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Costly Desires of a King In established democracies, the public sector allocates funds for infrastructure projects that represent a direct and real response to the needs of the people and contribute to their social welfare and development. Democratic practices also call for debate on the viability and economics of such projects. This ensures that public funds are spent efficiently and directed toward the most important aspects of development. The government of Bahrain has embarked on a dangerous adventure when it fiddled with priorities and interfered with the engineering aspects of projects. It seems that the driving criteria for major projects is politics alone rather than engineering judgment. The recent change of alignment of the highway leading to the formula one racing circuit (known as the National Loop Extension) is one such project. The change from the originally planned route has been in response to the King’s desire to keep the highway far from his Rawda palace between Hamad Town and Riffa’a. Despite years of feasibility studies and engineering design works that have been put into the project, the decision comes as an abrupt termination of efforts for the definition of the best route and the improvement of the transportation network. Professionals view this change with grave concerns. While the original design takes the highway along the east side of the most modern city in the country (Hamad Town), the new alignment results in a major, six lane highway, going through that city of over 60,000 population, in two places, tearing it apart into three areas. It is certain that if this change takes place, it will have serious social implications as it will disrupt a stable social fabric in the town. The financial implications are also huge. The new alignment will necessitate extra costs for the protection or diversions of existing services. The longer route of the new alignment will make the cost of the project higher by many million of Dinars. It also represents a fundamental departure from established theories and practices that call for the reduction of traffic inside metropolitan areas. The major highway into the city raises concerns about safety as well as damage to the environment. Such personal desires and interests of the king are at odds with the interests of the country and are becoming costly to the economy of Bahrain. Bahrain Freedom Movement

16 May 2003

Real change is needed Following the collapse of Saddam’s regime in Iraq, the King of Bahrain called for the Iraqis to be given the right to determine their destiny, and that they should shape the form of the new Government of Iraq. He also said he would be more than happy to host a conference for the Iraqi oppositions leaders in Bahrain so they can discuss freely the future of their country. Our people reacted with amazement to this call, arguing that if he believes that the people of Iraq should be have the right to decide the future of their country why doesn’t he let his own people (the Bahraini citizens) decide their own future and choose their own Government. Why is he imposing his uncle, the prime minister, on the people of Bahrain despite the fact that he is accused of reigning over the bleakest era of Bahrain’s history? The despotic approach of the Al Khalifa ruling tribe to the affairs of the country remains a source of tension among the people. When Al-Wefaq Society, the largest political group in the country, wanted to organise their general meeting two months ago, they had to struggle at every level to overcome the endless obstacles orchestrated by the ruling family. It is ironic that the ruler should issue his call to the Iraqi opposition. Furthermore, the new democratic experiment in the neighbouring Qatar, has dwarfed the pseudo-democracy of the Al Khalifa in Bahrain. While Sheikh Hamad personally abrogated the 1975 legal constitution and imposed his own constitution, the Qataris were given the right to approve or disapprove their new constitution. What happened in Bahrain took the country back to more than thirty years. There is a need for real change in the country if further political tension is to be avoided. Bahrain Freedom Movement

