Health Professionals In The Fight Against Torture

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By Dr. Laifungbam Debabrata Roy
As the world commemorates the International Day in Support of Victims of Torture again this year on 26th June 2011, it is time to remind ourselves solemnly of our responsibility as workers within an ethically grounded profession.  Torture is a crime against humanity and its practice dehumanizes both the victim and the perpetrator. Medical and health professionals who practice the humane arts of healing and health promotion have a serious responsibility to speak out and act ethically against this contemptible public health menace of torture.

The government of Manipur, like in other States of India, tacitly approves and supports the practice of torture and other cruel, inhumane or degrading treatment or punishment through its law enforcement agencies. This year, so far, we saw at least four widely reported cases of severe custodial torture by the Manipur Police and security forces. In February, Mr. Athokpam Angousana from Kumbi Napat Mayai Leikai was so severely tortured by Manipur Police Commandos during his illegal detention that he died as soon as he reached the RIMS Casualty. Soon after, in March, Mohammed Nawaz Sharif alias Sirajur Rehman from Lilong Haoreibi Sambrukhong was arrested by 28th Bn. Assam Rifles and tortured. He was brought to RIMS Casualty where he died soon after. The next month, in April, Mr. Salam Sanjoy Singh of Sagolband Moirang Hanuba Leirak was picked up by 12th Maratha Light Infantry attached to Patsoi PS and he died in the camp the same evening. In May, Mr. Thokchom Ranjit Singh of Lamlai Nungoi Village was arrested by
Manipur Police Commandos and tortured. He was brought to JNIMS Hospital, where he succumbed and the police left his dead body at the RIMS morgue. This is the tip of the iceberg.

The Indian government, through its highest executive office of the Prime Minister had promised the nation and the international community three years ago that the India would ratify the United Nations` Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which the government signed fourteen years ago in 1997. India has not realised this promise since then on the issue other than the introduction of a Bill in the parliament, the Prevention of Torture Bill 2010. The Lok Sabha passed the Bill on 6 May 2010. The Rajya Sabha, after considering the Bill constituted a Parliamentary Select Committee to review the Bill. The Committee after its review of the Bill suggested wide-ranging changes to the proposed law. The Bill is now back with the government and nothing much is heard about it since then. In the meanwhile, June 26 will be once again observed as the international day in support of the victims of torture.

The UN Convention has important aspects that are extremely relevant to medical and health professionals. Article 10 of the treaty obliges the State party to train medical professionals regarding the education and information on the total prohibition of torture. Article 14 of the Convention obliges the State party to “ensure in its legal system that the victim of an act of torture obtains redress and has an enforceable right to fair and adequate compensation, including the means for as full rehabilitation as possible.”

Medical and health professionals, especially working closely with lawyers, human rights institutions and law enforcement officers, have a vital role to play in gathering information about torture, in documenting torture for legal purposes, in supporting and rehabilitating survivors, in preventing torture (including via providing training about helping torture survivors and documenting the evidence of torture), and in prosecuting perpetrators. Obtaining useful testimony from survivors of torture and other ill-treatment is a complex challenge: many survivors are reluctant or unable to talk about their trauma, and may even be re-traumatised by giving testimony, especially in court under cross-examination. Medical professionals have a crucial role to play in supporting survivors through this process and also in explaining the impact of trauma on victims’ ability to provide coherent, consistent testimony. The article also explores the challenges of conducting effective, sensitive forensic examinations to gather evidence of torture. Finally, the impact of the Istanbul Protocol is discussed in relation to the importance of its standards in gathering and assessing evidence of torture.

Before 1970, little was known about the effects of physical and psychological torture. Following global outcry over the notorious torture practices of General Pinochet’s military junta in Chile, interest increased in how medical expertise and research could assist in documenting torture, supporting victims and helping doctors in countries receiving Chilean refugees to set up rehabilitation initiatives for torture survivors. At the same time, Amnesty International launched an international campaign on prevention of torture and called for medical doctors to support the fight against torture by documenting mental and physical signs of torture and by developing treatment methodologies. Following this call, Amnesty medical groups were formed and the network of rehabilitation initiatives for torture victims around the world expanded. In the past three decades, the network of health professionals working in the fight against torture has grown into a global movement: hundreds of rehabilitation centres – from Albania to Zimbabwe, from Chile to Cambodia – now assist over 100,000 torture victims worldwide.

