Section 4 – “INSIDE ISRAELI JAILS” / “FIGHTING TORTURE: THE LONG WAY FROM DENIAL TO OUTLAWING”

Table of Contents

Introduction

In 1999, after a fellowship year at Radcliffe College, Harvard University, I returned to Israel for the summer vacation. Renowned human rights advocate Lea Tsemel and her partner Mikado Warschawski prepared a small party for our friends at their charming house in Jerusalem. The party was planned for September 7th. Then, one day before the party—on September 6, 1999—the Supreme Court gave a groundbreaking ruling, prohibiting the five methods of torture used by Israel’s General Security Service. These amazing news turned the small, family-like party into be a big celebration, popping champagne bottles open, with friends celebrating a long awaited for victory.

We tried to digest the huge, wonderful surprise. The Israeli Supreme Court outlawed torture! All the arguments, all the complaints we brought before the court year after year were recognized all of a sudden, respected and became powerful: the ruling said so! Suddenly thirty-two years of “security heroism” that overruled anything else—of arrogance born of excessive power, of freedom to lie even to the Court—all of it came crumbling down in front of our eyes by a reasoned decision of the Court.

We know how to be angry; we know how to struggle; we know how to be stubborn and persevere in spite of being so often thwarted. But in a moment of true joy, I remembered Nathan Alterman’s poem, the gist of which is:

We are dwelling in a solid house of sorrow,
yet, in the moment of a sudden true joy,
the house's pillars will fail.

This ruling felt like bright light, a huge comfort after a long, harsh trip that makes all your bones ache. And there was heaviness and a kind of fatigue in our joy. The court said:

A reasonable investigation is one free of torture, free of cruel or inhuman treatment towards the interrogee, and free of any degrading treatment. There is a prohibition on the use of “brutal or inhuman means” in the course of an investigation… Human dignity includes also the dignity of the suspect subjected to interrogation… This conclusion is in accord with international treaties – to which Israel is a party – which prohibit the use of torture, of “cruel, inhuman treatment” and of “degrading treatment”… These prohibitions are “absolute.” There are no “exceptions” to them and there is no room for balancing.

At the party Lea read aloud something she had written in the form of an open letter to one of the torturers of the General Security Service (GSS, a.k.a. “Shabak”), the so-called Abu-Jerry:
I looked at you and you seemed to me pale and abandoned, as if you lost your whole world in one instant. This time you didn't walk out of the place with your confident, arrogant steps. Both of us remember very well all those long hearings, seeing file after file, where you explained that “this is not really torture” and that “state security” requires evidence to be kept as secret material, etc. Surely you counted in your memory all those countless times where you convinced everyone — like the wolf in “Little Red Riding Hood”— that an ear-splitting music is played only to prevent the prisoner from hearing and communicating with others, that a stinking sack over his head is there in order that he will not see, that his limbs are tied only so he shall not move, that the blows are there because he became unrestrained, that the blue marks on his body are an outcome of falling down the stairs, and anyway he has a long record and there is no other way. . .

You remember all those brown eyes begging for a little mercy, that brimmed with pain, that said we will do whatever you want, we will admit whatever you say. You cannot forget that deep in your heart you always knew there would be a moment when another kind of look would be in those eyes – for an instant you could read in their eyes the promise of revenge….

Lea's words said what we felt in that moment.

Almost 10 years before this party, I met Lamiya, a young Palestinian man who looked like a boy, sitting in a wheel chair. His left hand was held close to his chest in a strange position, motionless. His left leg, too, was motionless. On his chest were burn marks in the shape of parallel stripes caused by an electric heater pressed against his body and on his hands were circular burns. His face looked serene and he kept smiling all the time. Lamiya, then twenty five, had been brutally tortured for months in an Israeli prison. It took me a while to diagnose that he suffered from hysterical paralysis in his hand and leg as a result of being tortured.

Seeing Lamiya gave me a tremendous shock. This was my first encounter with someone who had undergone torture. My shock and horror intensified upon hearing the reactions of people with whom I discussed Lamiya 's torture: "This is an exceptional case; there's no torture in Israel." And: "Perhaps he is a dangerous terrorist–we must extract information from him in order to defend Israeli citizens."

The most discouraging reaction was that of total disbelief: You are too naïve, or stupid, to believe in his story. You are lying; Lamiya is faking. I even heard the claim that Lamiya had caused his own burns. Still, the most common reaction was outright denial: there is no torture in Israel.

Having seen Lamiya, I realized that merely tending to his tortured body and soul could not make up for the anger and shame I felt for being part of a society that uses torture. Thus, I felt the need to publicly expose the systematic torture – not the "exception to the rule”— but the routinely carried out torture in GSS and army interrogation facilities—with the participation of many physicians who condoned with what they had witnessed, and sometimes further enabled. I felt I had to openly and publicly campaign against torture.

For many years, we, the Jewish Israeli citizens, didn't think that systematic torture existed in Israel (even though attorney Felicia Langer appealed a torture case to the Supreme Court already in 1974). In the late 80s almost nobody could believe it was possible that torture was practiced in our society. In 1988-89, many tortured Palestinians, broken souls and bodies reached to PHR Israel the Association of Israeli-Palestinian Physicians for Human Rights (the original name of Physicians for Human Rights-Israel, back then abbreviated as AIPPHR). It took quite a while to comprehend the extent of the phenomenon, to realize that torture was not an exception but rather a horrific system that affected tens of thousands of people. It was a huge shock for us. It became clear that around 1,000-1,200 Palestinians were detained and “investigated” every month, meaning that around 10,000 people were tortured per year. Torture become routine: the tortured were picked up according to a list of names obtained from previously tortured people; in this vicious way the circle of torture expanded immensely.
The GSS lied all the way through, even to the Court, which routinely took their word without questioning.

Appeals by AIPPHR, like most others on behalf of tortured individuals to the High Court, ended up in most cases with the state releasing the prisoner/detainee. In this way the state prevented the torture issue from being brought before the court. The need to fight torture in a principled way, to show publicly a systematic phenomenon that is not rectified by releasing individuals who had been tortured, gave me the idea of organizing an international conference on struggling against torture with “the case of Israel” as the main subject.
For six months AIPPHR's board debated about this conference. I spoke to each and every one of the board members at great length about the justification of holding such an international conference. All, except one, agreed. He resigned from the board.

Some ideas that were brought up by the board members included these: It is dangerous to say openly that we are against investigations into terrorists; we might be seen as PLO supporters. Or: If the price for preventing killing of many Israelis is torturing one person – I'm willing to pay the price. Or: Tell me whose side are you on? One board member said to me: “I don't want my wife to get killed in the supermarket”. I answered: “why don't you go to the supermarket?” (This is, obviously, another issue.)

The conference took place in Tel Aviv on June 1993. The presentations were recorded and edited in a book in English: Torture: Human Rights, Medical Ethics and the Case of Israel, N. Gordon and Dr. R. Marton, eds. (Zed Books, London, 1995).

I have come to the conclusion that the wide acceptance or condoning of torture by the Jewish Israeli public stems from the ideological beginning of Zionism, before and after the establishment of the State of Israel, an ideology that puts the collective before the individual. This ideology is fading out gradually in the last two to three decades. In torture, the representative of the collective tortures the individual in the name of the collective and for its benefit. Hence stems the especially positive attitude of the Jewish Israeli public toward the phenomena of torture. Here one can nostalgically find the last fortress of the collective getting all its rights, and the individual – in this case the Palestinian who is the enemy and the foreigner – losing all his rights. This situation is very comfortable since the foreigner pays the entire price for this Jewish Israeli nostalgia.

Because the Palestinian individual (the foreigner and enemy) is not conceived by the Jewish public to be equivalent to the Jewish individual by nature, his (or her) distress is not conceived as immoral. Psychologically, the ambivalence between the individual’s moral stand and the good of the collective is not a painful one due to the lesser weight of the moral considerations. Ambivalence is painful and disturbing when the weights of the two issues are more or less equal. Avraham Shalom, a former head of the GSS, exemplified this view well: "In terror there are no morals. In fighting terror there are no morals. The only moral is what is good for the state." (In the documentary film, “The Gatekeepers,” 2013).

Yet the borders or the definitions of individual and collective are misleading in this case. Is the GSS investigator an individual? Not really. He sees himself, first and foremost, as a part of the collective. He serves the collective, always anonymous, the collective’s servant, following orders.

This halo, or cloud, around the GSS aroused even more admiration from the collective-Jewish society. This was the situation throughout many years, different governments and Prime Ministers. All of them, except one: Menachem Begin (Likkud). As soon as he became Prime Minister, in 1977, he invited the GSS's head, Avraham Achituv, to meet with him and ordered him to stop torture. Achituv asked: not even a slap in the face? Begin answered: no, not even a slap in the face. It is an order. For a year or so there was a significant decline in torture in Israel. Then, in the 1978, the GSS found a way to make a detour around Begin's order by developing collaborators, many of them Palestinians. They were called "birds," asfur in Arabic, who employed all kinds of painful and cruel practices against victims in the prison cells. (This is what happened in Lamiya’s case). Later on, in 1982, when Moshe Yitzhak Shamir became Prime Minister, torture was allowed again.

