Briefing Of The United States Commisiion On Security And Coorperation In Europe (Helsinki Commission) (As Released By The Helsinki Commission) - Physicians For Human Rights (PHR)

Statement

Moderator: Rep. Alcee Hastings

Panelists: Leonard Rubenstein, President, Physicians For Human Rights (PHR); Allen Keller, Bellevue/NYU Program For Survivors Of Torture

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REP. HASTINGS: Ladies and gentlemen, I welcome you to the Helsinki Commission's briefing with representatives for Physicians for Human Rights.

As chairman of the Helsinki Commission, I know that raising human rights issues is a two-way street. As Soviet dissident Andrei Sakharov once observed, the Helsinki panel (ph) only has meat if it is observed fully by all parties. I quote, "No country should evade a discussion of its own domestic problems, nor should a country ignore violations in other participating states."

The point of the Helsinki panel (ph) is mutual observation, not mutual evasion.

Gentlemen, good doctors, I have a full statement. I'm going to include it in the record. But I really am more interested in hearing from you than I am from me.

So if we could start with Dr. Rubenstein, I would appreciate it.

And I might add, ladies and gentlemen, their biographies as well as their full statements and other offerings are on our table outside.

So, Doctor, thank you all so very much for being here.

DR. RUBENSTEIN: Thank you, Congressman, and thank you for this opportunity to participate in this hearing and -- and this briefing and thank you for holding the briefing.

My colleagues and I will be discussing the findings and recommendations of a recent report by Physicians for Human Rights entitled "Broken Laws, Broken Lives, medical evidence of torture by U.S. personnel and its impact.

We have copies on the table if you don't have one. Physicians for Human Rights is an organization that for more than 20 years has employed medical and scientific methods to document violations of human rights so that truth can be determined and perpetrators held accountable. For these two decades, we have engaged in these medical evaluations throughout the world and led the process that led to international standards for such examinations contained in the manual on effective investigation and documentation of torture and other cruel, inhuman and degrading treatment or punishment, which is known as the Istanbul Protocol.

And for the past five years, we have been engaged in investigations and analysis concerning interrogation methods used by the United States to determine whether the United States itself engaged in torture or cruel, inhuman or degrading treatment and punishment.

"Broken Laws, Broken Lives" is the third report we have released.

Let me begin by -- about the report by giving you a little bit of context. Over the last four years, as a nation, we have increasingly learned about the process by which extremely harsh interrogation methods, such as isolation, stress positions, sleep deprivation, sensory deprivation, severe humiliation and many more, were authorized and adopted, first, by the CIA and then by the Department of Defense.

What ha been missing from this picture though is an understanding of the consequences of the decisions made about the interrogation methods on thousands -- and I emphasize -- thousands of human beings who came into custody of the United States. Only a tiny handful of whom have been charged with any crime.

And we're especially concerned with the period before any public disclosure, which was 2001 to 2004.

Often this discussion had an abstract quality, though torture and cruel treatment are anything but abstract. They result in searing pain and suffering and rob people of humanity.

So we decided we had to found out what happened to some of the victims.

To do this, we identified 11 men who were formerly in U.S. custody and who were willing to undergo intensive two-day medical and psychological evaluations under the standards of the Istanbul Protocol, which I mentioned a moment ago.

The sample was not random, but we did not exclude anyone who agreed to participate.

Four of the men were arrested or brought to Afghanistan and then sent on to Guantanamo. The other seven were held in Iraq, most in Abu Ghraib. All were eventually released and none were charged with a crime.

What we found across the board was the men experience a horrible stew of methods of torture and ill treatment that brought about intense pain, degradation and suffering. And it's suffering that endures to this day.

As always happens when governments start down the road to torture, intelligence gathering gave way to regime of cruelty that destroyed many of the men. There were five major findings I'd like to summarize. And Dr. Keller will describe the experiences of some of the men he, who was one of the evaluators, examined.

First, in all the locations, almost all the men were subject to combination of the kinds of techniques I mentioned a moment ago that were authorized by the Defense Department at various times, including isolation, stress positions, suspension, extremes of heat and cold, severe humiliation, use of dog and threats.

In Iraq, almost all of the men were forced to be naked for very long periods of time, often while isolated in cold, dark rooms and cells.

In Guantanamo, three of the four men reported being shackled to the floor for 18 to 20 hours at a time.

Also in Guantanamo, men were forced to take drugs without being informed of what they were or why they were being administered.

Second, all the men reported that the experience of being subjected to these and other techniques were on an intense level of physical pain and agony.

Former detainees describe the inability to move their muscles for 18 hours or being suspended by their arms as excruciating. A number of them loss consciousness during the process when they were being placed and kept in this stress positions.

Psychological pain and suffering where thought, if anything, worse. They experienced despair, fear and terror from being kept alone, often naked in lightless, cold rooms, from being exposed to excessive loud noise, from fear of dogs, from worrying about threats to their families, from the constant degradation and humiliation, and from the very disorientation and agony brought on by lack of sleep.

Seven of the men contemplated suicide despite the Muslim prohibition on suicide. One of them attempted suicide multiple times. Others simply wished for death.

For some, the severity of the psychological abuse also led to physical symptoms, including chronic headaches, chest pains and difficulty breathing.

Third, we found that all the men's suffering lasted for years after release.

As I mentioned, these men were in custody between -- most of them, between 2001 and 2004, though some were released later.

But they continue to suffer physical pain in joints, limbs and muscles.

And the horror most of all lives on in their minds. They can't sleep. They experience nightmares. They're severely hampered in their social and family relationships and in their work. They feel like their lives have been shattered.

And from a medical standpoint, the diagnosis of severe depression, anxiety and post traumatic stress disorder were common.

Fourth, we found that the authorized techniques, many of them themselves amount torture, begot yet additional forms of torture, proving once again that once torture starts, it cannot be contained. What I mean by this is that beatings became intense and common.

Particularly in Afghanistan, but also in Iraq, one man lost multiple teeth. Another had to be hospitalized. Two and possibly three men in Iraq were sodomized. Two men in Iraq were subjected to electric shock. And a third was shocked when pushed into a generator.

