| the following is an article meant for physicians from Medscape. Please do not contact the individual authors. thanks. ( '? Deaths of Detainees in the Custody of US Forces in Iraq and Afghanistan From 2002 to 2005 Scott A. Allen, MD; Josiah D. Rich, MD, MPH; Robert C. Bux, MD; Bassina Farbenblum; Matthew Berns; Leonard Rubenstein Medscape General Medicine. 2006;8(4):46. ©2006 Medscape Posted 12/05/2006 AbstractIn light of the large number of detainees who continue to be taken and held in US custody in settings with limited judicial or public oversight, deaths of detainees warrant scrutiny. We have undertaken the task of reviewing all known detainee deaths between 2002 and early 2005 based on reports available in the public domain. Using documents obtained from the Department of Defense through a Freedom of Information Act request, combined with a review of anecdotal published press accounts, 112 cases of death of detainees in United States custody (105 in Iraq, 7 in Afghanistan) during the period from 2002 to early 2005 were identified. Homicide accounted for the largest number of deaths (43) followed by enemy mortar attacks against the detention facility (36). Deaths attributed to natural causes numbered 20. Nine were listed as unknown cause of death, and 4 were reported as accidental or natural. A clustering of 8 deaths ascribed to natural causes in Iraq in August 2003 raises questions about the adequacy and availability of medical care, as well as other conditions of confinement that may have had an impact on the mortality rate. Readers are encouraged to respond to George Lundberg, MD, Editor of MedGenMed, for the editor's eye only or for possible publication via email:IntroductionUnder international law and US Army regulations, enemy prisoners of war are entitled to be treated humanely, provided with respect as people, and furnished with sufficient food, a hygienic environment, and necessary medical care as required by the state of their health.[1,2] The Geneva Conventions entitle them to be free of "any form of coercion" in attempts to secure information from them and protect them from torture and any form of cruel, inhuman, or degrading treatment.[3] The issue of torture and abuse of detainees in the custody of US forces, particularly at the Abu Ghraib prison in Iraq, has received a great deal of scrutiny in the press. However, to date, there has been no public accounting by the US government of deaths of detainees in US custody. Deaths involving torture and abuse are an important indicator of the adequacy of protections in place for detainees in that they represent the most severe cases of abuse. Deaths involving medical illness provide a window into the adequacy of medical care. Deaths due to enemy attack or use of force provide some evidence regarding the planning for and the securing of a safe and humane detention facility. MethodsIn October 2003, the American Civil Liberties Union (ACLU) along with Physicians for Human Rights (PHR) and others sought to obtain documents pertaining to investigations of abuse, torture, and morbidity and mortality of detainees in the custody of US forces under a Freedom of Information Act request. These requests ultimately led to the release of thousands of pages of redacted documents related to detainee detention, including multiple reports of detainee deaths that allowed the creation of this description. Primary documents for this review came from 3 distinct sources: Department of Defense criminal investigative reports, some but not all of which included autopsy reports; press accounts; and the publicly released reports of investigative panels including the Fay Report[4] and the Schlesinger Report.[5] The majority of cases were identified in documents obtained from the Department of Defense through a Freedom of Information Act request.[6] These reports included documents and statements from individual investigations into deaths of detainees in US custody in Iraq and Afghanistan conducted by the Department of Defense. Additional information on these cases was obtained from data made public by human rights groups[7] and journal articles.[8] Sixteen of the cases included in this review are also reported in a Human Rights First report on detainee deaths.[7] A minority of deaths were described in specific press accounts.