The Role of Health Professionals in Detainee Interrogation

A teenager tortured at Guantanamo, and the stalled legislation to ensure clinicians "first, do no harm"

On December 25, 2003, Mohammed Jawad, an Afghani teenager held in Guantanamo Bay, Cuba, repeatedly banged his head against the metal structures of his cell in an effort to kill himself. The dull echoes of the blows attracted the prison's guards. As they reached the cell, Jawad struck the solid surface once again. Even though suicide is prohibited in Islam, Jawad, a devout Muslim, thought that perhaps he could be forgiven in this case. The situation had slipped beyond his control, he told his attorney Eric Montalvo years later.

A month earlier, Jawad had been placed in isolation following the recommendations of a psychologist from a Behavioral Science Consultation Team in Guantanamo. A few weeks later, he had been moved to a cell block where no one spoke Pashto -- the only language Jawad knew when he arrived to the island -- in order to further enhance his feeling of loneliness. "He appears to be rather frightened, and it looks as if he could break easily if he were isolated from his support network and made to rely solely on the interrogator," the Army psychologist wrote in a leaked report intended for Guantanamo interrogators. "Make him as uncomfortable as possible. Work him as hard as possible," she continued.

Three days before Christmas 2003, Jawad's "comfort items" -- his mat, a copy of the Quran, among others -- were removed from his cell as a form of punishment for trying to talk to other detainees in the camp, according to court documents. On December 25, reaching a breaking point, he repeatedly slammed his head against the metal objects of his enclosure.

The incident was recorded in the official camp log of that day under the description "attempted self-harm." In March 2004, he tried to communicate with the inmates from his block, and he was punished once again with the loss of his comfort items. The prison, he would later tell his lead attorney, David Frakt, was "like a tomb, like a graveyard."

At least since Nuremberg, scrutiny over the involvement of health professionals with torture has been a critical subject in every war. (The word "torture," of course, is highly charged and its definition is subject to debate. For the purpose of this article, the word refers to the definition found in the United Nations Convention Against Torture, a document ratified by the United States.)

In the aftermath of the wars in Iraq and Afghanistan, ever since leaked reports and testimonies -- including that of alleged 9/11 mastermind Khalid Sheikh Mohammed, currently on trial in Guantanamo -- were published in 2004, the issue has attracted the attention of the media, health organizations, and political activists. Psychologists and doctors have clashed with their peers and with the Department of Defense over the role that health professionals should play in interrogations, given their oath to "do no harm." The Senate Judiciary Committee and numerous military investigations have confirmed that physicians and clinicians played a significant role during so-called enhanced interrogations, either through reverse engineering of the Survival, Evasion, Resistance, Escape (SERE) program, or through monitoring and assisting in CIA black sites and prisons like Bagram and Guantanamo.

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The Moral Medical Mission

Recently, that conflict reached politicians in Albany, New York. This year, State Senator Thomas Duane and Assembly Member Richard Gottfried sponsored a unique piece of legislation that establishes sanctions (including license removal) for state-licensed health professionals who participate in torture or improper treatment of prisoners.

"The bill presents an opportunity to fill a gap in state law on the regulation of health professionals that desperately needs to be filled," Leonard Rubenstein, the former president of Physicians for Human Rights -- an independent organization that fights human rights violations all around the world -- said in a public forum. "Almost everyone agrees that the idea that health professionals can participate in abuse of detainees and prisoners is indefensible. If that is the case, it is also indefensible to exclude such acts from state law on licensing and regulation of health professionals."

The Duane-Gottfried bill was the latest in a series of yet-unsuccessful efforts carried out by committed clinicians and doctors to establish a lasting impediment to torture, and to prevent -- nearly nine years after the fact -- events similar to those experienced by Jawad.

In 2004, Steven Reisner, a psychologist and anti-torture advocate who became one of the Gottfried bill's most outspoken advocates, read a New York Times article about a leaked International Committee of the Red Cross report. "There were two main lines to that document," he said last winter referring to the report. "First, that what was happening was tantamount to torture. And second, that health professionals were overseeing interrogations in violation of their ethics."