14 May 2003

Source: The Lancet Volume 361, Number 9368 03 May 2003 Overcoming obstacles in confronting torture Television images of torture chambers in Iraq and reports of the escalating use of torture in Zimbabwe remind us that this form of state-sponsored abuse continues unabated in many parts of the world. At the same time, there are growing allegations1 that some developed nations with a tradition of defending human rights might be sanctioning the use of coercive measures akin to torture in dealing with suspected terrorists. It is timely, therefore, to consider the reasons for the inadequate attention given to the topic by health professionals. Despite progress in apprehending and prosecuting perpetrators, torture continues to be used by more than 100 governments and by non-state actors such as armed militia in around 40 countries.2 Though much remains to be done, substantial progress has been made in the past decade in investigating the mental health consequences of torture.3,4 A consistent picture emerges of torture as a powerful risk factor in generating mental disturbance. In a study of Turkish ex-prisoners, participants who had been tortured showed pronounced increases in mental disorder.4 In a refugee camp in Nepal, torture greatly increased the risks of post-traumatic stress disorder (PTSD), depression, and anxiety.5 In four conflict affected countries, torture was a specific risk factor for PTSD in all but one population.3 Among Tamil refugees, of a wide array of war traumas, torture was the most powerful determinant of chronic PTSD.6 Although these studies are few in number, the consistency of the findings, especially in conjunction with documentation by human rights organisations, builds a picture of torture as a threat to the psychosocial wellbeing of vulnerable communities. If torture is a global health problem, why does it not feature more prominently in medical and psychiatric textbooks and in teaching and training programmes for health professionals? One obvious reason is the difficulty in obtaining access to torture victims held in prisons or living under oppressive regimes. Nevertheless, although research in such settings is difficult, it is not impossible.3,4 An additional challenge might be the discomfort many health professionals feel in confronting the reality of torture.7 Overcoming a natural tendency to recoil with disbelief and aversion to accounts of grotesque human cruelty is made harder for health professionals by the knowledge that colleagues in some countries are directly implicated in perpetrating torture. Strong psychological defences can be mobilised by health workers that encourage avoidance of the problem.7 Health workers may reassure themselves that torture is a political, not a medical problem, that such cruelty occurs in distant and foreign places and is not relevant to practitioners working in democratic countries, and that there is nothing that they can do to prevent such abuses. What, then, can health professionals realistically do? Strategies that help them to overcome their own avoidance of the topic could be the first step in mobilising collective action aimed at devising effective global strategies for prevention and treatment. To sensitise but not overwhelm health professionals, training in areas such as forensic assessment of torture victims should focus equally on the anxieties of the inexperienced professional as well as on technical expertise. Informed and well directed advocacy is critical. Although the main objection to torture is grounded in human rights principles, health professionals have sufficient information to state with authority that torture is damaging to the health and psychosocial wellbeing of survivors, a message that needs to be conveyed regularly and clearly at all levels of society. In practical terms, international health associations can have an active role in advocating for closer scrutiny of high-risk institutions such as prisons and detention centres. Attention is needed in educating research-granting authorities of the importance of scientific investigations into all health aspects of torture and the associated logistical and ethical constraints. Topics warranting attention are the evaluation of existing models of health care for torture survivors to clarify what works, and identification of personal, cultural, social, and institutional factors that build resiliency in survivors. By focusing on issues of adaptation, researchers and clinicians can portray a message of hope that depicts torture victims as people who can overcome their experiences to live meaningful, productive lives if they are offered appropriate conditions that promote recovery. Torture continues to be mysterious and foreboding, even for health professionals. The biggest challenge for the medical profession is not to succumb to feelings of helplessness and avoidance. We know enough about the health consequences of torture to indicate clearly that campaigns to prevent torture and to rehabilitate survivors should be a key mission for global public health. If we turn our backs on the problem, we play into the hands of perpetrators who flourish under conditions of international neglect and secrecy. Derrick Silove ———————————————————————— Psychiatry Research and Teaching Unit, Level 4, Health Services Building, Liverpool Hospital, Liverpool, NSW 2170, Australia ———————————————————————— (e-mail:d.silove@unsw.edu.au) 1 Summerfield D. Fighting “terrorism” with torture. BMJ 2003; 326: 773-74. [PubMed] 2 Amnesty International. Amnesty International report 2002. London: Amnesty International Publications, 2002. 3 de Jong JT, Komproe IH, van Ommeren M, et al. Lifetime events and posttraumatic stress disorder in 4 postconflict settings. JAMA 2001; 286: 555-62. [PubMed] 4 Basoglu M, Paker S, Paker O, et al. Psychological effects of torture: a comparison of tortured with non-tortured political activists in Turkey. Am J Psychiatry 1994; 151: 76-81. [PubMed] 5 Shrestha NM, Sharma B, Van Ommeren M, et al. Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal. JAMA 1998; 280: 443-48. [PubMed] 6 Silove D, Steel Z, McGorry P, Miles V, Drobny J. The impact of torture on post-traumatic stress symptoms in war-affected Tamil refugee and immigrants. Compr Psychiatry 2002; 43: 49-55. [PubMed]

7 Silove D, Tarn R, Bowles R, Reid J. Psychosocial needs of torture survivors. Aust N Z J Psychiatry 1991; 25: 481-90. [PubMed]

