Jacobo Timerman

In many parts of the world, torture is a fact of life. Every day, thousands of people are subjected to various forms of violence and are often forced to flee their homelands. There are now more than 18 million refugees in the world and hundreds of thousands of persons seeking refugee status. As health professionals, all physicians must be concerned with the protection of human rights, as defined by basic humanitarian laws. Violation of these laws often results in acute and chronic health sequelae in survivors of torture (Table 1). Violation of medical neutrality; attacks on hospitals and physicians; interference with the medical care of civilians; and the use of poison gas, land mines, torture, mass executions, systematic rape, or forced relocations are all forms of violence that affect the physical and psychological well-being of persons [2]. The scope of human rights violations is daunting and a challenge to human rights organizations, which need to adopt a broad vision in their work.

This paper focuses specifically on the issue of international torture and discusses the role of the physician vis-a-vis the victims of this specific type of abuse, even though the forms of abuse that affect health are as varied as they are pervasive. At many levels, opportunities exist for physicians to make a difference as clinicians and as advocates for the health of the public. Physicians can provide leadership, along with technical and analytic skills, to respond to the use of torture. In addition, international and local medical organizations can complement and expand the efforts of individual physicians by providing them with the infrastructure necessary to support these activities. As part of its commitment to the preservation of human rights, the American College of Physicians presents an overview of the possible ways to engage the medical community in the prevention and treatment of international torture.

Case 1

Mr. Hernandez is a 27-year-old man from the Philippines who is seeking asylum in the United States. He described to his physician the 11 months of his imprisonment. He repeated three times that he was continually tortured, during interrogations, with the "parrot perch" and the "trapeze" techniques. The "parrot perch" involved having his wrists bound to his ankles with his hips and knees in flexion; he was suspended by a pole placed behind his knees and in front of his bound arms. The pole was then raised, bringing him into a head-down position with the soles of his feet exposed to the torturers' blows. Two men working in synchrony used a piece of dried fascia from an ox to whip the soles of his feet. He was instructed to signify his willingness to confess by extending a forefinger. However, on multiple occasions when he extended the finger, he was accused of "playing games" and the finger itself was struck with the whip. The "trapeze" technique involved binding his wrists to his feet with his back in hyperextension. He was then suspended by the hands and feet while additional pressure was placed on his body by the interrogator, who pushed down on his back with his foot [3].

The Role of the Individual Physician

Physicians have skills that enable them to make a unique contribution to issues of human rights [2]. Through their clinical expertise (medical, surgical, psychiatric, and forensic), physicians can directly help victims of abuse. Knowledge and application of epidemiologic principles can be used to document the incidence of various acute and chronic health effects of torture and to give credibility to statistics about the prevalence of this type of human rights violation. As members of a respected profession with well-grounded traditions and ethics, physicians can serve as strong advocates for the prevention of torture.

Caring for Victims of Torture

Some clinicians will diagnose and treat victims of torture. Physicians are often the first to interview detainees who have been ill-treated or tortured. Given the constant migration of persons that characterizes our modern world, this role will become increasingly common, especially in some areas of the United States. For example, Randall and Lutz [4] suggest that 5% to 10% of foreign-born persons presenting in large, urban health maintenance organizations have been tortured in foreign countries. Physicians should be able to recognize the health consequences of torture, so that they can identify patients with signs and symptoms related to such abuses (Tables 1 and 2). It is also important that they provide patients with, or refer them to, the most appropriate care and resources available. Special medical curricula, books, and articles are available to assist the medical community in the management of victims of torture [1, 4-8].

Providing Expert Testimony

Persons who have been tortured or who fear that such abuses might occur if they remained in or returned to their home country may seek political asylum in the United States. The procedural aspects of requests for asylum are complex and are governed by international and domestic law. Several steps may be involved, from filing a written application to appearing before an immigration judge. Asylum is granted when the applicant presents convincing evidence of a "well-founded fear" of persecution, that is, fear that a reasonable person would have in the same circumstances.