With time, especially after the Landau Commission recommendations were adopted by the government in 1987, [The Landau Commission was a three-man Commission set up by the Israeli Government in 1987 following a long-running scandal over the deaths of two Palestinian prisoners in custody and the wrongful conviction of a Circassian IDF officer. The Commission, headed by former Supreme Court Justice Moshe Landau, found that the GSS (General Security Service/Shabak/Shin Bet) interrogators routinely used physical force during the interrogation of prisoners and then committed perjury at subsequent trials. In its conclusion, approved by Cabinet in November 1987, it lay down guidelines for the use of a "moderate measure of physical pressure".

Torture became more institutional, more organized, and more abiding regulations—which caused the investigator’s individuality to further disappear: no more private initiatives of torture; everything is done according to regulation. The “brave guy” of the GSS must be a part of the collective, subordinated to the collective’s rules. He has become a torture technician, using little individual imagination. The practice of torture became institutionalized and the targets collectivized.

The tortured Palestinian, is he an individual? Not really. Maybe in his own eyes he is one, and in the eyes of his family members. They will put his picture on the wall, they will whisper his name. But he is not an individual, in most cases, in his torturer’s eyes. For most Israeli Jewish Zionists, the tortured, an Arab, is a part of a collective of enemies.

The most important and the most difficult mission for us in AIPPHR was to open the eyes, minds and hearts of the Jewish Israeli public to the idea that the human rights of Palestinians are equal to those of Jewish Israelis, and that the necessary moral stance is of the highest importance. On the practical level we needed to convince the public that no collective good could be achieved by torture and that the regime was deliberately lying constantly about its so-called “life-saving merits.” In addition, we had to confront the Israeli medical establishment for its role in torture.

The confrontation with the Israeli Medical Association (IMA) was very hard on me. All the AIPPHR board members, except me, were IMA members since this was their professional union organization. They felt uncomfortable to denounce their colleagues, people they see at work all the time; there were also personal interests of promotion at hospitals at stake. On the other hand, AIPPHR's doctors met and treated victims of torture. This experience is a powerful and essential factor, which empowers the doctors in their moral conviction to stay on the side of the suffering.

A tortured person will tell the torturers what they want to hear: empty, mute speech, which does not accomplish the declared purpose of revealing secrets and information. In fact, the real purpose of torture is silence. Silence induced by fear. Fear is contagious and spreads to the other members of the oppressed group, to silence and paralyze them. Imposing silence through violence is torture's real purpose, in the most profound and fundamental sense. By the use of torture, by crushing the tortured person, the regime establishes fear and horror. If ten percent of the population is tortured, the whole population becomes paralyzed because they know what will happen if they antagonize the regime.

AIPPHR organized nine Members of Knesset to support and sign a letter and propose a law against torture in Israel. The signers were: Tamar Guzansky, Haim Oron, Tufik Ziad, Avraham Poraz, Shlomo Benizry, Yael Dayan, Nuaf Masalcha, Naomi Hazan, and Hashem Mahmid, from various parties (Labor, Meretz, Hadash, Shas). The bill was scheduled for discussion in the Knesset on June 16, 1993. An international conference on the topic, sponsored by AIPPHR was held three days earlier, on June 13 and 14.

While organizing the conference and deciding on its basic concept we were beset by many questions and dilemmas, such as: where should we hold the conference? In the occupied Palestinian territory? In Israel? If in Israel, should it be in Jerusalem, which is burdened with religious and political conflicts? Or perhaps in Tel Aviv, the most "Israeli" city, the pulsating heart of the Israeli-Zionist society? Who is our target audience? Physicians? Human rights organizations? The general public? Should we invite speakers to argue for the need for torture? Is there justification, from our point of view, in allowing them to bring their case before the public? Should we invite Knesset Members? And if so, should they be representatives of the Right? The Left? The center?

Should we publicly expose and condemn individual physicians whom we knew had given false medical statements so as to cover the infliction of torture practiced by Israeli interrogators? Or would it will be both fairer and more effective to address the fundamental issue of doctors' collaboration in acts of torture – collaboration that stems mostly from political obtuseness and unwillingness to understand the consequences of their acts, but also from the fact that there are no existing accessible mechanisms for them to report instances of torture which come to their attention or which they themselves treat.

Campaigning against torture in a place like Israel must entail more than condemnation and exposure. In order for it to be effective, we were striving to create a cohesive public position which would counterbalance the primal myths of the group. In a society where camaraderie among soldiers is of paramount importance, to talk of torture is tantamount to treason. Campaigning against torture in Israel must, therefore, strive to create a different kind of cohesive force, one based on respect for the human body and the human spirit, and for moral values which transcend those of the tribe.

The source of support and encouragement for us came from women and men who felt shame and anger at the sight of torture, which we were able to expose during the conference. Many of the conference attendees signed our letter petitioning for legislation against torture in Israel.

Following the conference I presented the letter and the signatures to the Minister of Justice David Liba’i in his office on June 16, 1993. He promised that he would recommend that the State Attorney Josef Harish hear the human rights organizations on this issue and establishes an inter-ministerial committee in the very near future to deal with the proposed legislation. It took 14 months–and many letters–until the committee was established in order to deal with the proposed law against torture in Israel. Then, two and a half years went by and nothing was done by the committee. Six years later, on September 6, 1999, the Supreme Court of Justice declared the interrogation methods used by the GSS and authorized by the government to be illegal.

And what of torture now? Though the Supreme Court outlawed torture absolutely in 1999, its decision created several loopholes large enough for torture to continue today. In October 2011 the Public Committee Against Torture in Israel and PHR-I (former AIPPHR) issued a joint statement entitled “Doctoring the Evidence, Abandoning the Victim,” which said in part:

Alongside the absolute nature of the prohibition on torture, the Court ruled that GSS interrogators who employed “physical means of interrogation in order to save human life” could, if brought to criminal trial, avail themselves of the “necessity defense” under the appropriate circumstances. The Court went further, adding that the Attorney General was authorized to set the guidelines with regards to the circumstances under which interrogators who ostensibly acted out of necessity would not be brought to trial. This ruling has had far-reaching consequences: the Attorney General has interpreted this authority broadly, and prepared a document essentially granting a priori permission for these same interrogation methods. This document became one of the central tools upon which the approval of torture in Israel is based.

Thus, despite there being a landmark decision in implementing the prohibition on torture in Israel, more than a decade after the court’s ruling not only do torture and ill-treatment continue to be implemented in interrogations, they also continue to receive the full institutional backing of the state.

Under these circumstances the prohibition of torture, already infirm, becomes a dead letter.

It is through these and other means that the interrogation room becomes a no-man's land: a space outside the law, where interrogators assume new identities, not subject to a known and defined system of rules because the details of the recommended methods of Landau commission were described in the classified appendix to the report. Within the interrogation room, interrogators are not beholden to any of the obligations which apply on the outside; the world of external enforcement remains beyond the threshold. The victim of torture and ill-treatment is left bare before his interrogators, stripped of all protection.

The false justifications for torture allow the regime to break the body and soul of humans, Palestinians in our case, in order to fortify those who lead the state and wish to go on with the occupation.

Any other reason given by the torturers is a lie including the clam of 'ticking bomb'. Torture doesn't yield high fidelity truth.

So, what about the truth? An Arab proverb says: Give a horse to the person who tells the truth, he will need it to run from his persecutors.

— Ruchama Marton, M.D., 2013

Articles

[Articles follow in chronological order.]

[Ed. Note: While the first article in this section, an early one in the life of PHR-IL, mentions solitary confinement as torture—a frequent theme in Dr. Marton’s work—it mostly details the process in which PHR-IL engaged in order to obtain information about any Palestinian prisoner held by the Israeli authorities, whether mentally ill or not, and is thus an important part of Section 4.]

UNTITLED

[Holland, 1993]

Over 50 percent of the complaints concerning human rights violations handled by PHR-IL pertain to prisoners. The complaint received by PHR-IL, either from the prisoner’s family or a human rights organization, concerns the denial of medical treatment.
PHR-IL received and handled over 90 such complaints pertaining to prisoners in the last five months of 1992, of which 60 percent concerned people held in the police prisons. Every complaint we receive pertaining to these prisons has to be accompanied by a waiver of medical confidentiality. If we do not attach the waiver to our complaint, the prison spokeswoman refuses to respond to our allegations. This policy began in September 1992, after PHR-IL quadrupled the number of complaints sent to the prison authorities. It seems that the spokeswoman, the chief physician and perhaps others were looking for a way to increase the endless bureaucratic procedures so as to complicate our work, and therefore introduced the demand that we attach a waiver of medical confidentiality. Attaching this waiver to the complaint does not enable PHR-IL to gain access to the medical files of the prisoner as one would expect, but only to receive a physician’s opinion of the prisoner’s condition. According to the prison authorities only the prisoner, his or her family or their lawyer can represent the prisoner and receive the medical file; PHR-IL cannot. This assertion still needs to be tested in court.

The standard action taken by PHR-IL once it receives a complaint concerning the denial or lack of medical treatment begins with collecting of relevant material: Waiver of medical secrecy, medical reports given prior to the arrest, age, gender and any other information that seems relevant. We send a letter with our allegations and the material we received to the spokesperson in charge of the prison in which the person is being held. In the letter we demand that the prisoner be examined by a doctor and that the results of the examination be sent to us. The spokesperson passes our allegations on to the chief physician, who demands a response form the prison doctor. The prisoner is then examined by a doctor who passes the results to his superior, then to the spokesperson and back to us. This of course is the standard procedure and is not employed in cases of critical medical need and torture, where we act differently.

