Post-Nasser: An Opportunity to Change the Culture of Rape Impunity in Michigan?

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 photo: BCGavel.com

Like so many Michigan State University alumni, I was sickened to hear the details of the Larry Nasser case and the role the university played in impunity for so many appalling crimes against girls and young women—there are allegations of assault against 260 victims.[1] The crisis of sexual assault on campuses and more widely in the United States comes up frequently, yet there seems to be limited systemic change that would make real impact. Perhaps there is too little political will by state or other governments to tackle this huge issue; perhaps financial and other interests of universities are directly divergent to robust reform; or perhaps protecting countless victims from sexual assault is not sufficient motivation for universities who prioritize their prestige, athletic programs and income over the rights and well-being of their students.

In some campuses, it makes for a deadly combination when athletes and sports programs are idolized and are not held accountable for their actions, to the point of impeding justice. Beyond the Nasser case, Michigan State has been under Department of Education oversight since 2014, who has been involved since 2010, due to the university’s mishandling of sexual assault and gender discrimination cases.[2] The cases that prompted the initial interventions concerned MSU’s mishandling of rape cases, one committed by two basketball players.[3] Once again highlighting the university’s true priorities, last fall MSU requested an end to the oversight since MSU was acting in ‘good faith’; this request was made even though MSU had still, at the time of their request, failed to provide documents for the Nasser cases to federal officers.

At MSU, it has been said that there is a “pattern of widespread denial, inaction and information suppression of such allegations by officials ranging from campus police to the Spartan athletic department.”[4] Indeed, MSU has gone to great lengths to suppress information about sexual assault and how it has handled cases including legal battles to withhold athletes’ names from police records, deleting information from incident reports and refusing to release information from internal investigations concerning how sexual assault cases have been handled.

The culture of impeding rape investigations and silencing of the issue perpetuates the human rights crisis in the United States, on college campus and more widely. A few quick statistics:

  • 1 in 5 women in the U.S. have experienced rape in their lifetimes. Based on population statistics at the time of the 2010 census, this amounts to approximately 31.4 million women.
  • 1 in 20 have experienced other types of sexual violence (in the 12 months prior to survey).[5]
  • A survey of undergraduate women found that 19% had experienced sexual assault since entering college.[6]
  • Out of every 1,000 rapes, 994 perpetrators will walk free.[7]
  • Women who have experienced rape often suffer severe and long term health consequences:[8]
    • 94% experience PTSD;
    • 33% contemplate suicide; and
    • 13% attempt suicide.

It is difficult to measure the health and human rights implications for any individual victim, let alone for this scale of sexual assault; some include psychological and/or physical trauma and mental health implications, invasion of bodily integrity and autonomy, the list goes on. Slightly easier to quantify, in 2008 alone, sexual assault came at a hefty price, costing the United States $750 billion in health care costs.[9]

While perhaps (and hopefully) not illustrative of the wider issue of sexual assault in the United States, the Nasser case and non-action of Michigan State serves a useful—albeit painful—example of how ineffective universities can be at handling sexual assault and broken justice systems. While there have been rape cases reported against Nasser since the 1990s, victim’s voices were silenced or university officials failed to take action.[10] Indeed, at least 14 MSU officials knew of rape allegations against him and did nothing.[11] Consequently, it took a period of 25 years during which hundreds of preventable assaults occurred, with cases so predatory and despicable, to remove this man from a position in which he was able to continue assaulting young women, and to finally bring him before the courts.

There has been some fallout and steps taken to improve the handling of sexual assault, including resignations from the president of the university and the head of the athletic department. The Department of Education, the NCAA and the Michigan Attorney General are investigating the (non) handling of the Nasser case.[12] A potentially significant step, there is proposed legislation in the Michigan Congress which would improve how universities and the state respond to sexual assault, including by establishing a Title IX ombudsman at the state Department of Civil Rights and increasing resources available to rape survivors.[13] While these measures will not prevent the violence and violations that have already occurred, perhaps the scale of suffering will motivate politicians and universities to step up and actually change things.