On May 7 of that year, a guard interrupted Jawad's sleep a few hours after Vice-Admiral Church visited Guantanamo as part of an investigation into detainee abuse. Jawad was shackled and moved to cell L48, where he went back to sleep. Three hours and 16 minutes later, he was awake once again, walking in chains towards cell L40. Two hours and 59 minutes after that, a guard came, put on his shackles and led him back to cell L48. Just after he arrived in his original cell, he was taken back to L40; two minutes later, he was shackled and returned to L48. The sleepless pattern continued for 309 hours and 53 minutes. In total, according to a log uncovered by Jawad's attorneys in 2008, he was transferred 120 times from cell to cell during 14 days, once every two hours and 50 minutes on average.

This sleep-deprivation technique, referred to as the "frequent flyer" program by Guantanamo guards, owed its inception to a group of psychologists who had been advising the CIA on how to conduct more aggressive interrogations. Via the Office of Legal Counsel of the Department of Defense and a series of executive orders during the Bush administration, the health professionals' recommendations had become standard operating procedure in Guantanamo to either punish or extract information from prisoners (at least 21 prisoners were subjected to the "frequent flyer" program, according to an Amnesty International report). 

This sort of abuse had supposedly been eliminated from the prison camp in March of 2004, when Major General Jay Hood assumed the leadership of the Guantanamo Joint Task Force. Authorities, consequently, denied having any knowledge of the incident. Jawad's treatment had violated Common Article 3 of the Geneva Conventions -- inapplicable to his case because he was denominated an "unlawful combatant." In a 2009 habeas corpus hearing, Ellen S. Huvelle, the federal judge who sealed his release, told U.S. prosecutors, "After this horrible, long, tortured history, I hope the government will succeed in getting him back home." She added, "Enough has been imposed on this young man to date."

Dr. Katherine Porterfield, a psychologist from the Survivors of Torture Program at Bellevue Hospital, learned about the Gottfried bill after she treated Mohammed Jawad while he was still imprisoned in Guantanamo. Jawad's case had first attracted media attention in 2007, when the government announced that he was to be the fourth detainee to be prosecuted under the Military Commissions Act of 2006. The fact that he was under 18 at the time of his arrest, a fact the government accepted, spurred organizations like Amnesty International and Human Rights Watch to raise the alarm about violations of several United Nations treaties regulating the treatment of child soldiers.

While these NGOs protested what they deemed the illegal trial of a minor, Porterfield, groups of medical associations and academics highlighted a different aspect of the case, a feature that, in fact, by that time had become a constant source of complaint among the medical community. Plain and simple, Jawad's testimony showed that doctors had participated in abuse (in this case psychological) that was ethically questionable and potentially illegal. In the words of Steven H. Miles, MD, a bioethics expert and the author of the book Oath Betrayed: Torture, Medical Complicity and the War on Terror:

Within the primary obligations to promote a person's well-being, distinctions are possible to allow behavioral scientists, psychologists, or psychiatrists to work with forensic interviews. It is one thing for such clinicians to train an interrogator in rapport-building skill and cross-cultural communication. It is quite another to use psychological, medical, and cultural information (especially when obtained in a clinical encounter) to degrade, frighten, or inflict physical distress on a person in order to coerce information from that person.

For Porterfield and the people who knew about the classified details of Jawad's treatment or of the so-called enhanced interrogation techniques used on the high-value detainees, Duane-Gottfried was an ideal proposal to prevent a similar incident from recurring.

"The Duane-Gottfried bill reaffirms the basic ideology of doctors; it gives teeth to the enforcement of medical ethics," said Dr. Allen Keller, Director of the Bellevue/NYU Program for Survivors of Torture. "I believe this is one of the central moral issues of physicians and of our society."

In 2007, the year Khalid Sheik Mohammed's Combatant Review Tribunal was held in Guantanamo, a group of doctors had approached Assembly Member Gottfried with what he thought was an ingenious idea: They could use state-licensing power as a lever to stop the involvement of health professionals in interrogations and torture. Since the Department of Defense required physicians to have a state license, then the state should have the ability to sanction the physicians it licensed. The battle, then, wouldn't have to be fought within medical groups or Congress, but rather at state legislatures.

In 2009, around the time Jawad's lawyers filed for a writ of Habeas corpus in the name of their client, Gottfried decided to move forward with the bill. Despite what at the time seemed like a promising future, the legislation failed to pass and hasn't even been discussed in the House's floor, even though it has been proposed in each of the last three years.

"To some extent, the issue is put in very blunt terms, 'Whose side are you on? The terrorists' or Gottfried's?" Gottfried said last winter, a couple of months before the legislation officially died once again.

