The role of the physician in ICRC visits to prisoners
01-12-1994 by Hernán Reyes
The ICRC visits prisoners all over the world. They include prisoners of war in camps and political detainees in prisons or police stations. In 1994, ICRC delegates visited more than 100,300 prisoners in over 50 countries.
The visits are carried out by teams of delegates which usually include at least one doctor. In some cases, physicians and nurses work together in the same teams or different ones according to the needs and circumstances. ICRC medical personnel receive special training on the institution's activities in places of detention.
The ICRC doctor/nurse has two distinct roles within the team of delegates carrying out such visits:
* He/she is responsible for assessing the state of health of the prisoners, as well as every aspect of life in detention that impinges on health (food, hygiene, medical care, etc.). This role is normally that of an expert adviser (in the sense that an " audit " of conditions is conducted, so as to inform the authorities). It is not normally the ICRC's role to provide treatment. In certain situations, however, the ICRC may have to take action in emergencies or provide basic medical care in cases of dire need.
* Where there has been ill-treatment or torture of prisoners, the doctor carries out a medical assessment of the prisoners concerned. Any medical data required to establish a file on the subject is taken down, so that the ICRC can call on the competent authorities to put an end to such practices. As a medical adviser from outside, the ICRC doctor also has a role to play among the victim s themselves, who usually feel they can trust him or her, whereas they often do not trust medical personnel belonging to the detaining authority. ICRC nurses do not usually work with victims of torture, but they may follow up such cases or, exceptionally, even stand in for the physician if one is not immediately available.
2. Assessment of prisoners' state of health
The assessment made by the ICRC doctor (or medical team) covers both the prisoners'state of health and the various systems set up within the place of detention to ensure their survival: food, hygiene, medical care, etc. The doctor /nurse must therefore assess all the various aspects of life in captivity. In order to obtain the information he/she needs, the doctor talks not only with the prisoners but also with the medical staff in the place of detention.
All prisoners complain about food in detention. It is " part of the game " , and in a way one of many safety valves used by prisoners to release tension. Real nutritional problems with adverse effects on the prisoners'health are a different matter.
If the supply of food is indeed unsatisfactory in quality or quantity, the ICRC doctor takes care to consult a representative selection of prisoners so as to arrive at an objective assessment of the situation. He/she must look for objective signs of malnutrition, such as loss of weight, symptoms of deficiencies (protein, mineral, etc.) and lack of vitamins (beriberi, pellagra, xerophthalmia, scurvy, etc.), any of which is an indication that the diet is not adequate. However, the absence of such signs does not necessarily mean that the rations supplied by the authorities are sufficient, since prisoner's relatives might be bringing in food that compensates for the inadequacy of the official rations.
As to the purely nutritional aspect of the issue, the ICRC doctor may, when necessary, make a detailed analysis of the food provided to prisoners in order to determine whether there are indeed deficiencies.
In no case, except in life-threatening situations, does the ICRC take the place of the authorities in providing the prisoners with food. It does, however, attempt to determine the cause of the shortcomings (insufficient funds, food being diverted for consumption elsewhere, incompetence, etc.) in order to propose a solution and thus help the authorities to meet their responsibilities.
Furthermore, the food provided by the detaining authority is one thing, whereas what actually appears on the individual prisoner's plate is quite another. Here the issue can be completely outside the medical province, and the system of food distribution and internal rationing, as well as possible bribery, " rackets " and internal spheres of influence, all have to be taken into account. The problem can be multifarious and should be approached with all these extra-nutritional factors in mind. It is here that cooperation and the exchange of information is essential between ICRC delegates and medical personnel, so as to find out the real reasons why the food supply is insufficient.
If sanitation [1 ] is unsatisfactory, with adverse effects on the health of those in detention, it is the ICRC doctor who assesses the situation, and decides what measures are necessary.
