The International Committee of the Red Cross (ICRC)has consistently expressed its grave concern over the humanitarian consequences and legal implications of the practice by the United States (US) authorities of holding persons in undisclosed detention in the context of the fight against terrorism
1.In particular, the ICRC has under-scored the risk of ill-treatment, the lack of contact with the outside world as a result of being held incommunicado, the lack of a legal framework, and the direct effects of such treatment and conditions on the persons held in undisclosed detention and on their families.The ICRC
made its first written interventions to the US authorities in 2002,requesting information on the whereabouts of persons allegedly held under US authority in thecontext of the fight against terrorism. Since then, it has made regular written and oralinterventions to the US authorities on the issue of undisclosed detention (see Annex 2).In particular, the ICRC transmitted two reports on undisclosed detention on18 November 2004 and 18 April 2006 respectively which consolidated the information previously transmitted 2and included more recent allegations of undisclosed locations,hidden detainees and third country detention. Both reports annexed a non-exhaustivenominal list of persons allegedly held in undisclosed detention by the US authorities
3.Despite repeated requests at various levels of the US Government (USG), the ICRChas not received a response to most of these written interventions. The main writtenresponse by the US authorities is the Note Verbale of 8 June 2005 which responds to three earlier written interventions
4.The US authorities have never responded to the two ICRC consolidated reports. On 6 September 2006,President Bush publicly announced that fourteen “high value”detainees had been transferred from the High Value Detainee Program run by the CentralIntelligence Agency (hereafter CIA detention program) to the custody of the Department of Defense in Guantanamo Bay Internment Facility (hereafter Guantanamo).The fourteen detainees (hereafter the fourteen) were reportedly held in the CIA deten-tion program from the time of their arrest, or shortly thereafter, until their arrival in Guantanamo
5.Throughout their time in CIA custody—which ranges from 16 months to almost four and a half years—these persons were held in undisclosed detention.Prior to this public announcement, the ICRC had never been informed by the USauthorities of the existence of the CIAdetention program, nor of the presence in UScustody of the fourteen. This is despite the fact that thirteen of the fourteen had beenincluded in the abovementioned ICRC written requests to the US authorities concern-ing undisclosed detention, the first of which were made in January 2003
6.The remaining detainee was not known to the ICRC. The ICRC was granted access to the fourteen in Guantanamo, and met with each of them in private for the first time from 6 to 11 October 2006 .The ICRC regards the confirmation of the present whereabouts of the fourteen bythe US authorities, and the subsequent access granted to the ICRC, as positive steps.However,it deplores the fact that these persons wereheld in undisclosed detention
It is essential to a proper understanding of this report that all of the elements of treatment and material conditions of detention individually outlined below be considered as forming a whole, as each constitutes an integral part of the situation of the detainees in the CIA detention program. In addition to the information contained in the following section,it is also necessary to consider the prolonged duration of the detention, the conditions of detention and treatment in the later stages of detention. and the role of health personnel and, in particular, the lack of legal framework governing the undisclosed detention of the fourteen. When understood in their totality, the undisclosed detention regime to which these persons were subjected becomes all the more disturbing. The ICRC wishes to underscore that the consistency of the detailed allegations provided separately by each of the fourteen adds particular weight to the information provided below.The general term“ill-treatment” has been used throughout the following section, how-ever, it should in no way be understood as minimising the severity of the conditions and treatment to which the detainees were subjected. Indeed, as outlined in Section
below,and as concluded by this report, the ICRC clearly considers that the allegations of the four-teen include descriptions of treatment and interrogation techniques—singly or in combina-tion that amounted to torture and/or cruel, inhuman or degrading treatment.
The fourteen were arrested in four different countries. In each case, they were reportedly arrested by the national police or security forces of the country in which they were arrested.
This … white paper, published August 31, 2009, after the new release of the May 2004 CIA Inspector General’s report, shows that the extent to which American doctors and psychologists violated human rights and betrayed the ethical standards of their professions by designing, implementing, and legitimizing a worldwide torture program is worse than previously known.