[9-18] In all cases, we identified deaths by name (when available), date, place, and reported cause of death. Press reports of deaths were only included if the report was specific to include at least 3 of 4 identifiers such as name, date, place of death, and cause of death. As data were culled from multiple documents and reports, a database was constructed with a case number for each unique death event. In cases where documentation redaction removed the name of the deceased, information was linked to a unique case identifier by at least 3 of the other identifiers: age, date, place and reported cause of death. Finally, the reference to 27 detainees deaths at Abu Ghraib occurring on 2 specific dates in the Schlesinger Report were included as they were specific to date of death, place of death, and cause of death. ResultsA total of 112 individual detainee death reports were found and reviewed. (see tables below) Of these investigation reports, 30 were found in press accounts, 14 were found in both Defense documents and press accounts, and 27 were found in the Schlesinger Report. Autopsy reports were available for 29 cases, of which 12 were homicides (defined for the purpose of this review as the deliberate killing of one person by another person), 14 were natural, and 3 were unknown or pending. For cases with autopsy reports, the pathologic reports appeared to support the reported causes of death. However, important contextual details, such as the conditions and events leading up to the death, were often scarce or absent. Sixty-six cases were identified by name, and 46 were identified by unique identifiers including place, time, and cause of death. Of those 46 unnamed cases, specific individual records were available for 19, while 27 were identified in the Schlesinger Report as victims of insurgent shelling at Abu Ghraib (5 deaths on August 16, 2003 and 22 on April 20, 2004). A total of 63 detainees reportedly died at Abu Ghraib from all causes. Average census and number of detainees and releases at Abu Ghraib were not available, but the average population in the facility was believed to be 2000 in late 2003 and early 2004.[19] Mortar AttackThe largest number of detainee deaths was reportedly due to injuries sustained during insurgent mortar attacks against the Abu Ghraib detention facility, which occurred on at least 3 separate occasions and resulted in at least 36 detainee deaths. US troops were also injured and killed in these attacks. HomicideForty-three detainees reportedly died as a result of homicide (37 in Iraq and 6 in Afghanistan). Homicide is defined by the Army's Criminal Investigation Division as "death resulting from the intentional (explicit or implied) or grossly reckless behavior of another person or persons."[20] Homicide for the purposes of death classification is a neutral term that neither indicates nor implies criminal intent. Of the Iraq homicides, 22 detainees reportedly died of gunshot injuries. Fifteen of those were shot during s or attempted escapes, and 2 expired in detention from gunshot injuries sustained during fire fights in the field prior to being taken into custody. Among all homicides, at least 11 involved blunt trauma or asphyxiation. At least 3 homicide cases have resulted in murder charges and 3 resulted in voluntary manslaughter charges. For the 12 homicide cases for which final autopsy reports are available, gunshot wounds accounted for 4 of the deaths. The remaining 8 homicides were due to: (1) pulmonary embolism due to blunt trauma; (2) blunt force injuries complicating coronary disease; (3) strangulation; (4) blunt force with rhabdomyolysis; (5) cortical brain contusion and subdural hematoma; (6) blunt force with compromised respiration; (7) asphyxia due to chest compression and smothering; and (8) asphyxia due to occlusion of the airway and blunt force injuries. Natural CausesTwenty reportedly died of natural causes, including 13 who reportedly died from cardiovascular causes. Among these deaths, there are 2 clusters. The first cluster occurred in August 2003 when 8 detainees died, reportedly of natural causes. In that cluster, 4 of the deaths occurred in a 12-day period at Abu Ghraib and all 4 were ruled cardiovascular after autopsy. The second cluster occurred in a 5-week period from May to June 2004 when 5 detainees died of natural causes at Abu Ghraib. All 5 had autopsies done. Three of those were reportedly due to cardiovascular causes, 1 reportedly died from peritonitis of undetermined etiology, and 1 case was ruled natural, although a specific cause of death was not identified. For the 14 cases for which autopsy reports were available, arteriosclerotic cardiovascular disease accounted for 9 of the deaths. The remaining 5 were due to (1) heat stroke; (2) hemoptysis secondary to pulmonary tuberculosis; (3) myocarditis; (4) peritonitis secondary to perforated gastric ulcer; and (5) peritonitis of unclear etiology. Unknown CausesThe cause of death was listed as unknown in 10 of the cases. This includes 2 cases that had autopsy reports and 1 case that had an autopsy but cause of death was listed as pending. Record of Manner of DeathIn a well-publicized death of an Iraqi general that resulted from trauma and asphyxiation, the on-site surgeon ruled the death "natural."[11] On review at autopsy, this death was eventually classified as homicide by the Office of the Armed Forces Medical Examiner.[8] According to the Church Investigation Report, in at least 3 deaths, "medical personnel may have attempted to misrepresent the circumstances of abuse, possibly in an effort to disguise detainee abuse."