Physicians can provide expert opinion on behalf of patients seeking asylum. The expertise, the objectivity, and the credibility of the medical profession are essential to persons who seek political refuge. The skills required for this activity—history taking and physical examination—are ones that physicians apply in daily practice. Health professionals can validate, using a thorough and careful clinical examination, the applicant's claim of physical or psychological torture. Physicians' testimony will be assessed by the immigration judge using criteria such as the qualifications of the physician (including professional experience, publications, memberships in professional organizations, and relevant expertise in the diagnosis and treatment of victims of torture) and the relevance and the reliability of the evidence brought forth in the testimony. Thus, strong medical testimony is based on the aspects of the clinical history and physical examination most specific to torture. Guidelines exist that can assist physicians in taking a history, doing a physical examination, and presenting evidence of torture-related psychological trauma; they can be obtained from Physicians for Human Rights and from Amnesty International [3, 4, 9-11].

Organizations such as Physicians for Human Rights have established networks of physicians who are willing to serve as expert witnesses and provide medical affidavits on behalf of persons seeking asylum. These networks of physicians are linked to lawyers, who become a primary source of referral for refugees. These networks have been extremely successful in providing patients with timely and appropriate medical testimony to support their case (Table 3). Helping persons seek and obtain asylum can provide physicians with concrete positive feedback and the confidence that their involvement is useful. It can encourage them to pursue work in human rights, work that is often emotionally difficult because issues of torture affect the core of our lives and extend well beyond purely professional boundaries.

Case 2

In 1990, Wang Juntao (one of the cofounders of the Beijing Economic and Social Sciences Research Institute) was tried without charge and sentenced to 13 years of imprisonment [12]. While in prison, Wang had hepatitis B virus infection, lived in a tiny cell (with the stench of an open latrine), and slept on a vermin-infested mattress. Within a few months, he was unable to stand up or breathe deeply. In March 1991, he requested and was denied medical care. When knowledge of this became public, international pressures increased on his behalf. Representatives from the United Kingdom spoke directly to China's then Prime Minister, Li Peng, and the U.S. Senate unanimously voted for a resolution calling for the intervention of President Bush. The American College of Physicians (representing the medical profession) joined these humanitarian efforts and conveyed its concerns about the mistreatment of Wang. This joint endeavor led to the transfer of Wang out of solitary confinement to a prison hospital where he received the care that he needed.

The Role of Medical Organizations

The key to an effective response to torture lies in concerted action on the part of the medical profession [13-15]. Physicians, regardless of their specialty and the way in which they express their medical skills on a daily basis, can respond to torture through their affiliation with the medical profession. Medical associations can expand and magnify the effectiveness of an individual physician's work. In addition, the strength of the medical profession is that it has no national boundaries. All physicians are colleagues and can assist each other wherever they live and work. The human rights activities of physicians in the United States will directly affect the professional lives of their foreign colleagues, who are often faced with disturbing ethical dilemmas. For example, physicians who live in rural communities in developing countries may become the spokespersons for the community and be arrested, imprisoned, or assassinated. Through epidemiologic surveys or other forms of research, physicians may uncover forms of corruption or activities such as extrajudicial executions. As a result, their lives may be endangered. They may also confront troubling ethical decisions as they are called to witness torture. They need and welcome the collegial support of their profession.

Adoption of Relevant Ethical Principles

Well-recognized medical and international ethical principles guide and support endeavors of the medical community (Tables 4 and 5) [13-18]. Medical organizations should incorporate these principles in their own codes of ethics and make their members aware of these statements (Nelson M. Torture and the implementation of codes of medical ethics as a means of prevention [Presentation]. American Association for the Advancement of Science: Torture, Medical Practice, and Medical Ethics: A Symposium; 1982). In addition, medical societies should educate their members about the content and the significance of these codes, disseminate them, support and protect members who abide by these principles, and deal appropriately with physicians who violate them.