[1] https://www.vox.com/policy-and-politics/2018/1/30/16934634/michigan-state-larry-nassar-investigations.

[2] http://www.espn.com/espn/otl/story/_/id/22211140/michigan-state-sought-end-federal-oversight-delayed-sending-feds-files-larry-nassar-espn.

[3] http://www.espn.com/espn/otl/story/_/id/22211140/michigan-state-sought-end-federal-oversight-delayed-sending-feds-files-larry-nassar-espn.

[4] http://www.espn.com/espn/story/_/id/22214566/pattern-denial-inaction-information-suppression-michigan-state-goes-larry-nassar-case-espn.

[5] https://www.cdc.gov/ViolencePrevention/pdf/SV-DataSheet-a.pdf.

[6] https://www.cdc.gov/ViolencePrevention/pdf/SV-DataSheet-a.pdf.

[7] https://www.rainn.org/statistics/criminal-justice-system.

[8] https://www.rainn.org/statistics/victims-sexual-violence.

[9] https://www.endsexualviolence.org/where_we_stand/costs-consequences-and-solutions/.

[10] https://www.cnn.com/2018/01/24/us/ncaa-msu-nassar-investigation/index.html.

[11] https://www.huffingtonpost.com/entry/michigan-state-larry-nassar-eight-accusers_us_5a60c9e9e4b01f3bca592311.

[12] https://www.vox.com/policy-and-politics/2018/1/30/16934634/michigan-state-larry-nassar-investigations.

[13] https://www.michigandaily.com/section/government/state-legislators-propose-bills-combat-sexual-assault-campus.

Posted in Human Rights; Tagged: , .



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This post was written by Michelle Rourke, visiting Fulbright Scholar from the Griffith Law School in Brisbane, Australia. Her article “Never Mind the Science, Here’s the Convention on Biological Diversity: Viral Sovereignty in the Smallpox Destruction Debate” was published in this month’s issue of the Journal of Law and Medicine.

Image Credits: Blue whale and Gouldian finch: Wikimedia; Smallpox particles: CDC Public Health Image Library

You probably don’t need any convincing that the blue whale is worthy of conservation efforts. Or that the vibrant Gouldian finch, clinging to existence in small pockets of northern Australia, should be brought back from the brink of extinction. But could you be convinced that deadly viruses are worthy of conservation?

While it’s unlikely that endangered mammals or birds have ever posed a source of personal value to you, it’s still easy to accept that these species have some intrinsic value to the world. In acknowledgment of this value, the global community committed to conserve the world’s precious genetic resources in 1992, adopting the United Nation’s Convention on Biological Diversity (CBD). The CBD is one of the most widely ratified multilateral treaties, with 196 state parties signing on to conserve and sustainably use the components of biodiversity.

So we’re all agreed: whales and colorful finches comprise an important part of the world’s genetic diversity that we are not prepared to see lost to extinction. But what should be done with pathogenic genetic resources when their only apparent purpose is to hurt or kill us? Is, for instance, the smallpox virus worthy of our conservation efforts? To date, the implicit answer to this question has been “yes”!

Stocks of variola virus, the causative agent of smallpox, are currently being held in two high-security laboratories, one in Atlanta, USA and the other in Koltsovo, Russia. Since smallpox was declared eradicated from the human population in 1980, the World Health Organization (WHO) has periodically debated the merits of destroying these stocks, and each time the decision has been postponed. In effect, we have been passively conserving variola virus for more than three decades!

Together, the USA and Russian repositories house more than 500 vials of viruses that are still being used in scientific experiments. Only some of these viruses have been genetically sequenced and the samples contain a wealth of genetic information that could ultimately be used to fend off future viral threats. And when it comes to smallpox, the greatest of those threats might well be bioterrorism.

