[Ppnews] Guantanamo prison military document lays bare the brutality of force-feeding.

Political Prisoner News ppnews at freedomarchives.org
Mon May 13 10:47:14 EDT 2013


*Al Jazeera's exclusive publishing of a key Guantanamo prison military 
document lays bare the brutality of force-feeding.*


Jason Leopold <http://www.aljazeera.com/profile/jason-leopold-.html>Last 
Modified: 13 May
http://www.aljazeera.com/humanrights/2013/05/201358152317954140.html

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Guantanamo Bay, Cuba - Hunger striking Guantanamo prisoners who are 
force-fed a liquid nutritional supplement undergo a brutal and 
dehumanising medical procedure that requires them to wear masks over 
their mouths while they sit shackled in a restraint chair for as long as 
two hours, according to documentation obtained by Al Jazeera. The 
prisoners remain this way, with a 61cm - or longer - tube snaked through 
their nostril until a chest X-ray, or a test dose of water, confirms it 
has reached their stomach.

At the end of the feeding, the prisoner is removed from the restraint 
chair and placed into a "dry cell" with no running water. A guard then 
observes the detainee for 45-60 minutes "for any indications of vomiting 
or attempts to induce vomiting". If the prisoner vomits he is returned 
to the restraint chair.

That's just a partial description of the "chair restraint system 
clinical protocol" which medical personnel are instructed to follow when 
administering a nutritional supplement to prisoners who have been 
selected for force-feeding by Guantanamo Commander Rear Admiral John Smith.

Standard operating procedure

The restraint system, published here for the first time, along with 
the feeding procedures policy, was contained in a newly revised Standard 
Operating Procedure (SOP) for Guantanamo hunger strikers, obtained 
exclusively by Al Jazeera from United States Southern Command 
(SOUTHCOM), which has oversight of the joint task force that operates 
the prison.

The 30-page manual contains the most detailed descriptions to date 
pertaining to the treatment of hunger strikers and prisoners who undergo 
force-feedings. The SOP replaced a previous SOP issued in 2003 - revised 
in 2005 - which was declassified several years ago by the Pentagon, 
albeit with redactions. The new, unredacted policy obtained by Al 
Jazeera went into effect March 5 - one month after Guantanamo prisoners 
launched their protest over the inspection of their Qurans.

The procedure appears to have been revised and implemented in order to 
deal with a mass hunger strike.

"Just as battlefield tactics must change throughout the course of a 
conflict, the medical responses to GTMO detainees who hunger strike has 
evolved with time," says the SOP. "A mass hunger strike was successfully 
dealt with in [2005] by utilising procedures adopted from the Federal 
Bureau of Prisons and the approach delineated in this SOP.

"However, the composition of the detainee population, camp 
infrastructure, and policies has all undergone significant change since 
the initial version of this SOP... Much of the original instruction has 
been retained in the form of enclosures. In the event of a mass hunger 
strike, these enclosures can be utilised as they have proven efficacy 
under mass hunger strike conditions."

The SOP notes that there are a number of prisoners who have been hunger 
striking since 2005, who have "proven their determination", and whose 
physical frailty have limited Guantanamo authorities' "options for 
intervention". The document goes on to say, "in the event of a mass 
hunger strike, isolating hunger striking patients from each other is 
vital to prevent them from achieving solidarity".

On April 13, guards staged a predawn raid at the communal camp and 
isolated more than 100 prisoners into single cells in an attempt to 
bring an end to the protest.

'Orwellian'

Leonard Rubenstein 
<http://www.jhsph.edu/news/news-releases/2009/rubenstein.html>, a lawyer 
at the Center for Public Health and Human Rights at the Johns Hopkins 
Bloomberg School of Public Heath and the Berman Institute of Bioethics, 
who reviewed the SOP document for Al Jazeera, said the revised 
guidelines were troubling because they prohibit doctors and nurses from 
acting independently and make clear that they are simply "adjuncts of 
the security apparatus".

Indeed, the SOP says that in order to effectively manage hunger 
strikers, a "close partnership" must exist between the Joint Medical 
Staff and the Joint Detention Group security force. Rubenstein 
characterised the relationship as "Orwellian".

"It is a very frightening idea that the medical staff is an adjunct of 
the security force," Rubenstein said. "The clinical judgment of a doctor 
or a nurse is basically trumped by this policy and protocol. Doctors are 
not acting with the kind of professional medical independence. It's 
clear that notwithstanding references to preservation of detainee health 
in the policy the first interest is in ending the protests."


Rubenstein pointed out the SOP does not provide any direction to medical 
personnel on how to deal with prisoner's who may be suffering from a 
mental health condition.

Currently there are at least 27 prisoners who are being force-fed, 
although some of the lawyers of the prisoners say the number is much higher.

The SOP says the Behavioral Healthcare Service (BHS) "will perform an 
assessment of the mental and psychological status of the detainee, which 
will be documented in the outpatient medical record ... BHS will 
continue to regularly evaluate detainees who continue on a hunger strike."