While the main obligation and concern of health professionals is the care of their patients, the knowledge gathered through direct access to victims, and specific medical expertise in identifying physical and mental signs of torture, generates crucial insights into the problems accompanying torture. Providing general and medical documentation of the details of the torture and the specific context in which it occurred is vital in designing effective strategies for preventing torture. This is essential because lack of information and relevant, accurate and reliable evidence is one of the major reasons that torture continues and impunity prevails. In a climate of impunity, crimes of torture can be safely committed without perpetrators risking arrest, prosecution or punishment. When torturers are not held responsible, torture will become a widespread, systematic crime.

Rehabilitation of survivors can be positively reinforced by torture prevention efforts. Often survivors seek both treatment and social interventions. In order to heal, they need recognition of the wrong-doing, for the perpetrators to be held accountable, and guarantees of non-repetition. Torture victims are often marginalised. Giving public testimony and receiving recognition from the authorities, and also society, of the violations committed against them can have a healing effect. Impunity has a detrimental effect on the healing process of torture survivors. If atrocities are not acknowledged, and if justice is not served (i.e. if perpetrators go free and there is no guarantee of non-repetition), then the trauma is more likely to persist.

In turn, torture survivors and health professionals can play a crucial role in fighting impunity and preventing torture. Rehabilitation includes keeping records for each patient; testimonies given by torture survivors are an invaluable source of knowledge about types of torture, those who perpetrate it, the contexts in which it occurs and other relevant details. Testimonies can indicate where and when the risk of torture is greatest: for example, at the very outset of deprivation of liberty by law enforcement officials. This, in turn, can direct preventive efforts, including via training for personnel who handle detainees at the very beginning of their detention.

Increasingly, medical organisations have echoed the obligation of health professionals to denounce and document torture, recognising that torture does not only cause severe physical and mental injuries, but is a crime absolutely prohibited under international law. Providing treatment and rehabilitation services to survivors, at the same time as gathering data and collecting stories to denounce torture, can involve a delicate balancing act as doctors must combine their therapeutic role with an investigative one while never losing sight of their principal responsibility: promoting the well-being of the patient.

A key element in the rehabilitation of torture survivors involves building a trusting therapeutic relationship that enables survivors to express their experience of torture either verbally, usually via telling their story, or nonverbally, perhaps using drawing or drama. This enables rehabilitation professionals to target interventions effectively in order to address survivors’ needs and to help them rebuild their lives. For some survivors of torture, this may be the first time they have been given a chance to tell of their experiences and this telling, or testimony, can have a positive therapeutic effect in itself. However, it is the health professionals’ responsibility to manage this process with sensitivity, to allow sufficient time for survivors to dictate the pace of their telling, and to use their understanding of the key issues of torture, and the survivors’ socio-cultural context, to inform their work as facilitators of such tellings. While sharing their story may be empowering for some survivors, it can also be a highly traumatizing experience. Wherever possible, there should be time to provide parallel, continuous and follow-up support after such therapeutic work. Torture survivors’ testimonies can greatly contribute to prevention efforts. Testimonies may be crucial in investigations and court cases relating to criminal, or disciplinary charges against perpetrators, and also to reparation claims.

However, for the vast majority of victims, going to court is, to say the least, an extremely unpleasant experience. Confronting the perpetrator, having to expose intimate details of humiliation or suffering to an audience, and being challenged during cross-examination can make the most determined person flinch. Facilities should be made available to survivors in the courtroom, such as a screen so that the survivor can be protected from the view of the perpetrator or, if possible, the opportunity to give testimony via video-link so that it is not necessary for the survivor to be in the courtroom with the defendant. It must be noted that testimony provided by traumatised persons may be incomplete or contradictory. However, inconsistency does not necessarily indicate that a statement is false. Individuals who give inconsistent testimony have not necessarily forgotten the event (or the details of it) but, as discussed above, may try to avoid speaking about certain aspects of their experience due to the overwhelming emotions that recalling the trauma raises.

Reliable statistical reports and official data on torture rarely exist. The conditions permitting collection of data, let alone scientifically designed research studies on the incidence of torture, are difficult to achieve in most situations where torture is a serious problem. Rehabilitation centres and health professionals are well-placed to gather information on all aspects of torture through direct contact with both survivors of torture and their relatives. Information gathering must, however, be accomplished with great care. Pressure is often placed on legal and health professionals to dismiss actions in torture-related cases: centres and professionals that operate in situations where torture is widespread and/or used systematically are familiar with the difficulties (and even dangers) that this brings. Survivors and their families are often reluctant to take action for fear of retribution and harassment. Exposing themselves by denouncing torture may lead them to face threats, intimidation or pressure to cease their activities. But despite the risks and constraints, documentation must be carried out; and only with solid information can effective prevention campaigns be designed and governments be monitored, and held accountable.