Undeclared samples of variola virus could still be sitting in suspended animation in freezers around the world, and the virus could be weaponized by someone with relatively rudimentary laboratory skills. While this might sound like the premise for a fictional Hollywood blockbuster, this very real possibility was highlighted in July 2014 when scientists at the US National Institute of Health found six glass vials labelled ‘variola’ dating back to the 1950s in a laboratory freezer in Bethesda. Two of the samples were still viable.

The threat of bioterrorism has weakened the political will to destroy the last remaining (declared) stocks of smallpox virus. Through sheer reticence, it appears that the passive conservation of these virus samples will continue. But it might be time to consider whether pathogenic genetic resources are worthy of active, purposeful and very deliberate conservation efforts.

It is difficult to make the case that viruses have some intrinsic value to the world, particularly to anyone suffering from a viral head cold. It is much easier to make the anthropocentric case that they are valuable to human beings! Virus samples are required to develop and test vaccines and medicines, they have been a key tool in helping to describe how the human immune system works and they are currently being used as delivery vectors in cancer and gene therapies.

There is lots to learn from viruses, not least of all how we can best tackle them. The variola repositories are not simply 500 or so identical specimens. These viruses are genetically varied, unique samples that could reveal information about the emergence and evolution of the virus, its host-cell specificity, how the disease manifests in humans and the molecular basis for regulating the host immune response.

These viruses are a library of genetic information, an historical catalogue of our history with smallpox. And there are still portions of that library that scientists cannot yet understand! Theoretical physicist John Archibald Wheeler famously said “as the island of our knowledge grows, so does the shore of our ignorance”. The more we learn about these viruses, the more we realise we have so much yet to discover!

We must seriously consider conserving pathogenic genetic resources, if not for us, then for future generations. This is precisely what the CBD aimed to do back in 1992. It was the global community’s way of insuring against our destructive short-term impulses and securing the world’s genetic resources for future generations. The treaty applies to all non-human genetic resources, not just the cool, cuddly and colorful ones.

In 2011, the cattle plague virus, rinderpest, was declared eradicated and as the world moves ever closer to declaring the eradication of polio virus, this issue is guaranteed to resurface. These viruses are more than just agents of disease; they are genetic libraries containing the information needed to combat those same diseases, and more! Just as nobody could justify destroying a library, there is little justification under international law for destroying these precious genetic resources.


Posted in Global Health; Tagged: .


The Ebola Footprint – Broader Than You Think

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This post was coauthored by Tom Vincent and Dr. Jean-Paul Gonzalez.  Dr. Gonzalez is the Deputy Director of the Center of Excellence in Emerging and Zoonotic Infectious Diseases at Kansas State University.

Photo credit: Sergey Uryadnikov/Shutterstock


Ebola virus disease is a hemorrhagic febrile illness that has case-fatality rates that vary from 32% to 88% across well-studied outbreaks.  Thankfully, the number of known outbreaks has been limited. Since Ebola first emerged in 1976, the CDC has recognized 26 separate human disease outbreaks of natural origin in Africa.[1]  The devastating 2014-16 West African outbreak killed more than 10,000 people and showed the world that the disease could not only spread beyond its perceived zone of endemicity but had a potentially broader footprint than previously understood. But the truth is, the Ebola virus presence is much broader than a collection of points on a map where the disease has surfaced.

The first evidence that showed that Ebola virus had circulated in areas without known cases of disease came in 1977, near the Ebola outbreak in Tandala, DRC, just 200 miles west of the first known cases in 1976.[2]  Blood samples obtained from individuals in areas with no previous symptoms of Ebola were found to contain antibodies for Ebola virus.  The presence of antibodies to any virus indicates a previous or ongoing infection with that virus. Because subclinical illness is always a possibility with viral infections, the presence of these Ebolavirus-specific antibodies could only be explained by exposure to the virus, which is somewhat reasonable in an area that is endemic to the disease.  But how do we know the true endemic zone of a virus such as Ebolavirus?