To this end, an international meeting on Doctors, Ethics, and Torture [5], held in Copenhagen in 1986, urged "all national medical associations which have not yet done so to ratify, publicize, and implement the Declaration of Tokyo as the definitive statement of the position of the medical profession with regard to this topic, and all scientific and professional medical bodies on the local, regional, national, and international level to incorporate the principles of the Declaration of Tokyo into their statutes."

The American College of Physicians has adopted the Declaration, and its principles are reflected in various policies. The College's Ethics Manual [18] states that where torture is concerned "under no circumstances is it ethical for a physician to be used as an instrument of government for the purpose of weakening the physical or mental resistance of another human being." The Manual also states that "participation in, or tolerance of, punishment of a prisoner by a physician beyond the punishments allowed by the United Nations Standards Minimum Rules for the Treatment of Prisoners is unethical."

Coordination of Letter-Writing Networks

Medical organizations can also develop and maintain letter-writing networks. Such efforts can raise the issue of human rights to governmental levels and put pressure on the appropriate authorities to respond to charges of torture. Several networks exist: For example, the Amnesty International Health Professional Network and the Amnesty International Urgent Action Network always welcome physicians who wish to join. The American College of Physicians also formed such a network in 1983 to provide guidance to physicians on ways to express their views (for example, whom to write and what to include in letters). These networks also suggest other ways physicians and medical organizations can intervene to ensure the release of unjustly imprisoned persons and to reinforce adherence to the principles of human rights by all countries.

The effect of letter-writing networks is difficult to establish, but there is evidence that suggests their effectiveness. According to the National Academy of Sciences, letters and other communications have been instrumental in the release or in the improvement of living conditions of prisoners of several countries, including Cuba, Israel, and Malaysia. The American College of Physicians along with the American Association for the Advancement of Science and Amnesty International wrote letters on the behalf of Dr. Fatemeh Izadi, a general practitioner in Iran, who was sentenced to 20 years of imprisonment for political activities. In December 1991, these organizations were informed of the release of this physician. In 1985, the network of the American College of Physicians was also involved in writing on the behalf of Dr. J. Delpe, a Haitian physician, who had been detained without charge for a period of 6 months. This physician was released that same year.

Continuing Medical Education

Physicians may need continuing medical education to work effectively in this area. Unfortunately, few continuing education courses exist on issues of human rights and the subject of torture [15, 19]. Medical organizations can contribute to the development of comprehensive curricula that cover a broad array of topics, from clinical guidelines on the care of victims of torture to guidelines about physicians' advocacy work. For example, in 1992, a 2-day course (sponsored by the Department of Social Medicine at Harvard Medical School and by Physicians for Human Rights) examined how medical, psychological, epidemiologic, and public health skills can be applied to interventions directed at human rights abuses that occur worldwide. Speakers from Physicians for Human Rights, the American College of Physicians, and the International Committee of the Red Cross and leaders in the fields of human rights, forensic medicine, psychiatry, pediatrics, internal medicine, epidemiology, and public health shared their knowledge and wisdom to guide health professionals in developing or using their existing skills as they apply to human rights. This kind of course provides an exceptional opportunity for physicians to gain the knowledge and skills necessary to do human rights work, at both the clinical and advocacy levels.

Medical Fact-finding Missions

Each year several missions are organized in various countries to investigate alleged human rights violations. Teams of legal, political, forensic, and other experts and of physicians, anthropologists, and sociologists have been assembled under the aegis of nongovernmental, intergovernmental, and governmental organizations. Medical associations participate by lending medical expertise to such missions. The success of fact-finding missions can be measured in concrete and symbolic terms. Fact-finding missions are critical because they allow the international community to clearly communicate its concerns about human rights violations. Missions can exert pressure on governments by making them aware that such acts as torture are being closely monitored and denounced by the international scientific and medical community.