" Sanitation " , in ICRC jargon , is a very extensive subject, covering such matters as:
- water supply, which must be sufficient in terms of both quantity and quality as a vital necessity for health;
- elimination of sewage and solid wastes, to avoid the poss ibility of contamination, disease and epidemics;
- vectors (ectoparasites, rodents, insects, etc.), the presence of which can cause the spread of various diseases (malaria, bubonicplague, rickettsiosis, etc.);
- general living conditions in the places of detention, the quarters themselves, rate of occupancy, ventilation, cleanliness, etc.
The system for providing health care within the place of detention is also studied by the ICRC medical team, with special attention to its actual functioning. This means that the doctor must inspect the premises (infirmary/sick bay, consulting room, etc.) and talk with the local medical staff (doctors, nurses, orderlies, etc.), whose opinions and, at times, grievances are very useful for understanding how the system works and why it may break down. Relevant factors may be very low pay of medical staff, resulting in absenteeism, insufficient funds made available for medicines, system sabotaged by the prisoners, lack of transportation for taking patients to hospital, feeling of insecurity among health care staff, and many others.
The ICRC doctor also listens to the prisoners'version of the way the medical facilities function. He/she may listen to some of them in private, away from the influence of the authorities, naturally, but also away from the influence of their own group, which, among political prisoners especially, may sometimes impair the objectivity of the information given to the ICRC delegates.
The ICRC doctor always makes a point of examining a representative sample of prisoners to obtain an objective idea both of their state of health and of the quality of the medical treatment provided by the detaining authorities. This sample will include any serious cases that come to light, whether raised by the prisoners themselves, or by the authorities, or from direct observation.
When working as a team, the doctor and nu rses decide together how best to go about assessing the situation. It is essential that each member of the team knows what to do. The doctor exercises overall control and has the final word on medical decisions, but he/she must know what the rest of the medical team is doing. Instructions on what is to be assessed in each place, and what is actually done, should be clear to all concerned. Medical personnel should also be in constant communication amongst themselves so that the global picture is kept up to date, and the medical coordinator knows who is doing what at all times. Nurses, if working alone, must assess the system and report to the medical coordinator, who may then decide whether further information is required in order to take action or request the authorities to do so.
In " normal " detention situations, the ICRC takes care not to act as a substitute for the existing medical system but endeavours to make it function as it should. Any " consultations " given at a prison normally only serve the purpose of assessing how the normal system functions. [2 ]
The means used to achieve this aim will, of course, vary according tocircumstances. Persuasion through dialogue with the local doctors [3 ] may be all that is needed to settle problems in some situations. In other cases, the ICRC may give aid in the form of medical supplies to a prison doctor who has nothing available, but who would otherwise be willing and able to provide medical care.
In assessing the various systems and the prisoners'general state of health, the purpose of the ICRC medical team is to obtain an objective view of any shortcomings and to identify the reasons for them. The ICRC as an institution is then able to put forward specific and practical proposals for improvements to be made by the detaining authorities.
It does so through " active diplomacy " by the delegation and by providing the higher authorities with an official written report on the ICRC's findings. A problem that has been described in a report submitted by the ICRC can no longer be ignored by the authorities, and the objective in submitting the report is that the ICRC's proposals should start a process of improvement. The prospect of another visit by ICRC delegates in the near future is a major factor in accelerating this process.
3. Role of the ICRC doctor in the event of ill-treatment [4 ]
If the prisoners tell the delegates that they have been ill-treated, the ICRC does its best to ascertain the facts and draw up a complete file, in order to notify the relevant authorities and insist that they put an end to such practices. In these circumstances the ICRC doctor examines the prisoners and gives a professional opinion on their state of health. Again, it is the global and not necessarily the individual assessment that is important here. Any possible relationship between lesions found and the allegations made is one element, but only one, of the overall assessment.