Endemic zones are primarily based on where disease can most likely be expected, and are determined by historical accounts of disease, as well as supplemental information such as where animals or insects that might transmit the disease are located.  With respect to the Ebola virus, outbreaks that occur in Central Africa, in or near the Congo River Basin, are expected; outbreaks that take place elsewhere are unexpected and can be problematic, as was the case for the West African outbreak.  And yet, scientists have highlighted the presence of Ebola antibodies well outside the endemic zone for disease for decades.

In the early 1980’s, research based at the Pasteur Institute in Bangui, Central African Republic, demonstrated for the first time that the population of central Africa presented natural antibodies against the Ebolavirus strains of Zaire and Sudan.[3] [4]  Research also showed for the first time that several mammal species had Ebolavirus reacting antibodies, including rodents, dogs, and others.  Initially, the scientific community was skeptical of the findings, due to the type of antibody tests used, and because the prevalence of these antibodies was unbelievably dispersed and at a high level of prevalence.  However, a 1989 follow-up study confirmed methodology and preliminary observations, and expanded the results to include similar observations in Cameroon, Chad, Gabon, and Republic of Congo (the latter two of these countries would have their first Ebola outbreaks in 1994 and 2001, respectively).[5]  Moreover, such Ebolavirus antibody prevalence was found in West Africa, preceding the catastrophic 2014-2016 Ebolavirus outbreak11.[6] [7] [8]  Subsequent studies have determined that 20-25% of persons living in or near the Congolese rain forest are seropositive for Ebola, despite never exhibiting symptoms.[9]

Today, Ebola antibody prevalence is widely distributed across the African continent in the absence of severe clinical presentation and/or outbreak manifestation.[10] [11]  A 1989 study even found Ebola Zaire antibodies among people living in Madagascar, an island country that has never had a single known case of Ebola, and which has been geographically separated from continental Africa for 100 million years.[12]  Remarkably, Ebola Zaire appears to be the most prevalent viral infection in Madagascar, despite a total lack of Ebola virus disease occurrence.

How is this possible?  Are Ebola virus infections more prevalent than we understand, causing subclinical infections?  Subclinical infection, a silent infection, is common for most of the viruses known to infect humans.  Maybe other strains of Ebolavirus, not yet isolated, do not cause disease and circulate more widely than we know?  Do these initially harmless strains eventually pass through animal (or even human) hosts, where they undergo genetic changes that make them pathogenic to humans?  The Ebola Reston strain, harmless to humans, actively circulates in the rainforests of the Philippines; how did this virus—initially and so uniquely known to Africa—get there?  These are the questions that researchers are pursuing, in the hopes that in the future, Ebola virus disease outbreaks can be better predicted, contained, or even eliminated by understanding the Ebola virus footprint that stretches much further across Africa than previously expected.



[1] https://www.cdc.gov/vhf/ebola/outbreaks/history/distribution-map.html

[2] Heymann DL, Weisfeld JS, Webb PA, Johnson KM, Cairns T, Berquist H. 1980. Ebola Hemorrhagic Fever: Tandala, Zaire, 1977-1978. J Infect Dis. 142, 372-376.

[3] Saluzzo JF, Gonzalez JP, Georges AJ & Johnson KM. 1980. Note préliminaire sur la présence d’anticorps vis-à-vis du virus Ebola parmi les populations du sud-est de la République Centrafricaine Bulletin de la Société de Pathologie Exotique, 73, (3):238-241

[4] Gonzalez JP, McCormick JB, Saluzzo JF & Georges AJ. 1983. Les fièvres hémorragiques africaines d’origine virale en République Centrafricaine Cah. ORSTOM, Ser.Ent.Méd. et Parasit., XXI, (2): 119-130

[5] Gonzalez, JP, Josse R, Johnson ED, Merlin M, Georges AJ, Abandja J, Danyod M, Delaporte, E, Dupont A, Ghogomu A, Kouka-Bemba D, Madelon MC, Sima A & Meunier DMY. 1989, Antibody prevalence against haemorrhagic fever viruses in randomized representative central african populations. Research in Virology (Annales de l’Institut Pasteur), 140, 319-331

[6] Gonzalez JP. Ebola Virus Circulation in Africa: a balance between clinical expression and epidemiological silence. 2005. Epidemiologie. 98, 210–217.