It takes from a week to three months from the date of our first letter until we receive an answer, depending on where the prisoner is being held and under which authority.

As a result of our complaint the prisoner does get examined by a doctor, which is important in itself. At times, following such an examination he or she is sent to a hospital for further examinations and treatment. One should note that these cases, which we define as our so-called successes, are in fact proof of medical negligence. If the prisoner had received adequate medical treatment, then he or she would have been hospitalized prior to our allegations and not after the prison doctor discovered that PHR-IL is concerned with that specific prisoner. Indeed, our basic success is putting the prisoner under a “spotlight.” It seems that the treatment a prisoner receives is somewhat better after we file a complaint. This assumption is probably true for some of the cases we handle while false for others.

As is usual when dealing with human rights, we fail more often than we succeed. Firstly, after we send the complaint we rely almost entirely upon the information passed to us by the prison physicians for knowledge of the prisoner’s condition. We know that some of these physicians cover up the cruel torture inflicted by the Israeli security forces, torture taking place in their wards and with their stamp of approval. This fact indeed raises doubts concerning the answers PHR-IL receives.

A blatant example of the ambiguity may be seen by the reply we received concerning the case of Hamisa Muhana: PHR-IL sent a complaint to the police department spokeswoman, stating that during her arrest Ms. Muhana was wounded from shrapnel in her left leg and eye and is now in pain. We demanded that Ms. Muhana be examined by a physician and that the results of her examination be sent to us. The prison spokeswoman replied that Ms. Muhana was examined as a result of our request, that “according to the physician’s opinion the prisoner is receiving adequate medical care. She has been examined by specialists in accordance with her medical needs and given treatment according to their recommendations. At this point her condition is stable and she is receiving medical care at the prison.”

This answer not only tells us absolutely nothing about the specific medical condition of Hamisa Muhana,¹ but also reeks of deceit. After receiving this answer we called Shuli Meiri, the prison spokeswoman, and told her that PHR-IL would not accept such an answer, that it could have been written about any prisoner and that it says nothing about this prisoner’s particular problems. One month later we have not received a more specific response.

In fact, in answer to over 40 percent of the complaints concerning medical conditions of prisoners, the authorities answer that the person’s condition is “satisfactory.” One might ask what a “satisfactory medical condition” is? Whom does it satisfy? The prisoner or the prison authorities?

Since we usually do not have direct contact with the prisoner, we pass such answers back to the person who filed the complaint, asking for a response. A problem we have experienced is that few people who originally complained come back to us and say they do not accept the answer we received, and that the prisoner’s condition is in fact “unsatisfactory.” Hava Keller is one of the exceptions. She worked with me writing letters and kept in constant contact.² Thus my criticism is twofold: First, PHR-IL does not accept the answer given by the various Israeli authorities; i.e. that the prisoner’s condition is satisfactory. To say the least, such an answer is very obscure. Secondly, we do not receive feedback from our sources. Such feedback might enable us to protest against such answers.

PHR-IL also goes into prisons in order to examine prisoners. In the past half year we sent five doctors to examine prisoners and received permits for two more independent doctors. These visits are very important since through them we can receive a trustworthy account of the prisoner’s medical condition. Indeed, it would be great if we had more physicians that were willing and had time to examine prisoners. However, we should not deceive ourselves that by having more independent doctors examine prisoners we make a big step towards insuring that these prisoners’ medical needs will be answered. The cases of Makdam Makdad and Mousa El-Koumsan will illustrate this claim and simultaneously raise the problems of mentally ill prisoners.

In the past six months PHR-IL has handled 11 cases of mentally ill prisoners held in custody. We think that these people should be in psychiatric hospitals rather than in prisons.

Makdam Makdad was injured by explosives while manufacturing a bomb, his left jaw and both legs were damaged and his right hand amputated. In 1987 he was sentenced to eight years imprisonment. In September 1992 PHR-IL received a request for intervention from “Gaza Team” human rights workers. They reported that Makdam was suffering from serious mental health problems and being held in solitary confinement in Gaza prison. They also stated that his family believes that he is slowly dying.

After repeated applications by PHR-IL for a permit to allow an outside medical examination as requested by the family, I visited Makdad in order to provide an independent medical opinion on his condition. I diagnosed him as suffering from chronic schizophrenia: “Makdad expresses unreal ideas and paranoid response” I wrote in my opinion; for example, “King Fahed’s men are acting against him in prison, burning his mattress… He sees himself simultaneously as Makdam Makdad aged 30 and Makdem Hasina aged 26.”

The IDF’s Deputy Legal Adviser in Gaza, Attorney Ronen Atzmon, had confirmed to the “Gaza Team” that Makdam was mentally ill and therefore being held in solitary confinement. In response to PHR-IL’s enquiries the prison authorities claimed that he was being held in isolation because he “does not integrate into the society of other prisoners.” They added that he had been discharged from a mental health center because he “refused to continue his hospitalization there.” Thus it is clear that not only I diagnosed Makdad as mentally ill; the prison doctors and authorities did likewise.

PHR-IL approached Makdad’s case both on the bureaucratic level and on the principle level.

By holding Makdam, who is mentally ill, in isolation, the prison authorities are acting in contradiction to previous decisions of both the Gaza military court and IDF Commander for the Gaza region. In a letter from Attorney Chaim Schmolvitch, Prison Services Legal Advisor’s Office, on March 27, 1992, concerning another mentally ill prisoner, it was stated that “the prison services have no place for psychiatric hospitalization in the Gaza region.” It was on this basis that this prisoner could not be held in Gaza. Holding Makdam in Gaza is another illustration of arbitrary and inconsistent decision-making that PHR-IL comes up against time and again.

In addition, PHR-IL considers it unacceptable that a prisoner in Makdad’s condition be held in solitary confinement. Such isolation is used as a form of punishment in prisons within Israel and around the world. Furthermore, prolonged isolation is an internationally recognized form of torture. PHR-IL claims that isolation can only lead to deterioration in Makdad’s mental state. Nevertheless, the prison authorities chose to hold Makdad in isolation, although according to law they have an obligation to provide Makdad the treatment appropriate to a psychiatric patient. We think their claim (mentioned above) that Makdad did not wish to remain in the psychiatric ward is not only irrelevant, but a rather cynical expression of concern for his wishes.

We wrote to the prison authorities repeatedly to voice a strong protest at the conditions in which Makdam is being held. On February 15, 1993, PHR-IL made a request to General Matan Vilnai for Makdam’s pardon in view of his chronic mental illness, as I demanded in my medical opinion. No reply has yet been received.Let it be clear that we are not talking of a particular case, but about a system. Makdad is not the only mentally ill person held in solitary confinement; there are quite a few others. In fact this approach is routine. One might ask why mentally ill people are held in prison rather than sent to psychiatric hospitals as should be expected. Our answer has to do with the psychology of people in charge: There is an accepted notion of revenge and spite towards such prisoners from the commanding officers. We know that these army and police officers have the power to implement this notion, and we indeed think they do not care about the essence of punishment or believe in rehabilitation.

The case of Makdad also exemplifies that the examination of an independent doctor does not necessarily help the prisoner. In fact, it rarely does. Looking over Makdad’s medical files in Gaza prison, I saw that he had already been diagnosed by a prison physician as mentally ill, and that nevertheless nothing was done.

Mousa El-Koumsan, age 28, of Jebaliya refugee camp, married with three children, ran down and killed one Israeli soldier and injured another on November 11, 1989. That night he turned himself in to the Israeli security forces.

Mousa was detained without trial for over two years at the end of which the state appointed expert, Dr. Baum-Neko, of the Eitanim Mental Institution, Jerusalem, found him unfit to stand trial and recommended his hospitalization at the Bethlehem Psychiatric Hospital. On January 30, 1992, Mousa was brought before the Gaza Military Court, and found mentally unfit for trial. On the same date, however, General Vilnai, the Southern District Commander, personally issued an order ignoring the state expert’s recommendation and instructing that Mousa El-Koumsan “be detained for a period of three years beginning this day and held in a closed facility in the Gaza region or in Israel, as determined by the prison authorities.” By now, Mousa el-Koumsan has been imprisoned for three and a half years without trial in the psychiatric section of Ramleh prison. Under the order issued by General Vilnai, his incarceration is to continue for about two more years.

The order of Southern District Commander Vilnai, under which Mousa El-Koumsan is being detained, is an implementation of clause 36B of the Security Instructions, 1970. This clause authorizes regional commanders to order a person’s detention, even if this person has been declared insane. It is a clause allowing the military commander to override both the official medical diagnosis and the resulting legal ruling that a given person is unfit to stand trial. It allows imprisonment without trial (as the person in question has been found unfit for this) and without the medical treatment required by the diagnosis. This clause, therefore, authorizes non-doctors to reverse the official instructions issued by a qualified doctor. As physicians and health professionals, we consider this clause a grave infringement upon fundamental medical and human rights. We protest this authorization of military officers to intervene in medical considerations. Put differently, the case of Mousa El-Koumsan reveals once more that in Israel so-called security reasons, no matter how ridiculous they are, can override any other considerations.

The cases of Mousa El-Koumsan and Makdam Makdad speak for themselves. They reveal the behavior of General Vilnai, Dr. Ziglboim, the chief physician of Israeli prisons, the judges in the Gaza military court and a whole group of attorneys working for the Israeli army and prisons. Since it does not seem that these people are acting out of ignorance, PHR-IL can only conclude that their actions towards El-Koumsan and Makdad are deliberate violations of human rights laws.