And in Iraq particularly, there was an environment of gratuitous cruelty.

One man was suspended by a winch, another stabbed in the check with a screwdriver.

Fifth and finally among our findings or key findings, medical personnel played a very problematic role.

Now some of the detainees reported receiving good medical care. And sometimes medical personnel intervened to stop abuse.

But others reported instances where medical personnel became cogs in the system of abuse, sometimes by sharing medical information, sometimes by turning a blind eye to abuse, and sometimes by patching up people so abuse could continue.

The medical record which we obtained in one case shows that the medical personnel saw a man severely decompensation become psychotic and suicidal. It was very clear that this treatment to which he was being subjected, including isolation, contributed to his decompensation. But they didn't address that cause. And, in fact, told the man at one point, when he begged to be removed from isolation, that that's a decision the interrogators could make. There was no evidence that the doctors or medics reported abuse. Now, in 2006, the Army reputed most of these forms of torture, although the new Army interrogation manual continues to allow isolation and sleep deprivation, limited -- sleep limited to four hours for certain detainees. So they -- these methods have not completed been eliminated by the department of defense. And of course the CIA has eliminated -- hasn't eliminated any of these.

So our first recommendation is for a firm prohibition on torture and ill treatment, including all the techniques and methods we found.

Second, we think there has to be accountability. As elsewhere in the world, we need to have the truth. Despite the investigations and hearings and many reports, we still have only a small glimpse of what thousands of men experienced. So we are calling for a full, independent, nonpartisan commission with subpoena powers to get access to documents and to personnel's testimony. And this also should include the role of medical personnel.

And I should add that for the past three years, Physicians for Human Rights has asked the Defense Department for an internal investigation of the role of medical personnel and abuse. And we've never had a response.

Of course, accountability must also include prosecutions for war crimes.

As General Taguba said in the preface in our report, "those who committed these crimes should be held responsible." Finally, we believe the government owes the victim. That begins with apology but also compensation and also access to rehabilitative services that torture victims deserve.

And finally, in setting future policy, we have to talk not just about ticking bombs, but about what happens to human beings when a regime of torture unfolds.

REP. HASTINGS: Thank you.

Dr. Keller?

DR. KELLER: Thank you, Congressman. Thank you so much for holding this briefing today, which clearly has relevance to our interactions with other countries and diplomatic relations and other things. And I believe nobody gets that better than this commission. So I thank you for holding this hearing today.

I was one of the medical evaluators in this study. And the 11 evaluations of former Abu Ghraib and Guantanamo detainees that my colleagues and I conducted, we fond clear physical and psychological evidence or torture and abuse, often causing lasting suffering.

As a physician with over 15 years of experience in caring for victims of torture and evaluating them from all over the world, I can tell you that -- the torture and abuse that these men endured tragically is second to none.

Let me share with you two examples.

Fist, a gentleman identified as Yusuf. He is in his early 30s and unable to find work in his homeland, he went to Afghanistan. Subsequently, he tried to go home and as he was trying to go home, he was detained at the Afghan-Pakistan border, then transferred to the detention facility, the U.S. detention facility in Kandahar. There he was immediately interrogated, beaten. He was stripped. The first night, he wasn't allowed to sleep because guards would hit the detainees and throw sand at them. While at Kandahar, he endured forced nakedness, intimidation by dogs, hooding, repeatedly being thrown against the wall. And he was subjected to electric shocks from a -- from a generator, as Len had alluded to. Subsequently, he was transferred to Guantanamo where, during the long flight, he was shackled to the floor of the plane. And the tight cuffs caused his wrists to swell.

Upon arrival at Guantanamo, he initially kept at Camp X-Ray, where he described the conditions of confinement as horrific. They were extremely hot outdoor cages with only a bucket for a toilet.

Lengthy interrogations, accompanied by sleep deprivations. Small infractions, such as speaking with other detainees, led to beatings. And a person who he believed was a physician checked the injuries of the detainees after the beatings. Three months later, he was transferred to Camp Delta where he said the conditions at least in the prison cells were better. However, the interrogations and being held in the interrogation rooms, which happened every other day, were quite brutal.

Although he denied being beaten while held in the interrogation room -- again, this speaks to how we assess creditability.

You know, you're -- you're looking -- when an individual was candid with you when they were treated well and when they weren't treated well, what physical symptoms they do and what they don't have. So it's from that overall impression. And I should say, on average, we took close to one, one and a half to two days per individual to conduct these detailed physical, psychological evaluations.

So back to Yusuf. While he was held in this interrogation, he was chained to the floor and forced to assume stressful positions. Ice water as poured on him. At other times, loud music was played. Sometimes they would make the temperature in the room very hot, other times very cold. There was someone, again, who he thought was a physician that would come and monitor his vital signs, clearly a violation of medical ethics. And on no occasion did the hot or cold stop after the good doctor paid his visit.

Demands for confessions were constant and they were accompanied by the interrogator's threatening him.

For example, his brother suffered leukemia and the interrogators told him, "Your brother's been arrested." And the soldiers also threatened to shoot him.

Humiliation was a routine part of the interrogations. He was forced to watch pornography. Soldiers tore the Koran apart in front of him.

And he described an incident in which a naked woman entered the interrogation room and smeared what he believed to menstrual blood on him.

At one point while at Camp Delta in Guantanamo, Yusuf asked to speak to a psychologist because of the sadness that he was feeling from separation from his family. He believes the psychologist shared this information with his interrogators, who exploited it by threatening him with spending the rest of his life in Guantanamo.

Following this interrogation, he was then moved to the worst section of Camp Delta where he wasn't allowed to have a blanket or a mattress.

He was later released after he signed a -- a form of -- of what he said was a false confession. And this was in the fall of 2003.

So while Yusuf acknowledged to us that he experienced symptoms of depression before his detention, the symptoms that he described afterwards were far more disabling and chronic.

He also now suffers from post traumatic stress. He has described difficulty functioning and has not found steady employment since his -- his detention. In short, he's a shell of who he was.

The next individual I'd like to tell you about is a man referred to in the report as Amir, who was detained in Abu Ghraib. He is in his late 20s. He was a salesman before being arrested by U.S. forces in Iraq in 2003.