[7] Gonzalez JP, M Ar Gouilh, JM Reynes & E Leroy. 2008. Bat Borne Viral Zoonoses Emergence PART I Synthetic Analyses Chapter 6 In People, Health and Forests Carol J. Pierce Colfer and Eckhard Kleinau, eds. Press.

[8] Schoepp RJ, Rossi CA, Khan SH, Goba A, Fair JN. Undiagnosed acute viral febrile illnesses, Sierra Leone. Emerg Infect Dis. 2014;20(7):1176–82. doi: 10.3201/eid2007.131265.

[9] Becquart P, Wauquier N, Mahlakõiv T, Nkoghe D, Padilla C, Souris M, Ollomo B, Gonzalez JP, De Lamballerie X, Kazanji M, Leroy E. High Prevalence of both Humoral and Cellular Immunity to Zaire ebolavirus among Rural Populations in Gabon, 2010, PLoS ONE 5 (2): e9126.

[10] Gonzalez JP. Ebola Virus Circulation in Africa: a balance between clinical expression and epidemiological silence. 2005. Epidemiologie. 98, 210–217.

[11] Bower H, Glynn JR. 2017. A systematic review and meta-analysis of seroprevalence surveys of ebolavirus infection. Scientific Data, 4:160133

[12] Mathiot CC, Fontenille D, Georges AJ, Coulanges P. 1989. Antibodies to haemorrhagic fever viruses in Madagascar populations. Trans R Soc Trop Med Hyg. 83(3):407-9.

Posted in Global Health; Tagged: .


The Institute’s Hepatitis Policy Project Launches New Website

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Sonia Canzater, Hepatitis Policy Associate, and Jeffrey S. Crowley, Program Director of Infectious Disease Initiatives, invite you to visit the Hepatitis Policy Project’s new policy-focused website on hepatitis C.

While there is already an abundance of general information available on the etiology, symptoms and transmission of HCV, this site is intended to provide the latest policy actions and most timely and relevant information related to the HCV crisis.

Content consists of links to relevant articles, study findings, features from thought leaders in the viral hepatitis space, and summaries of current policy issues written by the Policy Project team.

Our goal for the site is to fill a niche that is different than that of the CDC and other sites whose primary purpose is to provide information for the general public.

A highlight of our site is the Featured Expert Column that provides timely insights from leaders in viral hepatitis policy and advocacy.

Our inaugural expert column was authored by Dr. Rich Wolitski, Director, and Corinna Dan, Viral Hepatitis Policy Advisor, of the U.S. Dept. of Health and Human Service’s Office of HIV/AIDS and Infectious Disease Policy.

Please share the link to the site in your respective circles, and contact Sonia Canzater, Hepatitis Policy Project Associate, at sc1574@georgetown.edu with comments or inquiries.

Posted in Uncategorized;


The Truth Behind Home Health Aide Certification Requirements

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Home health aides (HHAs) play an important role in maintaining the health and well-being of the elderly, ill, and disabled.  This role varies from changing bandages and distributing medications, to grocery shopping and helping to pay bills.  Unlike other health care workers who are located in a health care facility, HHAs enter patient homes and thus have access to the most intimate parts of peoples’ lives and are often not supervised.  Because of this, it is imperative that HHAs are screened and that they go through a rigorous training process.