The goals of each mission may differ: One mission may be organized to secure the release of a physician who has been imprisoned and tortured; another may be organized to investigate alleged torture and its medical consequences on the population of that country. Carefully defined methods should be adhered to by members of any fact-finding mission to strengthen the reliability and the validity of the observations and of the information collected [4, 9, 20]. For example, the Minnesota Lawyers International Human Rights Committee has collaborated with forensic scientists to develop standards for doing autopsies to determine whether deaths occurred as a result of extrajudicial executions.

Fact-finding missions involve data collection to support or discredit allegations of abuses or torture. This may involve structured interviews with victims (as well as their families and friends) or with other witnesses and physical examination of victims, whether they are alive or dead. It may also involve visits to detention centers to gather evidence about hygienic conditions, medical neglect of prisoners, and participation of physicians in abuse. On their return, mission members prepare reports that are disseminated in a timely fashion to the appropriate audiences (the medical community, the public, or governmental authorities). For example, reports of individual missions have been published as monographs that are available from various organizations, such as Physicians for Human Rights, Amnesty International, and others. Unfortunately, these may not always be easily accessible to health professionals because only a few of these articles are published in medical journals [2, 4, 15]. Other mechanisms for dissemination, better use of media networks, special conferences held at professional meetings or in the communities, and continuing medical education courses should be more systematically used and evaluated.

In 1990, the American College of Physicians, the American Academy for the Advancement of Sciences, the Institute of Medicine, the American Public Health Association, and Physicians for Human Rights did a fact-finding mission in the Sudan. The delegation met with government officials and members of the medical community to discuss abuses of human rights. They also visited Sudanese physicians and other health care professionals held in detention. The objectives were several: to describe human rights abuses in the Sudan, to alert the country's officials to the international community's concerns, and to exert pressures on the government to restore human rights in the Sudan. Two physicians who had been imprisoned, sentenced to death, and tortured because of their political opposition to the regime of General al-Bashir were released hours before the team reached the capital city of the Sudan. An account of the prison conditions, the dismal living conditions of the Sudanese, and a description of the tenuous state of the population's health (a situation exacerbated by the lack of access to medical care) was published in a peer-reviewed journal that reaches thousands of readers [21].

These are just a few of the ways in which medical organizations can structure their human rights work. Medical organizations involved in human rights activities should meet regularly to plan and coordinate their efforts. For example, some organizations may be best suited to respond to urgent actions or specific case work, whereas others may see their role in education and policy development. Such coalitions will be needed for effective action given the broad scope of human rights activities.

Conclusion

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In addition to its historical and symbolic value, the involvement of the medical profession in human rights has achieved progress in the prevention of torture and in the treatment of its survivors. Human rights activities may involve a level of personal challenge and intense time commitment, such as testifying in asylum cases or joining a fact-finding mission. For physicians caring for patients who have been tortured, human rights activities will encompass the daily world of clinical practice. But, most importantly, as members of the larger medical community and through the involvement of their professional organizations, physicians can become active voices promoting human rights principles and denouncing their violations.

In the past 20 years, human rights issues have become a more prominent concern of the medical profession. Until 1975, international standards describing the role of the profession in response to torture did not exist. Health care for victims of torture was rare (and is still inadequate at present), and the special needs of such victims were rarely recognized and poorly understood. In addition, medical societies rarely made statements on the ethical implications of torture. There are now numerous declarations on the ethics of human rights abuses from national and international professional organizations and from the United Nations. Medical groups from organizations such as Amnesty International and from other medical associations are actively working in more than 30 countries on human rights issues [22]. An increasing number of medical journals are publishing articles that deal with human rights. For example, the Journal of the American Medical Association has for some years devoted an annual issue to human rights; the "Hiroshima Issue" is published every August. The American College of Physicians acknowledges and welcomes these activities and will continue to advocate for the rights of persons and communities to live in dignity and peace, free of the fear of unjust imprisonment or torture.