After his arrest, he was shackled, forced to stand naked for over five hours. For the next three days, he and other detainees were deprived of sleep and they were forced to run for long periods, during which time he injured his foot. When he pointed out this injury to a soldier, the soldier pushed him up against a wall and he lost consciousness.

Later, he was transferred to Abu Ghraib. And at first, he acknowledged that his wasn't mistreated, but then the abuse began. He was subjected to religious and sexual humiliations, hooding, sleep deprivation, restraints for hours while naked and dousing with cold water.

The most horrific incident that Amir recalled was that he was placed in a foul-smelling room, forced to lay down in urine and then was sodomized with a broomstick and forced to howl like a dog while a soldier urinated on him. After a soldier stepped on his genitals, he fainted.

In July 2004, he was transferred to Camp Buka where he said he wasn't abuse and then subsequently released.

And it was really striking, in all of these evaluations, that the points the individuals became almost the closest to tears wasn't necessarily when they were describing the physical abuse, but the sexual humiliations -- was where, you know, they would hang their head and often become quite emotion, that, and the uncertainty of when and if they would be released.

And so Amir continues to experience physical symptoms, including significant pain consistent with what he reported.

On physical, he had multiple scars on his body, including on his head, his legs and his penis. This is consistent with what he described. Psychologically, he suffers debilitating symptoms of post traumatic stress, disturbed sleep, anxiety, sexual dysfunction.

He's changed from a stable provider for his family to an unemployed man. Though the stressors related to the war in Iraq may well exacerbate his symptoms, he clearly understands that his most debilitating symptoms are attributable to his torture and sexual violations. And as he put it, quite emphatically, quote, "No sorrow can be compared to my torture experience in jail. That is the reason for my sadness." The individuals evaluated for this study were subjected to a variety of dangerous and harmful forms of abuse, often simultaneously. And these are referred to in the benign of, quote, "enhanced interrogation techniques," such as stress positions, sleep deprivation, sexual humiliations.

From a medical and a scientific perspective, there is nothing benign about these methods and they should be seen for what they are, gruesome, dehumanizing, dangerous. They are torture and they cause lasting physical and psychological harm.

So in conclusion, I would say this. We must ensure that torture and mistreatment, no matter what you call it, are neither condoned, nor take place under our country's watch.

Though perhaps invoked, albeit misguidedly, in the name of national security, the abuses committed by the United States have undermined our integrity and, I believe, have made the world a much more dangerous place. We must take responsibility for what has happened, as Len alluded to, and see that it never happens again.

Thank you.

REP. HASTINGS: Thank you very much. Dr. Allen, I think you heard that bell, but I'm going to try to stay to hear your testimony if I can.

DR. ALLEN: Well, thank you Congressman. And I will make an extra effort to make my comments particularly brief.

My colleagues both made reference to the issue or health professional participation in torture. As a former correction physician, or in common parlance, prison doctor, these issues are of great concern to me. And I just want to make some brief remarks regarding them.

Now, there's a number of ways health professionals can participate in abuse and torture. They can design techniques, as shocking as that sounds. They have done that. They can monitor of those techniques. They can participate directly. They can fail to intervene to stop it. They can fail to document a report up the chain of command or outside the chain of command. And they can treat and return a victim to the setting of torture.

Perhaps the most perplexing and worrisome is this idea of direct participation of health professionals, physicians and psychiatrists in particular.

And I just want to bring out two examples that are slightly beyond the scope of this report, but I want us to keep them in mind.

The first is the setting of hunger strike. And the issue there, of course, is the use of force feeding.

And the second related issue is the use in various settings of forced medication.

The central ethical issue that -- that is at play in both force feeding of hunger strikers against their wishes and forced medication of detainees against their wishes is violation of the issue of informed consent.

Informed consent is that process whereby a patient is informed of the risks and benefits of procedure understands why it's in their best interest or can help them either diagnostically or therapeutically.

Unless it sounds like a mere formality, think of any examine that you have undergone yourself, whether it's a dental examine, whether it's a pelvic exam, whether it's a prostate examine, and think of the difference between giving your informed consent for that process to continue, in which case it's uncomfortable, but it's either therapeutic and diagnostic and minimally traumatizing. Imagine any of those procedures progressing without your consent.

So the very fact that physicians have been placed in positions where they've been asked to engage in invasive procedures against the consent or against the express rejection by the patient is deeply disturbing and of concern to be as a physician. We should not be asking our -- our uniformed professionals to engage in such activity. So I'm just going to make those very brief comments now to put those issues on the table and turn it back over.

Thank you.

REP. HASTINGS: I can't really thank you enough for the piercing testimony and your report.

Several questions come to mind. Regrettably, I won't be able to put them. But Ms. Slaughter will be here and will ask the questions that I would have asked. Just for your references, if you would -- first, your recommendations are outstanding. I will scour the legislative terrain to see if any of it is already a part of legislation or is in draft to be.

And the one thing, the Independent Commission Study, I certainly would -- if it -- if it does not exist, then I will talk with Senator Cardin and other members of the commission, particularly Congressman Smith. And I think that we would file such a request. Additionally, you had access to medical records. And that's something in an ongoing trail that seems to be an issue of the one person who has been tried. And I would be curious if you can share with us how you accessed those records. And if you cannot, then I certainly understand that as well.

I and Senator Cardin and Representative Smith have spent a considerable amount of time on this subject. We began Helsinki around this year at CSCE with an unusual kind of hearing in that we had not done much domestically. And we went to the University of Maryland and the subject was torture. And we had colleagues of yours, mostly from academia -- not to suggest that all of you are not from academia -- but they were more oriented from that standpoint.

As a lawyer, I can just share with you that I'm personally disappointed that you would even have to examine 11 individuals.

I certainly am mindful that 11 persons is not a comprehensive enough study. I would be curious to know if you extrapolate that, what it would look like, in your opinion, with the thousands of other people that have likely been subjected, particularly in Afghanistan and Iraq. We know the precise numbers in Guantanamo. We don't know the precise numbers that have been skirted off to -- to unidentified locations and countries that we know that do commit torture. And yet, we subjected those persons to that kind of undertaking and black sites and stuff.