"What's missing is the determination of capacity that is required by 
international ethical guidelines as well as responsiveness to the 
detainee's needs," Rubenstein said.

Prisoners are designated as hunger strikers, according to the SOP, if 
they communicate, "either directly or indirectly (i.e. repeated meal 
refusals) his intent to undergo a hunger strike or fast as a form of 
protest or demand attention" or if they miss nine consecutive meals and 
their ideal body weight falls below 85 per cent of either previous or 
ideal weight.

Final authority

The SOP grants Guantanamo Cmdr. Smith - not physicians - with the final 
authority to select hunger-striking prisoners for force-feedings.

Nurses, who according to the SOP conduct the feeds, and doctors, are 
merely on hand to carry out the military's policy. Two weeks ago, 40 
more nurses were sent to Guantanamo to assist with force-feedings.

"In the event a detainee refrains from eating or drinking to the point 
where it is determined by the medical assessment that continued fasting 
will result in a threat to life or seriously jeopardize health, and 
involuntary feeding is required, no direct action will be taken without 
the knowledge and written approval of the [Joint Task Force-Guantanamo] 
Commander [Navy Rear Adm. John Smith, Jr.]," the document says.

Once prisoners are selected for force-feeding, Smith notifies the 
Commander of SOUTHCOM, Marine Corps Gen. John Kelly, who then alerts top 
officials at the Pentagon of the "necessity of initiating involuntary 
feeding of a detainee."

Although the SOP says medical personnel will make "reasonable efforts" 
to obtain consent from prisoners designated for force-feedings, the 
document also notes that if consent cannot be obtained "medical 
procedures that are indicated to preserve health and life shall be 
implemented without consent from the detainee."

Rubenstein said the authority granted to Smith in which he chooses the 
prisoners for force-feeding is concerning because it gives the commander 
complete control over a medical procedure and medical decisions that 
doctors should be responsible for.

In a letter sent to Secretary of Defense Chuck Hagel last month, 
American Medical Association president Dr. Jeremy Lazarus said the 
force-feeding procedure at Guantanamo, saying it "violates core ethical 
values of the medical profession."

"Every competent patient has the right to refuse medical intervention, 
including life-sustaining interventions," Lazarus said. "The AMA has 
long endorsed the World Medical Association Declaration of Tokyo, which 
is unequivocal on the point: 'Where a prisoner refuses nourishment and 
is considered by the physician as capable of forming an unimpaired and 
rational judgment concerning the consequences of such a voluntary 
refusal of nourishment, he or she shall not be fed artificially.' "

The United Nations has condemned force-feeding as both a form of torture 
and a breach of international law.

The revised SOP, however, says the Department of Defense and Joint Task 
Force-Guantanamo (JTF-GTMO) "policy is to protect, preserve, and promote 
life. This includes any serious adverse health effects and death from 
hunger strikes."

Currently, there are 27 prisoners who are being force-fed. Long-term 
hunger strikers who are force-fed, or as the SOP describes them, 
"chronic enteral feeders," "are notified by the corpstaff that 'It is 
time to feed.'"

Preparing for a mass hunger strike

The new hunger strike policy raises far more legal and ethical questions 
about the force-feeding process than the policy the military issued in 
2003 and revised two years later. Pentagon spokesman Lt. Col. Todd 
Breasseale told this reporter on March 4 there was nothing questionable 
about the way in which Guantanamo hunger strikers are treated.

Guantanamo officials, Breasseale said, "follow the Federal Bureau of 
Prisons (BOP) protocols 
<http://www.cbsnews.com/htdocs/pdf/bop_fbi_hungerstrikepolicy.pdf>regarding 
hunger strike management and involuntary feeding of hunger strikers."

However, according to a report 
<http://www.detaineetaskforce.org/read/#/244/>issued in April by the 
nonpartisan The Constitution Project, "at least some federal prisons 
handle hunger strikes very differently, and far less coercively, than at 
Guantanamo."

For example, "The written federal guidelines for force-feeding make no 
mention of restraints, and include several safeguards that are not in 
place in Guantanamo," according to The Constitution Project, whose 
members spent two years investigating the treatment of "war on terror" 
prisoners. "Prison guidelines require the warden to notify a sentencing 
judge of involuntary feeding, with an explanation of the background of 
and reasons for involuntary feeding, as well as videotaping of 
force-feeding. BOP requires that 'treatment is to be given in accordance 
with accepted medical practice.' Accepted medical practice requires an 
individualized assessment of the patient's situation that appears to be 
absent at Guantanamo. It also requires individualized counseling of the 
detainee..."

The newly revised SOP does not call for that type of counseling. 
Moreover, according to The Constitution Project, "The BOP's written 
policy on the use of restraints also conflicts with the restraint-chair 
protocol at Guantanamo."


"Federal prisons are known to use restraint chairs for inmates who are 
physically dangerous to themselves, other inmates, or guards, but at 
most federal prisons, the chairs are apparently not used for forced 
feeding," according to The Constitution Project's report. BOP 
"regulations make no provision to routine or categorical use in cases, 
regardless of an individual inmate's behavior, or the use of restraints 
in force-feeding."