[21] The chief limitation of this review is the incompleteness of released documents related to the cases. Documents obtained from the Department of Defense were heavily redacted. In many cases, names of the deceased had been obscured. At the same time, documents have been released in batches, and it is unlikely that this summary represents a full and complete accounting of all detainee deaths. It is also impossible to calculate per capita death rates, as the populations of the detention centers are not available. Finally, it is likely that the available documents fall short of a comprehensive list of all detainees who have died in US custody during the period reviewed. In addition to the methodological limitations in compiling the list, the existence of "ghost detainees" in US custody makes a full accounting by citizen reviewers outside the Department of Defense and the US government difficult. DiscussionWhile deaths of detainees in US custody have been the subject of some review in the literature, this is the largest and most complete description of US detainee deaths in Iraq and Afghanistan to date. Healthcare professionals face a daunting task in providing for the health of the large number of detainees taken into the custody of US forces during these wars. A variety of challenges including an ongoing insurgency with difficulty securing the detention facilities, insufficient preparation and staffing, and problems with policies and procedures may have contributed to a high number of deaths of detainees in US custody. These are not the deaths of people free in the community; they are deaths of detainees who were under or who should have been under medical care. From a medical professional point of view, all causes of death of patients under the care of medical providers are important indicators of the quality of care, including both access to and provision of care and protection by responsible authorities of the most basic human rights. The deaths due to mortar attack raise questions regarding the appropriateness of the use of the Abu Ghraib facility to hold detainees. The Geneva Convention requires that detainees not be confined in facilities that are vulnerable to artillery attack. Early on in the conflict, the wisdom of using Abu Ghraib, which was known to be in an insecure neighborhood, was questioned but ultimately the population remained in a vulnerable setting.[22] While security is a challenge throughout Iraq, no detention facility outside of Abu Ghraib appears to have suffered the loss of detainee life due to mortar fire. The homicides fall roughly into 2 groups: those shot by US troops in s or escape attempts within the facilities, and those who died as a result of trauma related to interrogation, restraint, and abuse. The 16 detainees who were fatally wounded while within the confines of the secure facility raise serious questions about security and operation of the facilities, level of staffing, and appropriate use of force. The International Committee of the Red Cross has expressed concern about "the excessive and disproportionate use of force by some detaining authorities," and goes on to say that "The use of firearms against persons deprived of their liberty, in circumstances where methods without using firearms could have yielded the same result, could amount to a serious violation of International Humanitarian Law."[23] The record also remains unclear regarding the timeliness in delivery of emergency resuscitation. At a time when battlefield fatality rate of US troops is at historic lows,[24] the number of detainees fatally shot during uprisings within the facilities appears to be high. Deaths attributable to torture and abuse deserve special attention. According to a review conducted by Human Rights First,[7] at least 11 detainee deaths may have been due in part or in whole to physical abuse or harsh conditions of confinement. They further concluded that at least 8 detainees in US custody were tortured to death. Steven Miles, reporting in this journal, put the number of deaths due to torture at 17, with 11 cases occurring in Iraq and 6 occurring in Afghanistan.[8] Many of these deaths involved torture or abuse related to harsh interrogations of the detainees by US personnel. The nontraumatic or natural deaths raise another set of concerns. What role, if any, did conditions of confinement such as aggressive interrogation, stress techniques, dietary manipulation, stress positions, use of fear, severe humiliation, isolation, and environmental factors such as extremes of heat and cold play in these deaths? What was the level of healthcare provided, and how accessible was it to the detainees? The clustering of reported natural deaths in August 2003 and May and June 2004 warrants further scrutiny as the available record does not adequately explain the phenomenon. Although many of these cases have had autopsies, it appears possible that some of the autopsies were performed without review of medical records and without good data about the immediate conditions of confinement leading up to the death.