I served on the Intelligence Committee and oversight is of no use because nobody will tell you the truth. When I got to Guantanamo, all I got was a dog and a pony show. And I'm absolutely certain, just as an observer and a person that did an awful lot of work in prisons as a judge and then as a lawyer representing prisoners and fighting against this kind of thing domestically that takes place long before many of our laws did improve it considerably.

That's just a long way of saying to you what my short feeling is -- is that I appreciate your courage. I appreciate your insight. And indeed, all of -- of -- of the recommendations that you offer in this report will be taken seriously by this commission. And I can assure you that we can manifest it in some form of legislative undertaken. And I believe, without speaking for him -- which I would never speak for a member of the other body -- but I do believe that Senator Cardin would share much of my sympathies that I've express.

Gentlemen, I thank you.

I'm fond of saying -- staff that works with me gets tired of hearing me say it, but the truth is it's hard to apologize for working. So I have to go and vote. And I thank you.

And if you would stay, Ms. Slaughter will continue the briefing.

DR. RUBENSTEIN: We can begin by answering some of Congressman Hastings' questions. I'll speak and then Allen can join me.

On the question of medical records, we -- (OFF MIKE) -- on the question of medical records, these were all released detainees. And one of the lawyers -- the lawyer for one of the detainees succeeded in getting the record through the Freedom of Information Act. And then the detainee consented to share those records with us.

For current detainee, getting access to medical records is far more difficult, really impossible. And the Defense Department has to date denied any request for any independent medical evaluations.

We actually suggested to the Defense Department a joint evaluation in which Defense Department physicians and independent physicians jointly do examinations so there was consensus about what the finding was. But that has not been allowed.

We think it really is important that these records see the light of day because they shed a lot of light on what happened to people.

On the question of extrapolation, the report states that we can't generalize from 11 cases. And the 11 cases weren't random.

What we can't say is what we found was quite consistent both with many of the policies related to interrogation and related to detention methods and reports of other observers, including the FBI, including reports from General Church and others. So we think that that consistency allows us to draw some conclusion that -- that it would not be a surprise to find that other detainees suffered similar conditions.

You want to add?

DR. KELLER: Sure. So first, I agree wholeheartedly with what Len said in terms of the need to evaluate the medical records. And there have been some very disturbing examples. And Dr. Allen can speak to this better than I of clear falsification of medical records, covering up deaths, for example.

In terms of how many people were arrested, for example, in Iraq, I -- I think we don't know the answer to that. What we do know is that, often, individuals were arrested in these sweeps where basically everybody within a certain radius was just arrested.

And perhaps there were some, you know, very bad individuals among those. But there were an awful lot of people who were just in the wrong place. And that was a theme that seems to recur, even through these -- many of these individuals whom we spoke with. So we really don't know the answer to that. But it's chilling.

And I actually have recently heard -- interviewed one of the military who was involved in these sweeps and voicing his own concerns about how many people they wrongfully arrested, putting them in a system where there was absolutely no mechanism for, you know, a fair process, let alone the hellacious conditions under which they were held.

And just one aside with Abu Ghraib, I think it's naive, at best, malicious, at worst, to think that this was, quote, "a couple of bad apples on the night shift."

So with regards to extrapolating what we learned from these 11 individuals, what does this tell us about a -- a larger pattern of U.S. behavior of the individuals. Clearly, it's not a random sample and it's a small one.

I will say, it's frankly very, very difficult accessing former detainees. And certainly, I would welcome the opportunity to go and do an independent, random study of detainees at Guantanamo or Abu Ghraib if we were ever given such access. But given that we're not, this was the best that we could do.

That said, these individuals were detained in multiple place -- Kandahar, Abu Ghraib, Guantanamo, at least two or three other prisons.

And so the patterns of abuse, of the sexual humiliations, of the forced standing, these -- again, this ridiculous term, quote, "enhanced interrogation techniques," a sanitized word for torture -- were methods that we heard, you know, over and over, be it at Kandahar, at Guantanamo or Abu Ghraib.

Now clearly, in Abu Ghraib, in terms of the conditions of the cells, you know, being filthy with feces and urine, you know, that, you know, was a whole other -- other -- other level.

But I think from this report one can at a minimum say this does support the hypothesis that these abuses were not random, were not isolated and that seems methodical and part of a pattern.

And I think that's why, as Len said, it's crucial -- crucial -- that we have a clear accountability.

I'll just say, as a doctor who cares for torture survivors from around the world, I am really worried that we have made this world so much more dangerous for the student activist in Africa or the Tibetan monk by what we have done. And I think it's going to take us years to undo the damage we've done. So we better get started.

REP. LOUISE MCINTOSH SLAUGHTER (D-NY): Thank you.

I'd like to ask a follow-up question, again, bearing in mind that this is a limited sample -- and I'm sorry, we'll come back, Dr. Allen, with several questions. But I'd like to stick with this for just one second.

Do you have a sense to what extent abusive treatment was directly related to information or intelligence gathering and to what extent it had a life of its own?

DR. RUBENSTEIN: It's both. There -- There is no question that in the development and approval process for methods that were designed to disorient and create dependence, techniques like sleep deprivation, isolation and other psychological methods, those were clearly related to interrogations. In fact, the standard operation procedure manual for Guantanamo, which was leaked back last fall, which was 2004, it basically says -- it says in black in white, in the first 30 days, people will be kept in isolation for the purpose of creating disorientation and dependence. So many of these methods were quite deliberate. And then, they do take on a life of their own.

When abuse and dehumanization is tolerated, it inevitably leads to worse. And that's what we say. That's how you end up with beatings and worse.

That the lack of control and the sense on the ground -- the soldiers on the ground, that they -- that they were supposed to break these people down, does end up removing restraint and so a whole new dimension begins. That's what we think the dynamic was.

DR. KELLER: I would add to that, that, yes, I think it did start with a misguided assumption that this was an important part of intelligence gathering. Actually, in the film by the same name as the manual, documentary standard operating procedures where a number of the soldiers who were in Abu Ghraib, you know, they commented how they would be specifically told by the interrogators, "OK, this prisoner should have a bad night. Make sure they have a bad night," which meant they wouldn't sleep or they'd be subjected to horrific -- horrific things.