Mohammed Jawad was captured by Afghan security forces in a crowded Kabul bazaar on December 17, 2002. He was picked up, along with several other individuals who were later released, after a grenade thrown inside a car nearly killed two American Special Forces soldiers and their Afghan translator. In the local police station, Jawad was accused of throwing the grenade and coerced into confessing, according to David Frakt, a member of the Judge Advocate General (JAG) Corps who was assigned to lead Jawad's defense in 2008.

Jawad at first denied participating in the attack, but the police threatened to kill him or his family if he did not accept the charges against him, Frakt said. The threats, later accepted as a form of torture under the Military Commission Rule of Evidence , were issued in front of high-government Afghan officials whose names were redacted from court documents. Jawad, at the time nearly illiterate and apparently under the effect of some kind of drug, signed with his fingerprint a confession written in Dari -- a language he does not speak -- in which he took full responsibility for the assault and expressed pride about it, stating that he would have done it again if he had the chance.

At around 10 p.m., U.S. security personnel took Jawad into custody and led him to Forward Operating Base 195, also known as the Kabul Military Academy. There, he was strip-searched and photographed naked. Once again, after denying having anything to do with the grenade attack, Jawad was coerced into confessing that he played a leading role, according to court documents . His account in front of U.S. interrogators, however, was fairly different from the one he had given to the Afghan police. He told them he had been drugged and initially denied having any involvement in the incident (he later confessed, according to military interrogators , and, allegedly, his confession was recorded in a missing videotape, which was never found despite a "service-wide inquiry" from a government prosecutor).

Jawad was transferred to the Bagram Theater Internment Facility on December 18, just a couple of weeks after severe beatings caused the death of two detainees in the prison. Records from interrogators and files that have been partially declassified state that, while he was there, he was hooded, placed in stress positions, thrown down a flight of stairs, kneed, kicked, sleep-deprived and threatened with being handed over to the Taliban. Military interrogators, who by that time had realized Jawad was a juvenile (he does not know when he was born; his age at the time of capture ranges from 15-17, depending on the account), played on his fears and on his constant cries for his mother to secure more statements.

He was transferred to the now decade-old prison in a military flight on February 6, 2003. Following his arrival, he received the traditional orange jumpsuit now associated with the detention center. The next day, he was interrogated by the FBI and placed in isolation for 30 days. The month-long seclusion, during which his only human contact was provided by several groups of interrogators, was designed to "wear down" new detainees, according to the standard operating procedures of Camp Delta.

As a whole, the Bagram and Guantanamo experiences prompted a deep feeling of mistrust in authorities, according to Dr. Katherine Porterfield.

"I've worked with survivors of torture from countries all around the world, but I had never faced a patient who initially doubted who I was, and who thought that I, as a doctor, might be there to harm him," she said.

His attorneys David Frakt and Eric Montalvo, two JAG officers who were assigned to his case, faced a similar reaction when they first met him. "He couldn't believe I was there to actually help him. He reasoned that since I was with the government then my role was to interrogate him or that it was all fake," Montalvo said.

Jawad's distrust was apparent even the day when Montalvo informed him that the government had withdrawn their case after a judge declared that most of the evidence supplied by the prosecution had been obtained through torture. Through the gates of Camp Iguana, Montalvo told his client that he was soon going to be released. Initially, Jawad's reaction wasn't the ultimate bliss that one would expect of someone who had now lived almost a third of his life devoid of freedom.

"In a way he had a measured response to some extent because he had been told many, many things that hadn't happened," Montalvo surmised. "At the same time he was happy that we were having that conversation. In the end, the sheer moment of joy was when he met me later in Kabul. We saw each other and it was his first day as a free man. There, he got down and kissed the ground."

After nearly seven years in captivity, Jawad returned to Afghanistan in August 2009, where he met President Hamid Karzai, who promised him a house in a PR stunt during a reelection campaign. The pledge was never fulfilled and life has been difficult for Jawad since he returned, according to Montalvo, who still calls him from time to time.

"He clearly had some psycho-social issues and he was basically deprived of his adolescent years, so he was sort of the boy in the bubble who went back to a society that is fairly harsh," Montalvo said. "He has no income and no support and has all these accusations against him still hanging on his back, so, how would you feel in that situation? It didn't go well for him."

"At the same time, he's alive and healthy and not in trouble, so, you know, it depends on what expectations you have."