[8] In assessing risk factors for abusive behaviors of US personnel against detainees at Abu Ghraib, the Schlesinger Panel cited "poor training, under nearly daily attack (sic), insufficient training of staff, inadequate oversight, confused lines of authority, evolving and unclear policy, and a generally poor quality of life."[25] It has already been reported that US Army investigators concluded that Abu Ghraib's medical system for detainees was inadequately staffed and equipped during the summer of 2003 when the first cluster occurred.[26] Although a report issued by the Army in 2005 recommended that the standard of care for detainees be the same as the standard of care for US patients in the theater of war, that recommendation has been rejected (pending further review) by the Surgeon General of the Army.[27] Documents pertaining to the Defense Department's own internal review of individual detainee deaths have cited shortcomings in detainee medical care including the qualifications of some health providers, flawed intake screening procedures, lack of procedural standards, insufficient record-keeping, and unavailability of interpreters to assist medical staff, particularly in the early period of the war. Multiple investigators have recommended that doctors or physician assistants either replace or provide closer supervision of military police medics in providing for detainees' primary care.[6] The absence of professional translators is also of particular concern, as it has required medics to use detainees in their place, leading one investigator (a military surgeon) to call medics' efforts to learn a detainee's health status "a guessing game," noting that the language barrier may have contributed to a preventable death.[6] The men and women who serve in the armed forces of the United States are, as a group, highly motivated, ethical, humane, and professional. The deaths of the 112 detainees reviewed in this report, then, beg the question: Were these medical professionals adequately supported in their task? Did they receive appropriate staffing and supplies, proper training in the screening and management of detainee patients, and proper training and support regarding the importance of medical autonomy as it relates to potential abuse of their patients? Medical professionals in the military are under pressure from competing obligations to their patients and to the military mission, duties that often come into direct conflict.[28] The medical community at large owes medical professionals serving in time of war full support in their mission of caring for all of their patients, including detainees in their custody. Any infringement on their ability to secure health and safety for their patients due to inadequate material support, inadequate resources, or encroachment upon medical autonomy is an infringement on the profession as a whole. The responsibility physicians and other health professionals working in detainee custody settings have to preserve and protect the patients under their care includes not just the provision of healthcare, but the protection of patients from torture and abuse, as has been asserted by both US and international bodies, including the American Medical Association (AMA), World Medical Association (WMA), and the United Nations (UN).[29] The AMA has asserted that physicians "should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great."[30] In light of deaths related to abuse and torture in settings where health professionals had a presence,[26] and the association of interrogations for creating a great potential for abuse, the AMA, the American Psychiatric Association, the WMA, and other professional associations have issued new ethical guidelines forbidding physician participation in interrogation of detainees.[31-33] Complicity in abuse may be passive, and may include failure to protest harsh conditions of confinement, or failure to document or report injuries that may be the result of torture or abuse. Continued use of aggressive interrogation techniques by US interrogators as authorized by the Congress with the passage of the Military Commissions Act underscores the continuing need for physicians working in detention settings to strive to protect the health and human rights of their patients. ConclusionIt is impossible to answer the many questions the deaths of these detainees raise with the limited information available for this review. At the same time, while the initial internal review conducted by the Department of Defense is a necessary first step, the inherent conflict of interest in an internal investigation argues for a comprehensive outside independent review of detainee deaths. Operations in Iraq, Afghanistan, and other countries are ongoing. Lessons learned about causes of detainee mortality could be put to immediate use in minimizing further loss of life and protecting human rights.
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Table 1. Causes of Death of Detainees of US Forces in Iraq and Afghanistan
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ADDITIONAL TABLE INFORMATION
see http://www.duckdaotsu.org/detaineedeaths.html
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