And, you know, what was clear in Abu Ghraib is you had -- and I believe in Guantanamo as well -- this phenomena of what I call moral disengagement, that individuals may somehow contextualize what they're doing as part of a greater good. And they rationalize what they're doing, such as the psychologist who is in the room monitoring the interrogation and misguidedly thinks, "Well, I'll serve as a buffer," whereas really they probably serve more as an enabler. And so the abuse, as Len said, I think intensifies.

And it's really -- the ironic things is, you know, and again, what we've learned, where did this procedures come from? We, you know, learned from the best, from, you know, a manual from the Chinese that I believe was entitled, "How to Extract False Confessions." So these methods were never intended for getting at the truth. What they were intended was getting confessions.

You can get -- you know, and one interesting things, having spent a lot of time over the past year talking with professional interrogators, you know, there was something I found in common with science is saying, "Garbage in, garbage out," that they would say, "Look, we can get anybody to say whatever -- whatever they want."

And then I also think that this language is so important. That somebody may say, well, as our former secretary of defense said, "Well, gee, I stand for, you know, I stand for four hours a day. What's so wrong with that? Have them stand for eight hours." Well, there's a profound difference between somebody standing by choice, who is actually moving around, versus somebody standing in one place for several hours, where the blood begins to pool. The legs swell. You can develop clots, which can go to the lungs and potentially be life -- life threatening.

Sleep deprivation, another of our presidential candidates said, "Hey, I'm sleep deprived. I don't think this is torture." Again, a difference between a presidential candidate with lots of comforts, I'm sure, although I don't doubt they're fatigue, versus somebody who has no idea when they're going to sleep again.

And after being deprived of sleep, you become paranoid. You develop symptomatic symptoms, headaches, dizziness. You have delusions. Not a -- not a good recipe for useful information.

So it does start as information gathering perhaps, but then I think it takes on a life of its own.

But it came -- it's important to realize it wasn't random. It was manualized.

DR. ALLEN: If I could just add again from my perspective of seven years working full time in a prison, there's an old study that we all point back to, and every one should be reminded of, the Stanford Prison Experiment. And it described the tendency of good people to do bad things when put in a setting when they have absolute power and control over another population. That phenomena is only enhanced when the population is demonized across a cultural barrier or a language and then certainly in a war situation. So from our perspective, we see these settings as tremendously high risk for abuse, which is why is all the more important to have operating procedures that go out of their way to draw a bright line and -- and make it clear that human dignity must be preserved.

Now, in this case, as my colleagues have already made blatantly clear, it was from the top level that said, "No, we're not going to do that. We might have our reasons why we're not going to do that." But that opened the door. And once that door is open, these tendencies of abuse, which are deeply ingrained unfortunately, are allowed to come forth.

REP. SLAUGHTER: Dr. Allen, I'd like to stay with you for a minute and go back to one of the issues that you touched upon, and that is the question of forced feeding. There -- there was a period of time after Guantanamo that Guantanamo Detention Facility was opened that there were no deaths at that facility. And this was something that was sometimes mentioned by U.S. officials at briefings. And I think they pointed to that as evidence of some level of care that was afforded to the detainees, that there had been no deaths at Guantanamo. However, in 2006, two Saudi detainees and one Umani (ph) detainee hang themselves.

And in 2007, a Saudi detainee was found dead in his cell. To my knowledge, there are no details about that particular case. But there have been four -- at least four deaths.

At one point, we also know or believe from reports, that there was a very large number of hunger strikers. One report in May 2006 suggested as many as 75 detainees, which out of the -- the prison population of several hundred is quite a large percentage, maybe 75, were on hunger strikes.

Subsequent to that, we started to get reports that the procedures used to engage in force feeding were quite harsh.

And I'm wondering if you can tell us something about the norms that apply for medical professionals? I do understand that the International Criminal Tribunal for the former Yugoslavia allowed one detainee to be force fed, one detainee before the court who was refusing to eat.

So what's the norm that's at play? And then, beyond the specific norm, when that norm is being implemented, is there something about the way that -- are there different methods of force feeding and some are more humane than others or some are less humane? Thank you.

DR. ALLEN: Well, there's a lot in that. And I'll try to address all your points. Feel free to redirect me if -- if I don't.

The history of the use of force feeding at Guantanamo and its possible relationship to subsequent suicides is a very provocative question, something I've wondered about. And it speaks more to the context in which hunger striking occurs.

Remember, and in particularly, if you wanted to design an environment that would increase the risk that there would be hunger strikes, they could not have done a better job than Guantanamo. The standard on how to manage hunger strikes, the ethical standard, has been articulated and recently updated for the World Medical Association. And that position is -- has been adopted by the American Medical Association. And that guideline is explicitly clear that under no circumstances would you force feed a competent and informed detained who is refusing nourishment after having been, you know, informed of the potential consequences.

Now, that seems like an odd thing for a medical, ethical group -- physician to take because obviously it could be at the odds with the duty to preserve life. But it is a position that has been formed by years and years of looking at an experience -- having experience and talking to people who have managed hunger strike situations. That it realizes that these really true-to-the-end hunger strikes generally only occur in situations where there are no other mechanism for the individual to protest their conditions of confinement or to assert their autonomy over their own body and their own health. So that's a very important value to be preserved.

And again, medical bodies have recognized that even thought duty to preserve life is a preeminent medical value, it does not trump a competent individual's right to make an autonomous decision about their own health.

So a couple of things appear to have happened over the course of management of hunger strikes at Guantanamo. One, as you note, they started to happen with increasing frequency and with larger numbers of individuals.

You know, this -- at one point, one of the camp commanders refers to this as asymmetrical warfare. This is a situation where you have a -- a -- a group of detainees who are so disempowered -- it seems like an absurd notion. Clinically, speaking that's entirely absurd. To me, it said there's increasing desperation among the detainees and that was a reflection of it.