When feasible, the doctor examines each case individually and also attempts to perceive the ill-treatment as a collective phenomenon that must be understood and discussed with the authorities in its entirety. It is important to distinguish between the two approaches, individual and general, and to pursue them in a different way.
The ICRC doctor must also inform, reassure and advise the victims of ill-treatment, as a " neutral physician " and sometimes the only doctor whom the victims can trust. Very often he/she is able to relieve their minds simply by explaining the after-effects of torture and the possibilities of therapy available once the prisoners have been released. In many cases the mere fact of being examined by such a neutral physician and told that something is " not broken " is reassuring. In other cases, hints on how to do certain physical exercises, for example, not only constitute sound clinical advice but may also be an important factor for restoring the prisoner's self-esteem and helping them regain a sense of control over events. This can have a very positive effect on morale when imprisonment is a long-term perspective.
In contexts where torture and its sequelae are the main issue, an ICRC physician may work with a nurse or team of nurses under his/her direct supervision, particularly for follow-up and special medical care. Clinical examination, however, is always carried out by a physician.
Although the ICRC does not have its own definition of torture, its doctors refer to definitions that are universally accepted, such as:
* the definition adopted by the World Medical Association (WMA) in the WMA Tokyo Declaration of 1975; and
* the definition contained in the 1984 UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.
None of the existing definitions of torture gives precise details of the " grey area " represented by cruel, inhuman or degrading treatment. This raises questions particularly in regard to conditions of detention. What degree of overcrowding constitutes degrading treatment? What is to be said of latrines shared by hundreds of prisoners in poor conditions of hygiene? Are intimate body-searches of detainees degrading? What about force-feeding of prisoners on a hunger strike? Here ICRC doctors are able to refer to certain texts;
* the UN Standard Minimum Rules for the Treatment of Prisoners (1955 & 1984);
* the UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment (1988).
For the ICRC, the Minimum Rules serve as guidelines, but not as absolute criteria. Depending on the circumstances and the possibilities of the detaining authorities, the ICRC may demand more than the strict minimum laid down in any body of rules.
4. Interviews with prisoners
The interview in private between the ICRC doctor or delegate and the prisoner is the most important stage in this type of visit. During the interview the doctor will naturally avoid anything that might seem like another " interrogation " . Here, tact at the outset and a sympathetic hearing are the essential requirements. Interviews cover a vast range of subjects, most of which (identity, location of next of kin, circumstances leading to detention, general conditions in the camp or gaol, etc.) are covered by the non-medical delegates. The medical team's interviews cover medical matters, as stated above, and the subject of torture, which obviously has medical components.
In questioning the prisoner about any ill-treatment to which he or she has been subjected, the ICRC doctor must bear in mind that this is invading a very personal sphere. This intrusion into a recent experience that the prisoner has tried - usually in vain - to forget may be traumatic. Some prisoners take the opportunity to " tell all " , since they need to talk about their experiences. The fact that they can talk to someone other than their fellow detainees may be beneficial in itself. Other victims are unable or unwilling to talk about their ill-treatment. In some cultures, where important matters are never addressed directly during a first meeting, prisoners will obviously be most reluctant to speak about su ch an intimate subject. The western " guilt culture " and the oriental " shame culture " will obviously manifest themselves in different ways, following torture, in interviews with victims from different countries.
Non-medical delegates who talk with these prisoners must take the utmost care not to invade their privacy. It is better not to pursue an interview on this subject than to cause distress. Here the other delegates can turn to the doctor in the team, who is by training and by experience more accustomed to this difficult type of interview. It is obvious that many prisoners of all cultures will be more at ease talking about torture, and particularly about its sequelae, real or perceived, with a doctor than with a " lay " delegate. Non-physicians should not be disconcerted by this, as they themselves would probably react in the same way. Nurses who have not been specifically trained to deal with torture victims should also refer such cases to the ICRC physician, or work in close cooperation with him/her.