Let it be clear that we are not talking of a particular case, but about a system. Makdad is not the only mentally ill person held in solitary confinement; there are quite a few others. In fact this approach is routine. One might ask why mentally ill people are held in prison rather than sent to psychiatric hospitals as should be expected. Our answer has to do with the psychology of people in charge: There is an accepted notion of revenge and spite towards such prisoners from the commanding officers. We know that these army and police officers have the power to implement this notion, and we indeed think they do not care about the essence of punishment or believe in rehabilitation.

In August 1992, PHR-IL approached the Defense Minister, the Minister of Health and the Minister of Justice about this case. Our letters protested the authority bestowed by this clause of the Security Instructions 1970 on the regional commander; the exercise of this problematic authority by General Vilnai in this specific instance; the apparent contradiction between clause 36B and additional clauses of the Security Instructions. Reminders have since been sent to all the ministers approached. No responses have arrived to date. We note that such delays in dealing with severe human distress are, of themselves, a violation of human rights. We continue our efforts to ensure proper hospitalization and treatment for Mousa El-Koumsan, in keeping with the medical recommendation. We also continue to petition for abolition of the injustice inherent in clause 36B of the Security Instructions, 1970, to this day with no success.
The cases of Mousa El-Koumsan and Makdam Makdad speak for themselves. They reveal the behavior of General Vilnai, Dr. Ziglboim, the chief physician of Israeli prisons, the judges in the Gaza military court and a whole group of attorneys working for the Israeli army and prisons. Since it does not seem that these people are acting out of ignorance, PHR-IL can only conclude that their actions towards El-Koumsan and Makdad are deliberate violations of human rights laws.

THE STRUGGLE AGAINST TORTURE IN ISRAEL: The White Coat Passes Like a Shadow

(Excerpts from a speech to the VI International Symposium on Torture as a Challenge to the Medical and Other Health Professions, Buenos Aires, June 1993)

The Association of Israeli-Palestinian Physicians for Human Rights—now Physicians for Human Rights-Israel (PHR-IL)— was established in March 1988. It was—and is—a group unaffiliated with any party, its members volunteers. Its various activities and the salaries of its administrative staff were financed by contributions from Europe and the United States. When we established PHR-IL, we thought that our role would be small and modest. Today, after more than five years of intensive activity, I know that there is no end to this work. Even if we had twenty more people working with us, we would not be able to respond to all the appeals we receive regarding violation of human rights.

Everywhere we go in the occupied Palestinian territory we see neglect, deprivation, destruction and bereavement. As physicians we have learned that the primary problem is not to heal the sick, but to mend the wrongs human beings do to each other. The worst of these actions is torture. The Israeli Medical Association (IMA) is a signatory to the 1975 Tokyo convention against torture, which states:

For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. The declaration explicitly forbade doctors from participating in torture in any circumstances, providing premises or substances or knowledge that would aid torture, or being present during torture or its threat. The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedure is suspected, accused or guilty, and whatever the victim's belief or motives, and in all situations, including armed conflict and civil strife.

Unfortunately, many Israeli doctors do not meet the demands and duties of the Tokyo convention.

Here are two examples of torture and the role of physicians taken from the many cases handled by PHR-IL, which illustrate that the Shabak (General Secret Service) tortures people. The euphemism for torture— “moderate physical pressure” as the Landau commission defines it—is not in a gray area; it is in the black area of torture.

The first example is the case of Nader Raji Michael Kumssia, a 25-year-old from Beit Sakhur village in the West Bank. He was arrested on the night of May 3, 1993, at his home and taken to the detention camp in Dahariah. Nine days later, on May 12, Kumssia was brought before military Judge Altbaur because the army wished to prolong his detention. According to the hearing record, Kumssia denied the charges against him and told the judge: "Yesterday and the day before I was tortured in the investigation. They hit me on the testicles and took me to the hospital.” The judge decided to prolong Kumssia’s detention. However, the judge wrote: “The commander of the interrogation center presented, at my request, a report from Soroka hospital, according to which, the prisoner [was] injured in both testicles (a rupture) as a result of a blow…”. On May 19, Kumssia was brought once again before Judge Livni, who decided against extending the detention for lack of evidence, but agreed that Kumssia would be held in administrative detention.³

Kumssia’s family requested that PHR-IL intervene on his behalf. We discovered that Kumssia’s medical file containing the medical report quoted in Judge Altbaur’s decision was missing from the Soroka hospital archives. The only document given to the family was a medical opinion written on May 19, eight days after Kumssia’s release from the emergency room. This medical opinion, signed by a urologist, reads: “Nader reached the emergency room because of a rupture in the scrotal region. According to the patient, he had fallen down the stairs two to five days prior to check-up…”

This medical letter was written retroactively, without any further examination. The document falsifies facts that were written in the previous letter that was quoted by the judge. It seems to us that it was written in an attempt to blur the facts. The physician did not report the rupture in the patient’s scrotum, which had resuled from a blow given to a man under interrogation, and ascribed to the patient the reason for the injury as "falling down the stairs." Can someone imagine a person falling down the stairs and getting hit in his testicles?

If this physician had had an obligation to report torture or other abuses to the Israeli Medical Association (IMA) and the police, and if he had known that the IMA would back him up, it is likely that he would not have failed as he did, and would not have been complicit in a crime of torture, contrary to medical ethics and the Tokyo Convention.

The second example is of torture resulting in severe emotional and mental damage. The role of physicians in this affair is even more despicable. Hassan Bader Abdallah Zbeidi, of Anabta village in the West Bank, 34, is a university graduate, married and father of four children. He was arrested at his home on September 25, 1992, and brought to Tulkarem detention camp. For 20 days his family did not know where he was. One month after his arrest, on October 28, Zbeidi was released from detention without having been charged.

“Released from detention” is a military euphemism. Actually, Zbeidi was taken to his home in a Palestinian civilian car because soldiers at a roadblock had ordered the passengers to drive him there. He was brought home in a severe catatonic state. He was not able to make any contact with the outside world and recognized no one, not even his wife, children or his parents. He did not respond or talk spontaneously, and he was incontinent. He had an empty frozen stare and his body was stooped and shaking. He remained frozen in whatever position he was placed.

What happened to Zbeidi in the interrogation wing of the Shabak in Tulkarem? We could not know. But we could guess – because at the same time, September and October of 1992, we received five complaints of torture from the Tulkarem prison. A recurring description of the tortures were: blows to all parts of the body, blows to the testicles, being tied to a pipe, a sack on one’s head, prolonged standing, and being strangled. One of these five prisoners, Mustafa Barakat, died during interrogation, at the same time in the same prison. The others were released without being charged.

The relatively large number of torture complaints occurred, ironically, during the High Holy Days—Rosh Hashanah, Yom Kippur and Sukkot. In a private talk someone told me that the investigators were frustrated because they had to stay at work in that very special time of the year; therefore they were more cruel than usual.

Omar Daud Jaber of Iktabah village, West Bank, testified that "Captain Louis" kicked his testicles, and administered heavy blows, prolonged standing, and hooding. Anan Saber Makhluf of Tulkarem city, West Bank, was tied to a pipe for five days in a row, strangled, received heavy blows and hooding. Gazy Omar of El-Gasoon village, West Bank, was hospitalized in Ha’emek hospital in a state of kidney insufficiency due to heavy blows. Mustafa Barakat died during torturous investigation.

Hassan Zbeidi’s incident is not an exception; this is another case of a person who was severely tortured and returned to his home disabled, perhaps with no hope. I examined him several times, and in cooperation with a Palestinian doctor from Nablus he received medication. His family was warm and supportive, and gradually there was a slight improvement in his condition. When I examined Zbeidi few months later he began to speak a little. He answered questions slowly, in a very low voice, with long pauses. He said that he remembers getting hit on his head and chest, that they banged his head against the wall and that he was strangled. He also remembers waking up from the beating in the hospital.

It is difficult to describe how many hours of work, telephone calls, faxes and calls to Knesset members, to the IMA, to lawyers and to fellow doctors had to be made in order to find a medical document or any other information that was connected with the Shabak interrogations and tortures. Many times this endless work produced no results.

Our appeal to the Shabak in the case of Zbeidi was answered in the following words: “An investigation was conducted by the Shabak’s controller in regards to the complaints of Hassan Zbeidi and Abed Jaber. The conclusions of the investigation were submitted to the justice ministry and no evidence was found which would indicate any deviation from Shabak work procedure.” Does this mean that these are the standard working procedures of the Shabak?

Despite the denials and the concealing of the facts and documents, we obtained a copy of the medical certification from the emergency room of Tel Hashomer Hospital, from 4:07 p.m., October 15, 1992. The attending physician wrote: “Main problem – quieter than usual recently. Memory disturbances. Doesn’t complain of anything in particular. According to the military doctor report: “sad, disoriented as to place and time. Appears to be in spasm.” (My emphasis.) His relevant findings were:

Calm, no pallor, cyanosis, or jaundice.
Head & Neck – no pathological findings.
Lungs – clean.
Heart – clear sounds.
Stomach – soft.
Arms and Legs – no pathological findings.
Examination of psychiatrist – no clearly defined problem.
Examination of emergency room neurologist – normal. Impression that patient is malingering.
Observations:
1. Follow-up of prison physician
2. Treatment with any placebo
3. If his condition gets worse – send to doctor.