What they started doing is increasingly using force feeding and very possibly, although we have yet to nail this down, intervened with force feeding before it was clinically indicated. Now, to the extent that there's some controversy about WMA and preservation of life versus autonomy, there is no controversy about the idea of forcing the feeding tube down someone's nose, through their esophagus, strapping them down to a chair or a table and pouring nutritional supplements through that tube when it is not medically necessary. So there is some question whether that has been done at the direction of a camp commander directing medical staff to intervene before it would be medically indicated. And if that happened, that's just such a clear violation that -- that's not even in the same category.

REP. SLAUGHTER: Thank you.

I'd like to go back to Dr. Keller with a different question. When you're interviewing or -- I'm not sure what the proper term is for when you're examining these individuals and you're trying to determine what's happened to them, it seems that some of the medical or psychological problems they may suffer now could potentially have been caused by preexisting conditions. And it seems that that must be a very difficult thing to sift through. And I'm wondering if you could elaborate a little more on how you figure out what was caused -- even when you find real problems, how do you determine what was caused by the conditions they experienced during their detention and what came before that?

DR. KELLER: Right. Well, so first, we have, as Len alluded to, an invaluable roadmap, arguably the gold standard with which to conduct these evaluations, specifically the Istanbul Protocol, a document recognized by the United Nations, which was the product of, I think, over 30 or may even 50 experts in the field of torture working for several years on developing standards on how such evaluations should be done.

So first, it all starts, you know, with a very detailed history. And, you know, one, we had the good fortunate of having time. As I said, for each of these evaluations we had both a medical and a mental health professional conducting the interviews. And it was often over the course of two days so that you had the opportunity if there was something, you know, that hadn't made sense or what have you that you, you know, can go back to them. And like everything else, the longer you spend with someone, the more of a sense you get about what they have.

And one thing that I was very struck by with everyone I interviewed frankly was their candor. You know, that individuals were very clear about what mental health problems, for example, that they had, which is nothing something necessarily even that, you know, the Muslim population would be forthcoming in talking about. But that there was, you know, one individual who had told us about, yes, in fact, had some suicide attempts before he was arrested. And this one individual I described describes some feelings of sadness. So similarly with scars with -- and I would do these -- we would do these detailed histories and then do a very detailed review of physical symptoms, a review of psychological symptoms, a review of -- you know, then a lengthy physical examine.

And individuals were quite candid that, "Oh, yeah, well, this scar, you know, I got from when I was playing soccer as a young boys. This one I'm actually not sure about. This one I'm sure came from, you know, XYZ."

So it's frankly -- it's contextual in that it's the overall picture from which one makes their assessment, you know, based on the consistency, based on their candor, their affect, and then what -- does it make sense?

You now, my wife, who is a former prosecutor, said that's always the important question, you know, does what they're saying make sense. And, you know, is it consistent with what you're finding.

I mean, if somebody pointed, as I have had in some cases, you know, to where it's clearly a vaccination scar and said, "Well, you know, I got this, you know, from where they burned me with a cigarette," that, you know, is problematic.

But I just was struck by the candor, struck by the affect, struck by the fact, again, that, you know, I think arguably the least likely population I could think of, based on my years of work with torture survivors before this, of being candid about sexual humiliations is a Muslim male population. So it was -- and actually, it was really -- really the most difficult part.

And I must say, you know, as we -- the -- the hundred pound or five hundred pound gorilla in the room was that there were Americans sitting across the table. And so, you know, there -- took some time for some reporte building. And frankly, good interrogators will tell you that that's what it's all about, you know, frankly, whether you're doing an interrogation or whether you're doing a medical evaluation, in terms of reporte building.

So I don't know if that...?

REP. SLAUGHTER: It does. And I would like to ask a follow-up question. Your testimony indicated that some of these individuals really needed to be referred for additional treatment afterwards, after -- based on what you observed.

And as you know, the former chairman of this commission, Congressman Smith, was the original author of the Torture Victim's Relief Act. And many of the commissioners have support that as well and supported funding for torture treatment centers in the United States and around the globe.

And I'm wondering if you have any observations on the adequacy of care that's available to these individuals now.

DR. ALLEN: Well, first, I must start by really just acknowledging Congressman Smith's and the late Congressman Lantos' and other's extraordinary leadership on what really was a bipartisan movement to -- to sponsor the Torture Victim's Relief Act, which provides for funding for torture treatment centers in the United States, such as our own. And there's a consortium now of more than 20 centers around the country, the National Consortium of Torture Centers, many of whom are funding through this.

And it's estimated that there are over 400,000 torture survivors here in the United States. And tragically, the world being the way it is, we're very busy. We have, I think, right now, 70 people on our waiting list.

The Torture Victim's Relief Act also provides for international funding, one directly and then also through the United Nations Voluntary Fund for Victim's of Torture. So I actually think that both on the -- the good news is that there is funding out there. The unfortunate thing is it's clearly been inadequate.

The Torture Victim's Relief Act is funded right -- it's been pretty much steadily funded at around $10 million a year. And now, it's at the point where I believe it -- it's authorized, you know, for, you know, being up to $20 million. But what gets allocated is consistently $10 million. And that's woefully inadequate.

And so I think being true to the spirit of the Torture Victim's Relief Act, that, yes, now being in the uncomfortable position of having been the perpetrators of this abuse, we have a moral responsibility, as Len stated, to acknowledge this, to investigate this, to apologize and to make sure that individuals have access.

I mean, pretty much all the individuals that I saw -- there was one individual who frankly had had, you know, quote, "the least benign treatment," who was emotionally in tact, I would say. Pretty much everybody else that I evaluated, you know, as I said, were shells of who they were and really needed physical and psychological services.

Some individuals that we evaluated, we actually were able to refer to centers and others we were sending back into an abyss where there were no services, so in Iraq, the former Guantanamo detainees. Unfortunately we have created a lot of need for torture treatment programs.

REP. SLAUGHTER: Thank you.

I -- I'd like to throw this next question open. Clearly, your report suggests that there are medical personnel that did not report on mistreatment that they witnessed, and there may have been medical personnel and went beyond that and, in some way, played a role in the mistreatment. And related issue of particular import, I think, are the reports on the waterboarding of three detainees. Some of those public reports have suggested there may have been medical personnel waiting in the wings. And I guess I'd like to hear you all speak a little bit more to the question of what those medical professionals should have been doing. I think, at one point, it's indicated in the report that it -- it -- there's no evidence in the cases that you looked at that any of these medical professionals reported anything to anybody.