Source; The Lancet Medical Journal. Volume 361, Number 9368 03 May 2003 The medical community’s response to torture One would have thought that decades after international treaties prohibited torture absolutely, the practice would no longer be debatable by serious people. But one of the perverse effects of the war on terrorism has been the revival of the idea that torture can be legitimate in so-called exceptional cases, such as a calibrated infliction of pain to interrogate suspected terrorists. And now, as in the past, it is impossible to discuss torture without addressing the role and obligations of physicians who might be asked to measure the imposition of pain, examine the health status of the victim, or who might learn of torture when examining detainees. The revived discussion raises anew whether the medical community’s condemnation of torture, though worthy, has been an adequate response. Almost 30 years ago, the revulsion in the medical community at revelations that physicians had participated in torture in dictatorial regimes was transformed into an eloquent statement of principle, the Declaration of Tokyo, by the World Medical Association (WMA). Looking back, the declaration is a remarkable document. Both terrorism, spectacularly displayed at the 1972 Munich Olympics, and guerrilla violence in the developing world were seen as threats as grave then as those from Al Qaeda and similar terrorist groups are today. But the WMA refused to equivocate, taking an absolutist stance: “doctors shall not countenance, condone or participate in torture . . . in all situations, including armed conflict and civil strife.” It cited the principle that doctors must have complete clinical independence in pursuing the fundamental purpose of relieving an individual’s distress and stated “no motive, whether personal, collective or political, shall prevail against this higher purpose”. The medical profession has reason to be proud of this pioneering statement, which significantly predates the 1991 UN Convention Against Torture, and remains as compelling as ever. Yet, torture has continued and doctors find themselves implicated, often involuntarily. Paradoxically, because of pressures authorities place on physicians, inadequate training in documentation of torture, and absence of support from peers even medical examinations of detainees–designed as a safeguard against torture–can become a vehicle for gaining medical sanction for practices that include torture. At worst, evidence of torture is suppressed,1 at best inadequately documented.2 The message we should take from this experience, though, is not that medical resistance is ineffective, but that three steps are essential to strengthen it. First, medical documentation of torture must be improved, and physicians protected from reprisals. The Istanbul Protocol for Documentation of Torture,3 which established standards and guidance for medical examinations of torture victims, can provide guidance for higher quality examinations of detainees and contribute to the protection of physicians. An ongoing Istanbul Protocol Implementation Project, sponsored by the International Rehabilitation Centers for Victims of Torture, WMA, Physicians for Human Rights, and the Human Rights Foundation of Turkey, should aid the process immensely. Second, passive participation in torture needs to be squarely addressed. A decade ago, the British Medical Association (BMA) urged a duty by doctors to take action to stop torture when they become aware of it.4 More recently, an international working group on dual loyalty and human rights in the health professions–defined as simultaneous obligations, express or implied, to a patient and to a third party, often the state–has proposed practice guidelines that would prohibit passive participation or silence in the face of torture. The report states that “a health professional passively participates [in torture] by permitting his or her clinical findings or treatment to be used by authorities to aid the process of torture.”5 The proposed guidelines urge health professionals not to be present when torture takes place (usually for the purpose of medical monitoring of victims) and “to report violations of human rights that interfere with their ability to comply with their duty of loyalty to patients”. National and international medical associations should adopt standards such as these, which create the expectation that physicians confronted with torture will act to stop it. Finally, the medical community as a whole needs to speak out far more forcefully against torture. No longer can the obligation be understood as attaching mainly or exclusively to physicians working in detention facilities. Both the BMA and the working group on dual loyalty urge professional organisations to speak out against torture and provide support to physicians in situations in which compliance with ethical and human rights obligations is difficult. National and international medical organisations should not shrink from this duty, of which the courageous stand of the Turkish Medical Association is an exemplar. Nor should associations tolerate the idea that torture is acceptable in exceptional cases. The WMA properly resisted that argument in 1975, recognising that exceptional cases inevitably lead to regimes of torture. Indeed, silence in such circumstances amounts to tolerance. The international medical community can take pride in its role in seeking to end torture throughout the world. Today, though, we face a crisis not only because torture continues, but also because it is being newly legitimised in some quarters. The considerable efforts by the medical and human rights community risk being undermined if a voice as clear as it was in Tokyo is not heard once again.

Leonard S Rubenstein