A team of PHR doctors authored the white paper, which details how the CIA relied on medical expertise to rationalize and carry out abusive and unlawful interrogations. It also refers to aggregate collection of data on detainees’ reaction to interrogation methods. Physicians for Human Rights is concerned that this data collection and analysis may amount to human experimentation and calls for more investigation on this point. If confirmed, the development of a research protocol to assess and refine the use of the waterboard or other techniques would likely constitute a new, previously unknown category of ethical violations committed by CIA physicians and psychologists. (click here to read original report)
The version of the 2004 CIA Inspector General’s report released on August 24, 2009 provides greater detail on the central role that health professionals played in the CIA’s torture program and reveals a level of ethical misconduct that had not previously come to light.
The report confirms that the CIA inflicted torture on detainees interrogated while in US custody as part of the agency’s counterterrorism activities and exposes additional interrogation techniques that had not yet been reported. It also demonstrates that health professionals were involved at every stage in the development, implementation and legitimization of this torture program.
The doctors and psychologists who laid the foundation upon which attorneys rationalized an illegal program of torture also actively participated in abusive and illegal interrogations, thus betraying the ethical standards of their professions by contributing to physical and mental suffering and anguish. The very premise of health professional involvement in abusive interrogations — that they have a role in safeguarding detainees — is an unconscionable affront to the profession of medicine.
The Inspector General’s report also reveals that medical professionals were directed to meticulously monitor the waterboarding of detainees to try to improve the technique’s effectiveness, essentially using the detainees as human subjects, a practice that approaches unlawful experimentation.
Physicians for Human Rights (PHR) has prepared the following analysis of the Inspector General’s report, building on the 2007 report by PHR and Human Rights First (HRF), Leave No Marks, which assessed interrogation techniques reported up to that time, which have now been confirmed by the Inspector General’s report. This paper provides an introductory summary of techniques newly described in the Inspector General’s report and then offers a more detailed medical analysis of those techniques. The paper then reviews the various ways health professionals were complicit in enabling the torture regime.
Summary of Newly Detailed Techniques
The Inspector General’s report describes several forms of abuse not previously reported that CIA interrogators and contractors implemented, and that from a medical and legal perspective constitute torture. These include:
- Mock executions and threatening detainees by brandishing handguns and power drills;
- Threatening the detainee with harm to his family members including sexual assault of female family members, and murder of detainee’s children; and
- Physical abuse including the application of pressure to the arteries on the sides of a detainee’s neck resulting in near loss of consciousness, and tackling or hard takedowns.
These methods have significant harmful physical and mental health consequences.
The report provides new details about previously reported forms of abuse referred to as “enhanced interrogation techniques”. The harmful health consequences of these forms of torture and abuse have previously been described by PHR, including in the reports Break Them Down, Leave No Marks and Broken Laws, Broken Lives.” (1)
The Inspector General’s report clearly questions the efficacy, ethics and legality of these as well as the previously mentioned “enhanced interrogation techniques”. The report also confirms the theory of a “slippery slope” in interrogation settings, namely that torture by its very nature escalates in the severity and frequency of its use beyond the approved techniques.
Medical Analysis of the Interrogation Techniques Described in the Inspector General’s Report
The adverse physical and mental health effects of stripping (forced nudity), isolation, white noise or loud music, continuous light or darkness (sensory deprivation), temperature manipulation, stress positions, sleep deprivation, attention slap, abdominal slap, stress positions and waterboarding have been previously described in the Physicians for Human Rights and Human Rights First report Leave No Marks. The following medical analysis focuses on techniques not previously reviewed by PHR.
As with the techniques previously analyzed, it is important to understand two key points. First, while the techniques are evaluated individually, these techniques were designed to be used in combination in a way that enhanced pain and stress.