At what point should they have done that? At what point is it -- do medical personnel say, "I can't. I have to remove myself"?

DR. RUBENSTEIN: First, to clarify on the reporting, we didn't have access to -- to whatever abuse reported were filed. What we did have access to in the medical record was there was no evidence in the medical record that you would have thought would be found there if they had reported it.

So it was like one case that we -- we are confident that it wasn't reported.

The standard is very clear that -- that physicians and other medical personnel cannot play any role whatsoever in torture, including being present. And that -- that's included because -- or two reasons. One, not to be able to help interrogators calibrate the amount of harm that's being imposed. And that's the problem with the behavioral science consultation teams, where the role is to calibrate harm.

And the second reason is they're not supposed to patch people up so they can be tortured some more. And that's what we think happened.

House professionals were in a difficult, conflicted position in these facilities because they were working in an environment where people were being subjected to torture and ill treatment. And you do have a responsibility as a physician to -- and other medical personnel, to provide are, but you can't be in a position of providing care so that torture can continue.

There was the case of a man who's should, I think, was dislocated. And it was put back and then back in a stressed position.

So that is where they were in the worst possible position. Now, there were some who may actually have played a more extensive role, like in waterboarding, where they are really part of the apparatus of making the torture take place.

But I think, far more common, it was that they were on the scene to patch people up and they had no support. And they thought of themselves, we think, as to be expected to provide care.

And so the only thing they can do is report, protest and -- and demand -- protest the treatment and demand it stop and that they will not have anything to do with patching people up. And that is a point of leverage.

And health professionals in the military have a little more autonomy than other soldiers, so that they could have spoken up. But it's not -- it's taking themselves out of the apparatus, which is the key.

And you may want to comment as well.

DR. ALLEN: Well, I think what I'd like to add to that is this issue of -- the role of health professionals does go beyond what Len was just talking about. We do have evidence now, particularly psychologists who helped design and -- and develop these techniques. And so, you know, that was going far beyond failing to stop and intervene. So I just do want to mention that the scope of participation was broader.

And the way that was achieved bureaucratically, so to speak, was that the certain health professionals were assigned outside the care domain and then were told, "You don't have to answer to traditional medical ethics. The guidelines, even in the Defense Department, but more likely in the CIA, created this new domain of health professional that, if not assigned to direct care, was not answerable to medical ethics. So I do want to make mentioned of that.

But back to the issue of the health professionals assigned to the care teams, my -- my concern is -- well, first of all, a big caveat. We don't know the full story of whether some health professionals did actually intervene. If so, we're not aware of a single episode.

Interestingly enough, although this is all very shrouded in secrecy, we are aware of non-professional soldiers intervening to stop torture and some -- and, in some cases, some lawyers. So it seems to me that after years of the profession expressing dismay that no doctors or medics of psychologists, or, you know, psychiatrists intervened, it seems to me, if there was a case, by now, it would have been trumpeted out and then talked about and then, you know, used as an example of good behavior. So I'm concerned that that has not come to light.

But the caveat is we don't have a full record. The last thing I'd like to say about that is to go back to Congressman Hastings' point about trying to have oversight when you can't get a straight answer and tie it back to the use of medical records.

You know, a lot of what we do is sort of forensic medical work. The medical record, if it can be obtained in a proper manner, such that there's proper consent and confidentiality is protected, might be one of the best pieces of information, as it's a standardly written, chronological record of what happened to these individuals. So that's something -- the answers to exactly what health professionals did are recorded somewhere. And at some point, that should be looked at.

DR. KELLER: I'd just like to add a couple of things from some of the individuals whom I interviewed that speaks to the question of, OK, what does medical participation mean.

So first, as was alluded to, developing techniques. And, you know, there -- there are a group of psychologists who, quote, "developed or used these methods had been used, you know, in the Sear (ph) training methods and then misapplied them. Arguably, they pilfered, plagiarized, whatever term you want to use, from the Chinese manual.

And apparently, these individuals, my understanding of the psychologists that were involved in that, were not really not individuals who had particular expertise in this area, but suddenly were put in this area of having authority and kind of went with it.

Among the individuals I evaluated -- I mentioned one, this very chilling example of the -- a Guantanamo detainee who had described several ways that doctors were involved. One, you know, when he was in Camp X-Ray, he described what he called robo cops on parade, you know, when there would be some -- they would do something wrong. Someone would be having their hands under the blanket or whatever and that the -- you know, the military guards, you know, in their armor, would march out and beat them up. And at the end of the parade was somebody they believed was a physician with a gurney there, you know, just to -- you know, just in case, and kind of check things out.

But -- and I asked the question, "Well, you know, did they ever hear that individual speak up." And they said no.

And the same thing I heard from Abu Ghraib detainees. There was one individual who I interviewed, who had been detained in a dark cell and who was claustrophobic and terrified. And he was, actually, as a punishment, forced to stand outside of his cell naked for several hours. And you know it's bad when that becomes your respite period because, when they went to put him back in the cell, he actually pleaded with a physician who was walking by. He said, "Please don't have them put me back in the cell." And the physician, I guess, asked a guard. But then said, "Oh, sorry, you know, you've got to go back."

That case of the physician monitoring the vital signs of the individual in this room where it's very hot or very cold -- that's similar to what's been documented with waterboarding, for example, in Argentina. I'm not so sure about the medical participation in waterboarding here. None of the individuals we evaluated reported waterboarding.

But, you know, there again, not in a therapeutic setting, but really, you know, kind of to measure or, you know, whatever, push to the limit, but not -- but not kill them.

And then the violations of confidentiality. There have been clear reports of sharing information, you know, so that weak spots could be extrapolated. And I, first hand, heard an example of that from this psychologist -- from this individual who reported that when he'd asked to speak to a psychologist, he'd spoke to somebody who identified themselves as a psychologist. There name, I believe, was taped over. But, you know, and talked about how lonely, and how much he missed his family. And he said, you know, he'd been interrogated like everyday, every other day, and they asked the same questions. And the next day after he spoke with that psychologist, the questioning took a totally different, you know, turn, zeroing in, as it hadn't before, on that issue of him missing his family. And, you know, that's what they kept at. And then they moved him to this -- this -- this area where it was even worse.

