar says.

Medicine’s limits and challenges

MoH Inspector General Taha Zeinelabidine examines cases of medical malpractice. “Tunisian law  only defines an error as doing what should not be done or neglecting what should be done without the intention of causing damage,” says Zeinelabidine. “There is a need to review the law to define an error. Failing to define it, the current law has left a gap that makes it very difficult to conduct litigation.”

To the contrary of what ADOSAVIAC says, Zeinelabidine claims that the number of medical errors does not exceed 300 a year, nearly equally distributed between the private and public sectors.

According to MoH statistics, the number of filed cases on medical errors increased from 249 in 2013 – 2014 (147 cases in public health facilities and 102 in private health facilities) to 300 cases in 2015. “Compensation is determined by the administrative court in terms of public facilities and by courts of justice in terms of private facilities,” says Zeinelabidine. “Doctors may be held criminally accountable for their mistakes.”

No conspiracy

Zeinelabidine refutes any connivance among doctors, citing the court having found some defendants guilty of malpractice. “We judge not by intentions but by results. In some cases compensation has reached tens of millions of dinars and the MoH pays a huge amounts in compensations annually.”

In 2014, says Zeinelabidine, the judge did not take into account the decision of the medical committee that examined the case of a young girl who had died in hospital. The committee said the doctor did what he had to do, but the judge believed that there was negligence in treating the girl, which led to her death.

In Tunisia, doctors found  guilty of negligence or misconduct  may be warned, reprimanded, suspended or may have their license revoked. Zeinelabidine claims that dozens of doctors have been imprisoned or had their licenses revoked.