Second, to comprehend the severity of the effects of these techniques, it is essential to consider the context of their use. In terms of both long and short term psychological effect, there is no meaningful equivalence between waterboarding when used as part of survival training of service men who have volunteered and consented to the procedure and who know that they are in an environment where they trust the mock interrogator to protect their safety and may stop the procedure at any time, and waterboarding of a high value detainee in a black site where the detainee is in actual fear for his life and safety. As the Inspector General’s report indicates:
“One of the psychologist/interrogators acknowledged that the Agency’s use of the [waterboarding] technique differed from that used in SERE training and explained that the Agency’s technique is different because it is ‘for real’ and is more poignant and convincing.” (2)
Analysis of New Approved Techniques Revealed in Inspector General’s Report
The additional approved techniques listed in the Inspector General’s report and not previously analyzed by PHR include shaving, hooding, restricted diet, prolonged diapering, “walling” and confinement boxes.
As with the previously reviewed techniques, while these techniques can have harmful physical as well as mental health effects, their chief objective is to produce psychological impact, and their chief risk is prolonged mental pain and suffering.
1. Forced shaving
Forced shaving of the head and beard was alleged by two of the fourteen detainees interviewed by the ICRC for its 2007 report.
Mr. Ramzi Bin-al-Shib alleged that, in his eighth place of detention, first his head was shaved and then some days later his beard was also shaved off. He was particularly distressed by the fact that the people who shaved him allegedly deliberately left some spots and spaces in order to make him look and feel particularly undignified and abused. (3)
In 2007, PHR physicians examined a former US detainee, who reported:
“When they finished hitting me… they shaved my hair. The only hair I had was in the middle. This was only to humiliate me.” (4)
Medical Analysis: Forced shaving obviously carries little risk of physical harm, and is chiefly designed to inflict psychological harm by means of humiliation, both personal and religious. Forced shaving was part of a campaign to sever the sense of self derived from religious belief, and was often accompanied by forced removal of religious articles.
In addition to the violation of cultural and religious taboos, forced shaving constitutes an intrusion into the personal space and bodily integrity of the person, infringing on autonomy and self-control. The combined effects of this type of treatment in combination with other techniques have been associated with long-lasting psychological injury such as posttraumatic stress disorder, anxiety and depression.
Detainees were blindfolded or hooded to instill in them a sense of fear, disorientation and dependency on their captors.
According to the February 2004 report of the International Committee of the Red Cross (ICRC) on treatment of detainees in Iraq:
Hooding [was] used to prevent people from seeing and to disorient them, and also to prevent them from breathing freely. One, or sometimes two bags, sometimes with an elastic blindfold over the eyes which, when slipped down, further impeded proper breathing. Hooding was sometimes used in conjunction with beatings thus increasing anxiety as to when blows would came. The practice of hooding also allowed the interrogators to remain anonymous and thus to act with impunity. Hooding could last for periods from a few hours to up to 2 to 4 consecutive days, during which hoods were lifted only for drinking, eating or going to the toilets.(5)
PHR reported in Broken Laws, Broken Lives that according to former detainees medically evaluated by PHR, hooding was used both during transportation and during interrogation.
Medical Analysis: When not used in transport, hooding is a form of sensory deprivation aimed at causing dislocation and confusion. Research shows that prolonged sensory deprivation can result in depression, depersonalization and psychosis. According to the ICRC report, hooding, and other observed sensory deprivation techniques resulted in
“signs of concentration difficulties, memory problems, verbal expression difficulties, incoherent speech, acute anxiety reactions, abnormal behavior and suicidal tendencies.”(6)
3. dietary Manipulation
Detainees were deprived of solid food for periods ranging from days to months. Mr. Abu Zubaydah alleged that for a period of two to three weeks during his initial period of interrogation, he was kept sitting on a chair constantly and only provided with liquid Ensure (a nutrient formula) and water. Mr. Binal-Shib reported that he went three to four weeks without solid food, and was only provided with Ensure and water. In addition, six other high-value detainees reported being deprived of solid food for periods ranging from days to weeks. (7)
Medical Analysis: While physical risks of a liquid diet are minimal as long as appropriate calories and nutrients are provided, the intent of dietary manipulation is to inflict psychological distress by infringing on the detainee’s sense of autonomy and self control and increasing discomfort and a sense of helplessness and dependency. While the risk of death or debilitation may be minimal, the effects on concentration and mood may be substantial.