So, and then finally, you know -- all -- as has been pointed out, it's a clear violation of medical ethics to, in any way, practice or condone any torture and that health professionals have a positive responsibility to report this.

There's debate with interrogations and being present. The out wire is the American Psychologist Association. All the other professional societies have said, "Health professionals don't have a place in an interrogation." Whereas, the American Psychology Association, although there's a lot of debate and argument - their meeting, I think, is at the end of August, so I think it will be a pretty interesting one about that. But they, so far, as an organization said, "No, there is a place."

And from my understating of what's happened in Guantanamo, for example, they really aren't -- you know, they think maybe, you know, we're there as containing the situation. But I think what happens is the -- the health professional there is like, well -- you know, they're there at the behest of the military so they're like, "Well, maybe I can wait a little longer." And the interrogator or whoever is thinking, "Well, if I cross the line, they'll stop me." And so the two enable.

And then the last thing I'll say is, having actually spoken to some health professionals whom I've known who've worked in Guantanamo, I remember there was one thing someone told me that I was really struck by, which is that he said, "You know, in Guantanamo, we learned that everybody stays in their lane." And to me, that almost became -- you know, what I was hearing was hear no evil, see no evil, you know? And so, and I asked, you know, "Well, did you find any evidence of torture." He said no. I said, "Well, did you look for it? Did you ask"? And, you know, there was kind of a shrug.

REP. SLAUGHTER: Before I bring this briefing to a close, I'd like to ask you if you have any final comments to make. And then I'd like to make two observations of my own. But if you -- if you have any final thoughts you'd like to share...

DR. RUBENSTEIN: Well, I would first like to thank the commission again for -- and Congressman Hastings for holding this briefing.

I think it's really important to recognize that these issues have not been sufficiently explored.

And in particular, it struck me as we're having this conversation that this is the first discussion in any official congressional activity of the medical participation issues.

So when people say we've looked into this enough, we haven't at all.

And so I'm both appreciative of this hearing, want to emphasize that there's much, much more we need to know.

DR. KELLER: What I'd like to add to that, yes, also is extraordinary gratitude for holding this briefing.

And, you know, I came initially scratching my head a little bit about, OK, why is the Helsinki Commission doing this? And, you know, I really get it because they -- they understand it. I mean, what have we wrought by what we've done? Ultimately, we've violated the Golden Rule. You know, for years, we told the Turks, we told the Soviets, we told whoever not to do this, not to do that, not to, you know, extrajudicially arrest someone, not to torture.

and so what we did was, we said, well, it's not torture, it's enhanced interrogation, you know, and all these other ridiculous things that, at the end of the day, one, in addition to making, you know, it more dangerous for those, you know, innocent civilians -- and it's important to know, most torture victims aren't terrorists or terrorist suspects. They're, you know, student advocates. And it's never really about -- or, you know, people seeking freedom. It's never about information. It's about quieting and intimidating. So we've made the world more dangerous for them.

But I also think in terms of the international policy level, which, you know, clearly the Helsinki Commission understands, it's made a much more difficult row for us to hoe.

How can we hold others accountable? How can we possibly done this when we have done these things? And so that's why it's so crucial that, you know, better late than never that we take the high road and that we say, OK, these things happen.

We're going to investigate it. We're going -- there's going to be accountability. It's not just a whitewashing of, well, a few bad apples on the -- on the night shift. So accountability is -- is -- is crucial. It's not as simple as, well, let's just put this behind us. Because unless we really examine this and document and -- to have accountability, it will never be behind us.

And then, I am left with thinking that tragically there is, I fear, going to be an even greater epidemic of torture. It's documented to occur in 100 countries now. I think what we have done has empower -- emboldened -- not that Robert Mugabe, for example, needed any excuses. But I think I have -- he has been quoted as saying, "Well, you know, look, the U.S. does this." And so on and so forth. National security is what's always or often invoked in the name of torture. So I think we've made it a lot easier for despots to do what they want to do. So I fear we're going to see a lot more torture survivors.

And again, that goes back to an issue that Congressman Smith and others have led on, which is that I think there's going to be a much greater need for increased funding to care for torture survivors, one, who have suffered at our hands and, two, who were victims because, you know, there's more torture probably going on now because of these emboldened depot regimes.

DR. ALLEN: I had the opportunity, with DHR, earlier this year, to travel to Libya to examine one of their leading dissidents and political prisoners to verify, A, that he was still and alive. And our goal was to try to protest his treatment and conditions. And we had to confront the officials of Khadafy's government about his treatment. And we were immediately told in response, "Who are you to say anything about how we treat somebody in our custody? We haven't done any of the things that you have been alleged to do as part of official policy."

You know, I think that it's obvious to all of us that we've done great damage to ourselves.

As a physician, it disturbs me that we've done potentially great damage to our profession and our standing. And medicine is based on the practice of trust. And when detainees can no longer trust their physicians, providing medical care in detention settings will be and is impossible.

So I think the important thing is to thank you for allowing us to talk about this issue.

I think there's an understandable denial on the part of the American government and the American people to not want to think about the fact that we've done bad things. But the only way to repair this damage that we have done is to have an open discussion about what has happened, look at why it's happened, document explicitly what's happened, and -- and make some revisions on our policies and move forward and correct our path.

Thank you.

REP. SLAUGHTER: Thank you.

I'd like to conclude, first, by thanking each of you for coming down today and participating in this briefing. You bring singular areas of expertise with you. And we have benefited enormously from -- from your being here today and sharing that with us.

But secondly, I'd also like to commend to anyone who has not yet done so the preface to this report written by Major General Antonio Taguba. General Taguba, as my colleagues here remember, was one of the high-ranking officials tasked with investigating the abuse at Abu Ghraib. And his report -- his preface to the report describes this as the largely untold human story of what happened.

His preface is short, but very compelling. So with that, and the recommendations, it's a great book end for this report.

And I want to thank all of you for being with us here today. Thank you so much.

The briefing is adjourned.

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