The use of restraint chairs to force-feed Guantanamo prisoners was 
introduced in 2006 on the recommendation of a forensic psychologist and 
three consultants from the BOP who visited the prison in 2005 following 
a massive hunger strike. Human rights groups, who say the use of 
restraint chairs are a form of punishment and an attempt to break hunger 
strikes, have criticized its use.

Identifying Prisoners for Force-Fee ding

The SOP contains a "General Algorithm for a Hunger Strike," described in 
the document as a "simplified outline for the medical management of 
detainees on hunger strike."

It notes that after a prisoner is identified as a possible hunger 
striker a medical officer performs a physical and the behavioural 
healthcare service conducts a psychological evaluation. The prisoner is 
then "counseled" about the dangers associated with a hunger strike.

"If detainee continues to hunger strike and clinical criteria for the 
initiation of enteral feeding are met ...the detainee may be admitted to 
the Detention Hospital or designated feeding block if medically stable.


Authorisation is obtained via chain-of-command from JTF-GTMO Commander 
to begin enteral feeding."

Before being placed into the restraint chair, medical personnel offers 
the prisoner one last chance to eat voluntarily. If the prisoner refuses 
the "medical provider signs medical restraint order" to force feed the 
prisoner and encourages him to use the restroom before he is shackled.

The guard force then "shackles detainee and a mask is placed over the 
detainee's mouth to prevent spitting and biting," states the chair 
restraint protocol. "Detainee is escorted to the chair restraint system 
and is appropriately restrained by the guard force."

A 10 or 12 "French" size (3.3/3.6 millimeters in diameter) feeding tube 
is then placed into the prisoner's stomach through his nostril. He is 
given a topical anesthetic, such as viscous lidocaine for his nostril 
"unless detainee refuses." A sterile surgical lubricant, such as olive 
oil, is applied to the feeding tube.

"Placement of the feeding tube in the stomach is confirmed using" air 
insufflation along with a stethoscope and a test dose of 10 milliliters 
of water to ensure it reached the detainee's stomach.

"The feeding tube is secured to the prisoner's nose with tape and "the 
enteral nutrition and water that has been ordered is started and flow 
rate is adjusted according to detainee's condition and tolerance."

The SOP says a feeding can "be completed comfortably over 20 to 30 
minutes," a claim disputed by Guantanamo prisoner Samir Naji al Hasan 
Moqbel, who described in a widely read /New York Times /op-ed the 
intense pain he experienced from being force-fed.

The administration of two powerful drugs, in addition to a wide range of 
over-the-counter medication, further undercuts the assertion that 
force-feeding can be completed comfortably in a half-hour or less. The 
two drugs at issue, according to the force-feeding policy, are 
Phenergan, which is used to prevent motion sickness, nausea, vomiting, 
pain or as a sedative or sleep aid, and Reglan, which is used to treat 
heartburn caused by acid reflux. Long-term use of Reglan has been known 
to cause <http://drugs.com/reglan.html>the irreversible neurological 
disorder, tardive dyskensia.

The SOP states that if a prisoner vomits or attempts to induce vomiting 
after he is placed in a "dry cell" following the "nutrient infusion," 
his "participation in the "dry cell will be revoked and he will remain 
in the restraint chair for the entire observation time period during 
subsequent feedings."

The SOP contains a separate protocol for dealing with prisoners who bite 
their feeding tubes. That policy also belies claims in the document 
about the ease of force-feeding a Guantanamo prisoner.

Indeed, according to the biting protocol, "If the detainee is able to 
get the [enteral feeding] tube between his teeth, the RN [registered 
nurse] shall...direct the guard staff to stabilize the detainee's head 
in the midline position... Hold traction on the tube for as long as 
necessary for the detainee to relax his jaw; then continue safe removal 
of the tube. This may take considerable time."

Prisoners are not supposed to remain in restraint chairs for more than 
two hours.

One prisoner, Fayiz al-Kandari, a Kuwaiti who has been detained at 
Guantanamo for more than 11 years and is currently being tube fed twice 
a day said through his defense attorney, federal public defender Carlos 
Warner, that the size of the tube being used on him - 10 French - is too 
large and too painful.

"It takes several attempts to get the tube into the right place," Warner 
told Al Jazeera. "Once it goes down his throat he has a difficult time 
breathing. There's a gag reflex."

Lt. Col. Samuel House, a SOUTHCOM spokesman, told Al Jazeera "medical 
professionals" who conduct the force-feedings, "carefully evaluate each 
patient to determine the appropriate size of tube to use."

"A 10 [French] size feeding tube is tiny," House said. "It can be used 
in children as young as six months and is the recommended size for 
a one-year-old child according to standard pediatric references. Bottom 
line: either a 10 or an 8 Nasal Gastric Tube is tiny and should not be a 
big problem in an adult."

House added that all prisoners are given a choice at mealtime: "eat a 
hot meal, drink the nutrient, or receive an enteral feed."

/Follow Jason Leopold on Twitter: *@JasonLeopold * 
<https://twitter.com/JasonLeopold>/

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