In addition to supporting victims and collecting general data, health professionals can provide medical forensic documentation, based on physical and psychological examinations that can be critical for prevention purposes. Standardised medico-legal reporting, in particular the use of the so-called Istanbul Protocol (the Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment), which was endorsed by the UN 10 years ago, has increasingly provided the basis for gathering solid evidence in torture cases.

It can be difficult to prove that a person has been tortured, as torture mostly takes place in secrecy or hidden from scrutiny. The torture may have taken place many years ago, and documentary or physical evidence may therefore have disappeared. Wounds may have healed or the particular method used may be one that leaves no visible marks. Many torture methods are designed specifically so as to inflict maximum pain while leaving minimum physical traces. It therefore takes specialised knowledge and skills, and knowledge of appropriate medical and legal procedures, to investigate and document cases of torture and to bring these to court. In addition to the fact that obstacles to obtaining legal redress for torture survivors are numerous, many cases do not lead to justice for torture survivors primarily because physical injuries have not been appropriately documented by doctors and/or used effectively by lawyers in legal proceedings.

The Istanbul Protocol is a unique guide that enables legal and medical professionals to methodically investigate, document and report cases of torture. The Protocol introduces common standards for the assessment of such cases, including methods to facilitate interviews with survivors, safeguards, diagnostic tests, and anatomical charts, as well as instructions for the interpretation and evaluation of findings, including information about how to correlate evidence to create a credible scientifically-based interpretation of testimony to support individual allegations of torture. Physical and psychological examinations form the core of the documentation process. Both are necessary to reveal the full picture of the injury caused by the alleged torture. Often specialist examinations and laboratory tests, as well as previous medical reports from hospitals or general practitioners, are required as supplementary documentation. The Istanbul Protocol provides guidelines for the medical evaluation itself, but there is no standardized practice for managing interaction and collaboration between clinicians. It is essential that the forensic examination of an alleged torture victim is conducted with sensitivity to avoid re-traumatizing the patient. It is also important to understand that the forensic documentation of an alleged case of torture must be approached in a multi-disciplinary context. One of the major advantages of the Istanbul Protocol is that it provides a framework for the collaboration between medical and legal professionals that recognises the different ethical allegiances of the two professions.

Effective medical documentation requires specialised expertise, skills and experience that, unfortunately, are not always available. Increasingly, efforts are being made to improve the capacity among relevant professions. Health professionals in care-settings that are accessed by victims of torture share a common goal with legal experts and human rights activists: to eradicate torture and its effects, to fight against impunity, and to promote the prevention of torture. Beyond applying different treatment methodologies to help torture survivors, and their families and communities, health professionals use their expertise to provide the support, information and documentation needed in the joint drive to prevent torture in three key ways:

(1) Rehabilitation support is essential to individual survivors, and their families, in rebuilding their lives, and also to the justice system and human rights advocates fighting against torture.

(2) Specialised support helps survivors to give testimony about the torture they were subjected to and helps to protect them from being traumatised anew. This is crucial for judges, prosecutors and lawyers, who depend on credible witnesses being able to provide as full an account as possible of the alleged torture; if this is not possible, it is difficult to obtain sufficient information to successfully prosecute. It is therefore in the interest of the court, the investigating authorities, and lawyers that torture survivors receive appropriate treatment before, during, and after giving testimony. Human rights advocates can also benefit from obtaining comprehensive, reliable testimony from torture survivors as this can be used to promote policy change to prevent torture.

(3) Equally useful is the data collected on an on-going basis by rehabilitation centres. Facts and figures gathered on the demographics of torture survivors, the frequency with which torture of inflicted, and the types of torture used in specific places and circumstances strengthen the knowledge base that is necessary to monitor states and hold them accountable with regard to their international obligations. The Istanbul Protocol, the most powerful tool available for effectively documenting torture, has become an accepted standard for medico-legal reporting and providing evidence in legal proceedings. These guidelines provide legal and health professionals with a framework for working together to investigate and document torture and, thus, to gather detailed and comprehensive evidence.
(Dr. Laifungbam Debabrata Roy is the Chairperson of the Steering Committee at Human to Humane Transcultural Centre for Torture and Trauma, Lamphelpat. He may be contacted at [email protected])

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