Four doctors, as far as we know, examined Zbeidi: an army doctor who referred him to the emergency room, an emergency room physician, a psychiatrist and a neurologist. Even with such clear evidence of the serious injuries inflicted on Zbeidi, not one of them raised his voice to protect him. Furthermore, the emergency room doctors ignored the fact that the army doctor’s clear, brief, statement that “he is disoriented as to place and time” described a psychotic state in medical language. Was it the emergency room doctor who said this or the army doctor? Unclear. All three civilian doctors ignored his serious condition, diagnosed him as a malingerer and gave him a placebo.

These doctors neither put him under medical supervision nor reported to any authority that his injuries had resulted from the Shabak interrogation. They returned him to his torturers, even though their written recommendations implied that they understood the seriousness of his conditions. This can be learned from recommendation number 3, that if the condition worsens, refer him to the doctor. One can read this medical language as a hint to the fact that the doctor means that the condition of a deceiver cannot get worse, but the condition of a patient can.

These civilian doctors, who were not under any pressure from military or security commanders, chose to collaborate with the torturers out of their own free will. They betrayed the trust that was given to them as physicians, on both the ethical and the medical levels. If these doctors had been required to report the existence of torture, they would not have allowed Zbeidi, who went mad out of pain and terror, to be returned to his investigators/torturers. In a different atmosphere, Zbeidi would get a proper attention to his mental condition and a proper psychiatric care.

Physicians everywhere easily and efficiently internalize the social atmosphere of their time; thus, most of them become loyal servants of the regime in their society rather than being critical of it. In many countries/regimes and at different times in history, medical doctors perceived themselves as “pure professionals” or comfortably apolitical professionals who wouldn't see their part in collaborating with the regime as a political act. Such was the case in Nazi Germany, in various countries in South America, the U.S.S.R., the U.S.A., and also in Israel.

The following form illustrates the knowing compliance of these doctors in the system of torture. It was discovered by attorney Tamar Peleg, who found it hidden in a prisoner’s file that had been given to her. She gave it to PHRI and to Davar newspaper journalist, Michal Sela, who published it in the newspaper. It is an official medical fitness form the doctor fills out after examining a prisoner in an interrogation center in Israel. The form reads:

Medical Fitness form
Dep. of interrogation
Form of Medical Fitness
No. of Prisoner ______________
name ________________________
date __________________________
1. On ________ I examined the above prisoner and his medical findings are:
a. ___________________________________________
b.________________________________________
c.________________________________________
d. ________________________________________
2. As a result of the above, the medical limitations on the conditions of imprisonment are:
a. Are there any limitations to the prisoner’s stay in an isolated cell
Yes/No
b. Are there any limitations to the prisoner’s chaining
Yes/No
c. Are there any limitations to wearing head/eyes cover
Yes/No
d. Are there any limitations to prolonged standing
Yes/No
e. Does the prisoner have physical injuries (before entering
interrogation)
Yes/No
f. Main medical limitations:
1) ______________________________
2) ______________________________
3) ______________________________
4) ______________________________
Doctor’s signature __________

Notice what it says: “Does the prisoner have physical injuries (before entering the investigation)?” What are we to make of this? That essentially the doctor is saying that despite past injuries, the prisoner should be able to endure sleep deprivation, starvation, exposure to intense heat, to freezing cold, to pain from blows, being tied in painful positions for long periods of time, being forced to stand for long periods, having one’s head covered by a stinking and suffocating sack, exposed to ear-splitting music for hours, being humiliated, sexually exploitation, and having his spirit broken by prolonged solitary confinement.

By signing this form the physician knows that he is giving his services, agreement and approval to a systematic process of breaking one’s soul and body.

Physicians could learn from legal precedents that ban evidence obtained through torture. Jurists, not physicians, were the first to publish evidence in the early 18th century saying that there is no connection between pain and truth. They banned the use of torture for legal purposes and disqualified confessions obtained by inflicting pain or torture. The jurists’ objections to torture stemmed from their concern about the reliability of data collected in this way, not out of moral concerns. One assumes that the heads of the Shabak, the army, and the police also are aware of this spurious relationship between pain and truth. Nevertheless, torture and brutality are still practiced and physical and psychological “pressure” still applied. One might ask why, if information extracted by pain is so doubtful or unreliable, the security forces use this method. Might it be that the claim of life-saving information is not the real one but some other purpose?

Why do they torture? They do it because the real objective of torture is to break the spirit of the person and destroy his personality. The judicial system necessitates a pragmatic approach, not a moral one. A physician should, in the first place, be committed to professional ethics and personal morality. What causes a person physical or mental suffering should be unacceptable to the medical profession. The most important statement of Hippocrates’s oath is: First, do no harm, primum non nocere. It is a minimal demand that one must not transgress.

The white coat passes like a shadow through the interrogation procedures: the “coffin,” the “refrigerator,” the “banana tie” the Al-Shabach tie and the terrifying darkness of blindfolding or hooding.⁴

The doctor is present in the background, behind every torturer-interrogator. A doctor makes a pre-torture examination. He gives medical approval of “fitness for interrogation.” A doctor monitors during the torturing process. A doctor examines and takes care of the prisoner after being tortured. A doctor writes a medical opinion or a pathologist’s report. In all these situations, the doctor provides his services to the state, and not to the patient. The doctor who collaborates with torturers is their partner in crime. If a prisoner dies during the interrogation, the doctor is in fact assisting in a murder. Doctors, nurses, medical assistants, and judges, all those who see and know and cover up are partners in the crime.

As humane beings we must oppose torture with all our might, and a particular obligation rests on the physicians. We, who live under a democratic regime, should act within the framework of democracy. In other words, we are obliged to refuse to cooperate in committing crimes against human beings.

How is Israeli society facing the fact that the State of Israel is using torture? There are two main psychological defense mechanisms. The first one is a political argument we hide behind: the idea that the practice of torture is one of the symptoms of the occupation, and we console ourselves that it will disappear when the occupation disappears. But torture belongs to a world-view where human rights have no value. Torture existed before the occupation and will be there after it is gone if we do not change our world-view of which it is a part.

The other one is denial. Many Israelis think that torture happens in another place or at another time: in World War II, in South America, but not here and now. It is difficult and painful to think that there are torture cellars in the state of Israel. In our Jewish high moral standards it cannot exist. This is why so many Israeli Jews are unable to allow themselves to know about it. One of the objectives of the Israeli PHR is to show clearly that torture, even if it is called by different names, is carried on here systematically. It is not an exception. We, PHR-IL, would like to disturb the peace of mind achieved through denial and ignorance that lead to passivity. We need to involve the public in an active struggle against torture.

Violent and cruel methods of interrogation do not add to our security, even if they are done in the name of security. The amoral norms not only do not contribute to our personal safety, or to that of the state as a whole, but they lead to increasing circles of social disintegration.

If we as citizens or physicians do not ensure that it is forbidden to harm a person’s body or soul for any reason whatsoever, not even for the sake of the state, we will find ourselves supporting directly or indirectly the destruction of personal and social morality.

Unfortunately, in order to promote the struggle against torture, we cannot rely on the personal ethics of the citizens and physicians. We must rely on harsher regulations, on the regulations of the law. This is why we support the legislation which is being submitted to the Knesset.

Moreover, we demand that the IMA require every doctor to report all instances of torture that a doctor comes across to its ethics committee and the police. The IMA must initiate an information campaign for physicians and give them every support necessary so that they can confront this difficult task in the emergency rooms and in the hospital departments. In this way we will fulfill our personal and professional duties and cease to collaborate with criminal acts on behalf of the state.

DOCTORS AND THE DUTY OF INTERVENTION

[Excerpted from “Doctors and the Duty of Intervention,” Palestine-Israel Journal, Vol. VI, No. 1, 1993]

In June 1993, PHR-IL organized the first and only international conference on torture in Israel. As a result, I was invited to talk about PHR-IL’s activities on a popular TV talk show. I brought with me Z., a Palestinian who became catatonic as a result of torture. At the time, the use of torture against Palestinians was extremely widespread. People were taken from their homes in the middle of the night and did not return for many weeks. In most cases the families didn't and couldn't know where the detainee was being held. During detention people were brutally beaten, and various legally-sanctioned "moderate physical pressure" methods were used against them. (Such "moderate physical pressure" had been declared permissible by the Israeli authorities. However, the Landau Commission noted that "The physical and psychological means of pressure permitted for use by an interrogator must be defined and limited in advance, by issuing binding directives.”)

Z. was detained in September of 1992. At the same time, four other Palestinian men were detained. All were taken to prison in Tulkarem. One died during investigation; that is, he died of torture. Z. lost his sanity and remains in a catatonic state today and is no longer in touch with reality. We were able to learn what had happened in the investigation from the stories of the other three prisoners, which tell of cruel actions I prefer not to describe here.

In 1993, the term "torture" was still taboo in Israel. The systematic use of torture completely contradicted the self-image that "we are human, we have moral Jewish superiority, we are untainted.” As a result, there was a complete denial of torture in the Israeli public and the media, so much so that the Israeli minister of justice, Professor David Liba'i, said to me in his office, June 1993: "There isn't any torture in the State of Israel. Our security services do not torture." The problem is not the “not knowing”; the profound problem is what one knows but doesn't want to know.