Home health aides usually work with patients who need more extensive physical and or medical care than a typical family can provide.  There is no formal education requirement (including a high school diploma) to secure a position as an HHA, although certificate and training courses are available from many postsecondary institutes.  Some HHA and hospice agencies, however, may require a high school diploma from their employees.

According to the US Bureau of Labor Statistics, HHA educational requirements vary depending on the employer.  Aides who work for organizations that receive funds from Medicare or Medicaid must complete formal training, while those who work for private companies are not required meet these obligations.  More experienced aides, such as certified nursing assistants (CNAs) and licensed practical or registered nurses, often provide on-the-job training for new aides.

Federal Requirements

Throughout the US any home health agency that accepts Medicare must employ certified home health aides.  Federal law states that HHAs working at a CMS (Centers for Medicare and Medicaid Services), must have 75 hours of training, including 16 hours of on-the-job training. This is the minimum number of required hours, and states can then choose if they want to license HHAs working in the state and if any additional training is needed.  However, it is important to distinguish facilities that accept CMS and those that do not.  Private companies that do not accept Medicare do not have certification requirements.

State Requirements

As mentioned above, HHA certification requirements vary greatly by state.  In Wyoming, there is no HHA specific training program or designation.  In order to work as an HHA, one must complete an approved CNA program.   The state of Wyoming then sets standards for how home health agencies train their home health aides. State law requires home health agencies to provide 16 hours of additional training upon being hired in the first two weeks.

In Wisconsin, potential HHAs must complete a CNA training program and then successfully complete an exam and a background check.  To be a CNA in Wisconsin requires a minimum of 120 total hours of training, including 32 clinical hours.

In Vermont, to work as an HHA an applicant must first be a Licensed Nursing Assistant (LNA).  The LNA training program includes 80 hours of total training, with 30 hours of clinical training.  After the training, all LNAs must pass a state exam and register with the state.

Washington, DC Requirements

Washington, DC only requires the bare minimum number of training hours (75), including 16 hours of on-the-job training.  Many states require more than this bare minimum and some states even require formal training such as a CNA or another nursing degree or certification to be an HHA.   In Washington, DC, in order to be certified, home health aides must successfully complete a training program, pass a competency exam issued by the District of Columbia Board of Nursing, pass a criminal background check, and submit an application along with a fee to the District of Columbia Board of Nursing.  However, for private companies that do not accept Medicare, these certification requirements do not apply.

The District of Columbia Home Health Aide certification by examination was established in July 2012 with the final publication of the Home Health Aide Regulations.   The regulations were derived from the revised Health Occupations Revisions Act of 2009, which place Nursing Assistive Personnel under the authority of the Board of Nursing.  The District of Columbia Home Health Aide Regulations were last revised and amended in September 29, 2017.

Many HHAs could be “waived in” or “grandfathered in” in the past, meaning they could waive the examination to be certified as an HHA. There are now four ways to be certified as an HHA in Washington, DC: (1) Certification by examination, (2) certification by endorsement, (3) certification by renewal, and (4) reactivation of certification.   The examination has 2 parts: a written section and a skills section.  HHA certifications expire October 31st of every odd numbered year.

There has been a history of fraudulent HHA applications in Washington, DC with HHA applicants submitting certification applications directly to the Board of Nursing themselves.  Many applicants have submitted fraudulent educational certificates and applications.  Because of this, the Board now requires applications to come directly from the HHA’s employers, and for those applying to take the HHA examination, the HHA schools must send lists of graduates to the processing unit.

Due to the nature of their responsibilities and the Importance of their roles, HHAs should be thoroughly trained and vetted, arguably more than health care workers who work in health care facilities.  However, this is not always the case due to relaxed training and education requirements that vary from state to state across the country.  This is especially worrisome in the nation’s capital, which has some of the least restrictive requirements for HHAs, and a history of loopholes, such as the grandfather clause, that allowed for unqualified and unverified HHAs to work in the District.

Posted in Health reform, National Healthcare; Tagged: , , , , , .


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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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