After listening to the story of ill-treatment, the ICRC doctor examines the prisoner. The examination takes place in private, ideally without an interpreter (provided that the ICRC doctor is fortunate enough to speak the language of the prisoner's country). If an interpreter is needed, the best way is for the ICRC to have a good one who not only knows the language but is also familiar with cultural and religious aspects of the country. If such a person is not available, the prisoner him/herself can choose one from among fellow detainees. An interpreter should, however, never be imposed on a prisoner, particularly for such a personal subject as torture. Fellow detainees may speak the language, but one never knows what other factors, influences or enmities may be involved.
The physical examination has three main aspects:
* First of all, it is part of the normal rel ationship between a doctor and a patient. The prisoner moreover expects it, particularly if he/she has not been seen by the medical officer in the place of detention, either for lack of time or because of negligence.
* Secondly, the ICRC doctor must see for him/herself exactly what physical consequences, if any, the torture has had. He/she must gain a clear idea of the various methods used, and of any physical sequelae. This is not to minimize, obviously, the psychological sequelae, which are however more difficult to determine and deal with in a detention situation.
* Finally, examination of the victim is essential for the ICRC doctor to provide the prisoner with the only immediate service possible: a tentative diagnosis of his/her condition and an estimate of future recovery prospects. Often the doctor is able to add some practical advice (for example, prescribe physiotherapy that the prisoner can perform him/herself or on fellow inmates, and answer any questions asked by the prisoners as to future disabilities, physical or otherwise).
Nurses involved in this type of work, or visiting prisoners on their own with non-medical delegates, must try as far as possible to follow the above-mentioned guidelines. It becomes their responsibility to refer to the medical coordinator all medical cases they feel need assessment by a physician. When visiting prisoners who have been victims of torture, nurses should carry out a medical assessment only insofar as they feel capable of doing so. They should refer all difficult cases to the medical coordinator or ICRC doctor.
In the medical field, as elsewhere, the ICRC does not attempt to take the place of the detaining authority. The ICRC normally provides no medical treatment and the ICRC doctor cannot replace the medical officer in the place of detention. The task of the ICRC medical team is to carry out an overall evaluation of the situation, with special attention to diet and sanitation. The doctor (or nurse) must assess conditions in order to discover the reasons for any shortcomings. The purpose is to cooperate with the local authorities in finding specific and practical solutions for any problems observed. With respect to ill-treatment, the doctor must not only carry out a general survey of the phenomenon but must bring whatever solace he can to the victims he/she meets. This is done through personal contact, however brief, the " doctor-patient " relationship being a special occasion during which the doctor is able to provide information and advice and often to reassure the victim. If a doctor is not available, the nurse may fill this role in so far as he/she feels capable, and should refer complicated decisions and medical cases, particularly where torture victims are concerned, to the ICRC doctor. The medical team will as far as possible, determine in advance how to share responsibilities, and how a comprehensive assessment is to be achieved by means of teamwork.
1. Term that includes all matters connected with water supplies, sanitary engineering (drainage, sewerage, etc.) and hygiene.
2. Exceptionally, the medical consultation can also serve the purpose of compiling lists of critically ill or wounded patients. These lists are then submitted to the detaining authorities with a firm request for the patient's release, repatriation or transfer to medical facilities as the case may be.
3. In many countries, this type of dialogue can only take place physician-to-physician. In other contexts, the nurse may also be able to deal w ith medical interlocutors. This has to be determined beforehand among the members of the medical team.
4. The term " ill-treatment " is the one currently used in official ICRC documents. It refers in fact to cases of torture and of cruel, inhuman or degrading treatment, as defined or cited in various international conventions again torture. The use of the term is not due to prudery or timidity: it enables the ICRC to report on these matters without running the risk of automatic rejection by the authorities (as would happen, for example, if the word " torture " were used). The subsequent description of the facts leaves no doubt as to what is meant (see below).
Hernán Reyes MD
ICRC Medical Division