In the TV show to which I brought Z., we were scheduled to be included in the circle of guests and to speak for 15 minutes. The host of the show saw us and immediately placed Z. in the audience. I was seated far from the camera. When I realized that most of the program was over and we had not been called to speak, I stood up and said loudly: "While you and the audience at home are having fun, people are losing their minds because of pain and fear. I call it torture." I pointed to Z., who was sitting stone-like. The camera followed my hand.

Yossi Peled, a former Israeli general who was the prime guest at the show, shouted back: "It is inconceivable that torture is practiced in Israel." The audience applauded. I answered: "You are applauding because you are hearing what you want to hear. I can tell you, this man and thousands like him are being systematically tortured by Israeli interrogators." No one spoke and no one applauded. Peled's phrasing is revealing: "It is inconceivable" that in the State of Israel torture is carried out. That is to say, Israelis cannot possibly carry out torture. The possibility that torture is practiced in Israel is antithetical to our self-image to the extent that it becomes inconceivable.

In the TV show, all the elements of the Israeli situation played a part: General (Res.) Peled as a policy-maker, Z. as the victim of torture, myself as the critic of the consensus, and the audience representing the majority of the Israeli public. In that drama the official spokesperson lies, and the audience is glad to be offered an idealized image of itself; the victim stays silent, and the critic cries out, trying to undo the fabric of the comfortable national consensus. The silence at the end of my dispute with Yossi Peled was a sign that the audience experienced a certain shock. This shock might have opened the eyes of some and perhaps even initiated the need for better reality testing.

THE PRACTICE OF SOLITARY CONFINEMENT IN ISRAEL AND PHR-IL’S STRUGGLE AGAINST IT

(Excerpted from a speech to the Physicians for Human Rights assembly, Holland, 1995)

The main grounds generally used for holding a prisoner in solitary confinement are: state security, prison security, prisoner’s safety (being either the isolated individual or his cell-mates) and the maintenance of order and discipline. PHR views the last reason, “order and discipline,” as especially ominous, since it practically opens the door for unlimited use of solitary confinement against prisoners without any disciplinary hearing or fixed legal procedure.

The first justification for holding a prisoner in solitary confinement, “state security,” includes cases such as Mordechai Va’anunu, who dare speaking publically about Israel having nuclear weapons; Prof. Abraham Marcus Klingberg, a scientist who disclosed state secrets to the Soviet Union; and many others far less publicized and mostly Palestinian prisoners, who are kept in solitary confinement with no access to the outside world and with almost no lobbying for their release.

The second justification, “prisoner safety,” has emerged as almost a necessity in Israel. By imprisoning the mentally ill in facilities with insufficient psychiatric services available, prisons are forced, for the safety of either the mentally-ill prisoner or his cellmates, to isolate the individual.

The vast majority of the mentally-ill prisoners held in solitary confinement should not have been tried in the first place. According to Israeli law, accused individuals who can prove they are not “responsible for their actions” usually avoid a trial, and are instead directly admitted to psychiatric hospitals, where they receive appropriate treatment. It could not be coincidence, therefore, that Palestinians who are charged with offenses and brought before military or civilian courts in Israel are only rarely found to be “unaccountable for their actions.”

Incarceration of the mentally ill raises the problem of forced hospitalization within prison walls. We all know the meaning of this double restriction of personal freedom, and can easily imagine how it can be abused as a method of intimidation, punishment, revenge, or extracting confessions.

Another problem is the functioning of Israeli psychiatrists in cases of Palestinian mentally-ill prisoners and detainees. Here is an example of the various complications stemming from the practice of solitary confinement of mentally-ill prisoners:

Jamal Abu-Issa, 30, married with four children from East Jerusalem, stabbed his Jewish employer in 1994. He was arrested, tried, and sentenced to five and a half years. He was placed in solitary confinement, since—according to prison authorities—he posed a threat to himself and to others. On the face of it, he is a typical case of a Palestinian terrorist attacking Jewish Israelis; but the story of Abu-Issa does not end here, and its continuation is worth, in my opinion, closer scrutiny.

Abu-Issa had suffered a mental crisis, and was apparently psychotic several months before that incident. Both his Jewish employer, for whom Abu-Issa worked for ten years, and his wife recalled that Abu-Issa “had behaved strangely” for quite some time before the attack. However, we will probably never know whether his mental illness, which was only beginning to show at that time, would have developed at such a speed and to such degree had he been given psychotherapy and anti-psychotic medications instead of being locked in solitary confinement. Following the trial, unable to take care of Abu-Issa, the prison administration decided, like in many other cases, to put him in solitary confinement. As an outcome of this move, Abu-Issa’s mental state deteriorated significantly. He had anger attacks, did not recognize his family, almost stopped eating and drinking, and later totally gave up personal hygiene and developed severely paranoiac delusions. Refusing hospitalization, only once was Abu-Issa sent for observation and treatment to the Prison’s Mental Health Center. Here, a significant improvement in his mental conditions occurred.

There is no doubt that Jamal Abu-Issa was severely mentally ill. However, the only solution the prison administration could devise for Abu-Issa was solitary confinement, which only deteriorated his fragile condition further.

The debate over solitary confinement brings to the surface difficult ethical questions as to the complicity of the Israeli psychiatric establishment in ill-treatment bordering in torture, and in denying prisoners basic medical human rights. I cannot avoid the conclusion that, in the case of Abu-Issa, as well as in many others, psychiatrists have played a role in the continuing suppression of Palestinian, and – more specifically – have served as executors of government policy instead of attending to the needs of their patients, the prisoners.

THE CASE OF HASSAN BADER ABDALLAH ZBEIDI

[Fourth European Conference on Traumatic Stress, Paris, May 10, 1995]

[Ed. Note: Two years after Dr. Marton talked about Hassan Bader Abdallah Zbeidi in her presentation in Buenos Aires, pps. xxxxxxxxxx, she gave additional information about this case in Paris.]

Originally, we were under the impression that Zbeidi could not recognize his family members. After he began speaking a little, it became clear that Zbeidi could hardly remember anything. He begun learning to recognize the faces and names of his family members. Slowly he moved on to memorizing the names of relatives and friends. When Zbeidi would go out in the village with his brothers and observe someone he could not remember his reaction would be one of fear and closing in. Zbeidi had great difficulty concentrating, and could not adjust to his old environment that suddenly seemed so unfamiliar. Insomnia permitted Zbeidi only two or three hours of fitful sleep each night. As well, nightmares—powerful reminders of his traumatizing experience in the Tulkarem detention center—further deprived Zbeidi of sleep. Reminders of the detention center also manifested themselves during waking hours, sometimes disguised as "bad thoughts”— paranoid delusions (his wife speaking Hebrew with female Israeli soldiers and laughing at him), or in the form of intrusive, over powering memories.

More often, the way of reenactment of the traumatizing experience was by somatic or behavioral phenomena. Zbeidi, originally a calm person, began to act violently, having temper tantrums, smashing objects within his reach, shouting at his children, and beating his wife. As a consequence of this violent behavior, Zbeidi's wife sought to divorce him.

It has been said many times that one central feature in the experience of trauma is the loss of self-control. In other words, the victim is incapable of intense fear of annihilation. This is true for several traumatic experiences, of which torture – our topic for today – is one of them.

Zbeidi lost control of his life, his sanity, his memory, his behavior, and his interpersonal relationships. Time and again, he failed to recognize me and where he was. One year later, his family thought that by letting him handle simple trade, by giving him money and responsibility, they could encourage his rehabilitation. Nevertheless, Zbeidi's reality judgment remained poor. He started to develop megalomaniacal ideas, spending large amounts of his brothers' money, while at the same time growing very suspicious of them, and quarreling with them and their employees. These disputes, coupled with Zbeidi's deteriorating relationship with his wife, left the family support structure in disarray. At this point, the family's efforts to rehabilitate him ended.

In September 1993, Zbeidi disappeared from home, and was found by strangers who proceeded to take him to a mental health hospital. Here, Zbeidi was again diagnosed with "acute catatonia." The family refused hospitalization, and since this incident, Zbeidi remains at home, taking narcoleptic drugs. He still does not talk spontaneously, and remains withdrawn and reserved.

During the past two and a half years, Zbeidi has been complaining about headaches and pain in his ears. Upon examination cognitive impairment and other symptoms which point to dysfunction of the brain, can also be detected. After suffering blows to the head, one can expect brain injury, or post-concussive syndrome to appear. Symptoms range from headaches, fatigue, dizziness, insomnia, depression and anxiety, to complete memory impairment.

In order to make a proper diagnosis of post-concussive syndrome, we must determine whether the person was unconscious, and if so, for how long. According to the Shabak report on the Zbeidi case, Zbeidi did in fact lose consciousness, and also suffered from an episode of convulsion while under detention. Nevertheless, the Shabak report is unreliable because it omits necessary details such as the number of blows dealt to Zbeidi, the time frame, period of unconsciousness, and type of convulsion.

The complaints of temporal headaches, loss and later impairment of memory, personality disorders, cognitive deficits, and decreased concentration are all typical signs of brain damage to the anterior temporal lobe. We know that similar symptoms are found in professional boxers.

In conclusion, Hassan Zbeidi is suffering from severe post-traumatic stress disorder, indicating a chronic state of psychosis and maniformic behavior which alternates to deep depression. At the same time, he suffers from post-traumatic concussive syndrome.