4. Prolonged diapering
Detainees were placed in diapers and denied access to a toilet for prolonged periods of time. According to the ICRC Report, high value detainees in CIA custody were placed in diapers for prolonged periods for transport.
The detainee would be made to wear a diaper and dressed in a tracksuit… The journey times obviously varied considerably and ranged from one hour to over twenty-four to thirty hours. The detainee was not allowed to go to the toilet and if necessary was obliged to urinate or defecate in the diaper.(8)
he ICRC report states that one of the detainees, Mr. Bin Attash, was compelled to wear a diaper for a prolonged period:
[H]e commented that on several occasions the diaper was not replaced so he had to urinate and defecate on himself while shackled in the prolonged stress standing position. Indeed, in addition to Mr. Bin Attash, three other detainees specified that they had to defecate and urinate on themselves and remain standing in their own body fluids.(9)
Medical Analysis: Prolonged diapering especially when combined with leaving the subject in a diaper soiled with urine and feces can result in both physical and psychological harm. Prolonged exposure of the skin can result in skin infection, skin breakdown and ulceration and urinary tract infections. In addition, the placement of a normally continent adult in a diaper will likely lead to efforts by the adult to resist urination or defecation, which in turn will likely result in bowel cramping and bladder spasm.
Access to toilet is a universally recognized minimum standard for prisoners and detainees. In spite of the physical risks, the chief aim of this technique is to cause psychological stress through humiliation, induced dependency, loss of autonomy, and regression to an infantile state.(10) Like all such techniques, especially when combined with others of the ‘DDD’ type (debility-dependency-dread), these are cumulative and lead to short and long-term debilitation. At Guantánamo, the standard operating procedures included requiring the detainee to ask the interrogator for toilet paper, food, and religious articles. Here, the torturers go even further, returning the detainee to pre-toilet-training levels. When combined with a liquid diet, the experiences of regression, humiliation, and dependency are magnified.
Six of the fourteen high-value detainees interviewed by the ICRC reported being placed in a neck collar or roll and then slammed against a wall. According to the CIA guidelines, slamming against a wall could be used twenty or thirty times consecutively.
During the walling technique, the detainee is pulled forward and then quickly and firmly pushed into a flexible false wall so that his shoulder blades hit the wall. His head and neck are supported with a rolled towel to prevent whiplash. (11)
Although the guidelines require that the wall be a specially constructed flexible one, some detainees alleged that they were also slammed against concrete wall using the collar during transport.(12)
Mr. Bin Attash alleged that during interrogation in Afghanistan:
“on a daily basis during the first two weeks a collar was looped around my neck and then used to slam me against the walls of the interrogation room.” (13)
Medical Analysis: Walling results in blunt trauma and acceleration/deceleration type injuries. Blunt trauma can result in bruises and bleeding from ruptured blood vessels. Studies have observed persistence of musculoskeletal pain cause by blunt trauma even a decade after the trauma has occurred. In rare cases, repeated beating can cause damage to muscle tissue and muscle breakdown resulting in release of muscle enzymes resulting in a life-threatening condition called rhabdomyolisis. In addition, walling can expose the subject to risk of whiplash type injury to the neck and spine. (14)
Psychological stress, which is the primary aim of the procedure, is achieved by use of surprise, generating a startle response, an experience of shock, loss of control and helplessness. Also, rage is engendered which turns to further humiliation, insofar as the detainee cannot fight back.