Still, there is a third aspect of this case, the political one, that must be addressed as well. Zbeidi was examined by several doctors working for the Israeli government. Only one, an army doctor, decided to send Zbeidi to an emergency room with a letter reading: "[Hassan Zbeidi] is disoriented as to location and time." The other doctors who examined Zbeidi in the emergency room described him as malingering, and recommended he be given placebo medication. The doctors presently returned Zbeidi to the detention center and his interrogators in spite of his poor medical condition.

PHR-IL has initiated a civil suit against the State of Israel on behalf of Zbeidi. We believe that every case of torture should be exposed and confronted for the sake of the human rights, and as a means of support and help for the victim. We are struggling to secure a law outlawing torture in Israel, one that will also require doctors and paramedics to report any suspicion of torture. PHR-IL has seen cases in which doctors have given medical documents and deliberately incorrect diagnoses in order to cover up the practice of torture by the Shabak.

In the case of Zbeidi versus the State of Israel authorities asked two medical specialists to offer their opinion regarding Zbeidi's condition. These two expert psychiatrists defined him as a "conversive case," or as suffering from "some other kind of factitious disease."

I could argue this diagnosis of conversion by referring to the work of psychiatrists like Lindy, Green and Grace (1992), whereby the process in which trauma is dissociated and relieved in somatic symptoms is described as a somatic reenactment of the trauma. It is to be distinguished from the conversion reaction by its nature of being a reproduction rather than a symbolization of trauma, as represented in the dream work of the post traumatic stress disorder.

THE ROLE OF MEDICAL PROFESSIONALS IN PROTECTING HUMAN RIGHTS: THE SITUATION IN ISRAEL

[Presentation given to meeting of the International Professionals Forum in the Middle East, Dead Sea, April 6-10, 1997]

The participation of doctors, directly or indirectly, in the practice of torture in Israel and other countries is a terrible reality that Physicians for Human Rights – Israel (PHR-IL) has endeavored to confront during the past 10 years.

The linkage between torture and the medical practice needs no explanation in this forum. The World Medical Association's Tokyo Declaration (1975) prohibits the participation of doctors in torture. Yet while the Israeli Medical Association (IMA) signed this convention in 1981, this symbolic act did not alter the everyday reality or prevent doctors from participating in torture. As a consequence, three years ago PHR-IL demanded that the IMA incorporate the principles of the Tokyo Declaration directly into its ethical code. In addition, PHR-IL drafted an addendum to the code, whose main points – as well as the story behind its rejection by the IMA – I would like to present to you.

It is common knowledge that physicians can play a central role in safeguarding the rights of weak groups, especially whenever physical and mental well-being is threatened. This responsibility stems from two sources: first, the relation of trust that should exist between doctor and patient; and second, the doctor's ability to detect problems not immediately seen by others. These facts place the doctor in a unique position that enables him/her to come to the defense of human rights.

The primary principle guiding PHR's ethical code addendum was the need to protect the helpless—children, battered women, the elderly, prisoners and detainees (especially during interrogation)— from abuse by relative and state authorities. The second principle reflected the overriding duty of doctor to patient, even when a conflict arises, and that it must remain so, in order to protect the patient's well-being, dignity and mental health, despite any other commitments, such as loyalty to state, religion or gender.

PHR-IL's goal to have the above principles enshrined in the IMA's ethical code sought to encourage the physician to act according to the ethics of his/her profession. Unfortunately, as I will explain shortly, our demand was not met by the IMA. To provide you with a background leading up to the IMA's decision, I will first present a brief overview of PHR-IL's addendum.

In recent years within the Israeli medical community, the issue of child abuse received a great deal of attention and measures for its prevention were devised. The central tenet underlying these measures was the duty to report abuse, a task placed mainly upon health professionals. In other words, to help detect and prevent child abuse, doctors were expected to be vigilant and were legally bound to report any case where abuse might be suspected.

Carrying this line of reasoning and pro-activity over to individuals in state custody-including prisoners, detainees and those under interrogation, we can identify a second group that is similarly defenseless and vulnerable to physical and injury at the hands of the very authorities responsible for their well-being. Abuse in this situation is more likely because the detainee, unlike a child, has been deemed an outcast and is typically the target of hatred. Yet while mental and physical torture is illegal and widely condemned within liberal societies, manifestations of the authorities' racist, sexist of religious prejudices are expressed in this way and have been reported countless times by the media and human rights organization. Clearly, measures for prevention of this type of violence should and indeed have been sought.

PHR-IL's first proposal to the IMA ethical code sought to identify individuals requiring urgent medical attention under state custody as possible victims of abuse. As in the case of children, it would be the physician's responsibility and duty to report any suspicion of violence, thus providing a measure of prevention and deterrence against any such abuse.

Obviously, in case of state abuse, it would be problematic to report suspicion of abuse back to the state. One would not expect the police, prison or army authorities to deal in an unbiased manner with such complaints. Therefore, PHR-IL suggested that reporting be made to an independent body. We called upon the IMA to initiate and take a leading part in the formation of such a body. And while the issue is chiefly of concern to doctors, PHR-IL believed other health professionals, including nurses, social workers, and psychologists, should be involved.

Another important area requiring ethical guidelines is the role of medical professionals who are employed—even of temporary basis—by custodial authorities (as in reserve military service for example). There are many documented cases whereby doctors have found themselves forced to act against their professional conscience and ethical principles in the name of state or employer. Moreover, this subject has been extensively discussed and dealt with by various bodies, including the British Medical Association and the World Medical Association. The conclusion reached in each case reflects a common understanding: doctors' primary obligation rests with the patient and not their employer (the state). The series of guidelines that emerged from these bodies aimed to establish a closed network between doctor and patient, free from nonprofessional intrusion. They also sought to prohibit any kind of participation by the professional in acts of torture, including rules for forced feeding during hunger strikes. In this respect, PHR-IL's proposal followed internationally recognized guidelines.

PHR-IL also pointed out the need to reinforce these guidelines with practical measures. We proposed that an organization centered around the IMA be established to assume responsibility for implementation of the aforementioned principles on a regular basis and through established mechanisms. Since PHR-IL regards the IMA as an independent embodiment of common professional conscience, we considered it the most appropriate body to be centrally involved in the proposed monitoring system.

On an operational level, it is important that the envisioned body be equipped to deal with appeals in real time, with a type of "hotline" for this purpose. Additionally, a program to teach relevant ethical principles should relayed to medical students and doctors and repeated periodically – a task ideally suited for IMA together with local medical schools.

To sum up: PHR-IL proposed that the IMA initiate an organization to which medical professionals would be obliged to report suspicions of injuries inflicted by custodial officers. This organization would also accept reports of any incident where a doctor was prevents by the authorities from fulfilling his professional duties as dictated by the addendum to the ethical code. The responsibility would rest with this organization to act and take measures according to its investigations.

In 1995, the IMA's Annual Convention ratified a new compilation of medical–ethical rules. Previously, Dr. Ram Ishai, former chairman of the IMA ethical committee, promised that one of the rules would deal with toe doctor's duty to report any suspicious injuries identified of examined patients. Nevertheless, the final version ratified by the convention addressed only minors and individuals under guardianship. This change effectively excluded reporting of prisoners potentially tortured by their interrogators.

A second problem with the watered-down rule called for physicians to report only to, and I quote, "the proper authorities." What or who are they? That is not specified. In other words, the ethical rules do not give proper guidance to those health professionals who wish to act according to their professional ethics.

The IMA failed to act upon PHR-IL's other suggestion: there is no hotline and there is no organization dealing with allegations of torture. What remains is the constant denial of complicity by Israeli doctors in the practice of torture. Recently, a member of the British Medical Association wrote to the IMA stating that he is prepared to raise the issue of the IMA's lack of involvement in combating torture before the World Medical Association, demanding the organization's expulsion from the world body. It behooves PHR-IL to support such a measure if the IMA fails to take a more active stand in the struggle against torture in Israel.

THE IMPACT OF ISOLATION ON MENTAL HEALTH

[From “The Impact of Isolation on Mental Health,” in Threat: Palestinian Political Prisoners in Israel, Baker and Matar, eds., Pluto Press 2011)

In his book The Carrot and The Stick, Israel's first Coordinator of Government Activities in the Occupied Palestinian Territory (1967-1974), Shlomo Gazit, states that since the earliest days of the occupation, solitary confinement has served as the most important strategy for breaking the spirit of Palestinians and coercing them to collaborate. Gazit writes:

The great advantage of defense regulations and administrative measures was the creation of circumstances in which the detainee was “broken,” confessed his guilt and cooperated with his interrogators. Here the most important means for “'breaking” interrogated persons (at a time when there existed strict instructions to avoid exerting physical pressure during the interrogation) was the absolute isolation of the interrogated person (from his family, his attorney, Red Cross personnel and even other detainees) during the initial phase of detention and interrogation.

The occupation is the broader context in which solitary confinement of security/political prisoners, as well as its reasons and effects, should be viewed. Social, national and individual aspects are all relevant. I am referring to the occupation which began in 1967 of the Gaza Strip, East Jerusalem, the West Bank and the Golan Heights. The detention of most political/security prisoners begins with periods of solitary confinement of varying lengths. Psychologists employed by security agencies and the accumulated experience of detention in isolation in Israel and world-wide have all served as the scientific and particularly the practical foundation for use of this type of detention. An examination of the psychological impacts of solitary confinement can fill Gazit's statement with concrete content, and explain why isolation has served as such a central strategy in "breaking" Palestinians since the earliest days of the Occupation.

It is precisely the damage that solitary confinement causes to the prisoner's psyche and personality that is often viewed by the detaining authorities as its most useful aspect. According to Haney and Rhodes, one of the destructive effects of solitary confinement is the transformation of the detainee into an asocial, shattered being (title and page go here). Solitary confinement is employed in the service of the occupation, while it earns the official backing of "security grounds."

Many studies have been conducted on the psychopathological effects of solitary confinement and their findings are unequivocal. Solitary confinement produces:

Deep psychotic reactions such as visual and auditory hallucinations, paranoid states, disorientation in time and space, states of acute confusion and thought disturbances.
Emotional instability and extreme emotional disturbances, the experience of depersonalization and derealization, rage and anger, negative attitude and affect4, compulsiveness, memory loss, attention and concentration difficulties, fear, panic, fear of death, depression, hopelessness, apathy, loss of joie de vivre.
Disturbances of body image, self-mutilation, experience of suffocation, excessive masturbation, startle reaction.
Physiological states created by the anxiety that results from solitary confinement: prisoners develop symptoms of the gastroenterology, vascular and sexual/urinary systems. Sleep disturbances and extreme fatigue. Tremor, recurrences of heart palpitations, recurrences of excessive perspiration.
Long-term effects: Solitary confinement frequently produces permanent mental disturbances and a feeling of insecurity. In fact, each of the pathologies described above may become chronic both in prison and outside.
Social pathologies: The total social isolation sometimes causes prisoners to withdraw and fear relationships with other people. It may be said that the prisoner's social personality is obliterated or distorted to such an extent that prisoners have lost the ability to handle themselves and live their lives in the company of others. This may be manifested in prisoners' preference to remain isolated even when they are given the option to leave solitary confinement. Prisoners may also suffer attacks of irrational violence and rage.

Psychotic reactions

There are several types of psychotic reactions to solitary confinement: visual and auditory hallucinations, disturbances of thought and concentration, and memory loss. A large percentage of prisoners in solitary confinement suffer from hallucinations: one study reports 38.4 percent while another indicates 50 percent. Several explanations have been offered as to the cause of these hallucinations. Williams suggests that the brain may require a certain quantity of stimuli in order to function, in the absence of which it creates its own stimuli.

Most people who were placed in solitary confinement described thought disturbances as well as the inability to control their thought processes. One described tasteless, odorless, confused thoughts. The appearance of thought disturbances creates fear and panic. One person said he thought this meant he was going mad. Following a few days in solitary confinement, states of acute confusion have been reported.

Emotional disturbances

Extreme, deep anxiety is the most common feeling among prisoners in solitary confinement. Gradually, fear and despair take over and break down the prisoner's mental and physical soundness. The feeling of deep anxiety and total abandonment along with thought disturbances and hallucinations produce an ongoing state of doubt and insecurity. All of these cause the loss of self-confidence and self-worth and bring about the loss of identity. An example may be that of the Palestinian prisoner A. who had been held in individual isolation in the Israeli prison for about six months, as she did not get along with other prisoners. She was held in individual isolation during her previous three-year sentence as well. When the prison authorities wished to remove her from isolation, she refused: "I no longer believe in anything or anyone… I feel alone and am trying to survive the rest of my sentence.” The Israeli Prison Authority's psychiatrist wrote about her need to talk, just in order to shatter her loneliness, and that she clearly used her visits to him as an opportunity for conversation: "The prisoner agreed to have a conversation. She does not want to be examined [and] is interested only in conversation." Yet he was unresponsive: "During the examination she speaks in a stressful manner about many things, many topics… It is impossible to speak with her… She talks about how she is being harmed and not treated… goes into long, irrelevant explanations, asks for help."

Long-Term effects of solitary confinement

Solitary confinement "is designed to induce disorientation and confusion… [and thus]…isolate the individual from his or her sense of self in such a way that it will prove very difficult for the victim ever to recover and function normally again,” Williams [put citation here]. Persons who were placed in solitary confinement have reported that symptoms continued after their release. They often suffer from dependency; limited concentration, attention and memory; and confusion. Research has shown that these long-term symptoms do not disappear over time, but rather become worse if left untreated.

Social pathologies

Solitary confinement requires the prisoner's maximum adaptation in order to survive under the difficult, abnormal conditions. Sometimes adaptation is total, transforming the prisoner's mental structure into a replacement of his/her previous one. Thoughts, the manner of organizing life's activities and the emotional system all undergo complete transformation to enable survival in solitary confinement. The prisoner suffers from flattened emotion, shallow thought, inability to withstand minor external stimuli, irrational rage, inability to plan and initiate normal activity, dependence on external systems to organize one's life, loss of ability to control one's behavior, anxiety triggered by the presence of another human being. For some prisoners, these symptoms become permanent and do not enable them to re-adapt to life within a social system. Most importantly, in some cases it is impossible to heal these social pathologies.

One of the presumed objectives of imprisonment is the prisoner's rehabilitation and return to society as a better citizen. Solitary confinement stands in stark contrast to this possibility. In fact, prison not only denies basic human rights during confinement, but may even prevent prisoners from conducting new lives outside of prison. It eradicates and reshapes their personality, rendering it inappropriate for "normal" life.

Mentally ill prisoners in solitary confinement

Some prisoners have suffered from emotional problems prior to their detention, some from mental illness such as schizophrenia. For these prisoners, adapting to life in prison is especially difficult. They become the "unsolvable problem" of prison authorities and other prisoners, due to the behavioral disturbances they manifest as a result of their mental illness. Subsequently, they are placed in solitary confinement. The prison thus punishes prisoners for their mental illness. Prison authorities do not know what to do with them, there are no budgets for psychotherapy, and solitary confinement is a practical “solution” for these prisoners. Certainly, solitary confinement is not a substitute for the psychotherapy that mentally ill patients so desperately need. Solitary confinement irreparably shatters whatever is left of these prisoners' personality.

Over the years of PHR-IL’s activity, we have found that schizophrenic prisoners are often systematically given a wrong diagnosis. Although they are typically on anti-psychotic drugs, the commonplace diagnosis is “manipulative,” “malinger,” “hysterical” or “imposter” or some other odd diagnosis that does not exist in the diagnostic manuals, such as “anxiety of imprisonment.” All these misdiagnoses fail to define Palestinian prisoners as mentally ill, placing them outside the realm of mental illness. Subsequently they are perceived as responsible for their actions, and specifically, fit to stand trial and carry out prison sentences.

I recall a clear-cut example elucidating this method: Prisoner M. from Gaza was accused of attempting to run over an IDF soldier. During his trial, the military judge was struck by M.'s unusual mental state and ordered a psychiatric exam for him. M. was examined at a psychiatric hospital, where the psychiatrist who examined him found him to be chronically schizophrenic. The judge then determined that M. was unfit to stand trial. At this point Major-General Matan Vilnai, Commander of the Southern Command, intervened, sentencing M. to three years in prison, by power of his authority as Commander, under article 36B of Security Provisions Order (No. 378) of 1970.

In other words, the army disregarded and canceled out the psychiatric opinion as well as the military judge’s ruling, so that a Palestinian prisoner would not escape a prison sentence.

In prison, the authorities could not find a solution to M.’s difficult behavior, and he was soon placed in solitary confinement. When I examined him in Gaza prison some time later, M. was devoid of humanity. He spread feces on his cell wall, was unable to identify his family members and could not utter a single coherent sentence.

Solitary confinement and the occupation

In his book, Imagined Communities, Benedict Anderson argues that a nation is an "imagined political community" (p. 6). It is imagined because for the most part, its members do not know and have never met each other. The important point for our purpose is that according to Anderson, despite the differences among the different individuals who make up the community, it is founded on a deep affinity among its members: "The nation… is always conceived as a deep, horizontal comradeship. Ultimately it is this fraternity that makes it possible, over the past two centuries, for so many millions of people, not so much to kill, as willingly to die for such limited imaginings" (p. 7).

In Israel, solitary confinement should be viewed as one of the practices of the occupation, whose objective is to shape submissive, compliant subjects who will fail to develop a national consciousness, a community as defined by Anderson.

Another reason for holding Palestinian prisoners in solitary confinement is that the GSS or IPS (Israeli Prison Service) have determined that the prisoner would put Israeli security at risk if allowed to be in contact with other prisoners. The case of Marwan Barghouti, who has been held intermittently in solitary confinement, is just one example of how security grounds are sometimes used merely as an excuse to exert pressure on the confined individual or others to act in a manner desirable to Israeli agencies. The grounds for placing in solitary confinement notwithstanding, its impacts on one’s mental and physical condition may be severe and permanent, as I have described.

One of the most basic stimuli that we need and which is indeed essential to our very existence is the feeling of solidarity, that we are accepted by others, the need to hear, speak to and touch another human being. All of these essential needs are denied prisoners in solitary confinement. As a result, development of a powerful sense of the loss of ability to feel is unavoidable. An individual who suffers from a feeling of emptiness and hollowness feels nothing. To lose the ability to feel means risking the death of the psyche.

Charles Dickens wrote of solitary confinement: “I hold this slow and daily tampering with the mysteries of the brain to be immeasurably worse than any torture of the body.”
I believe that solitary confinement is equal only to lobotomy – except that the process of solitary confinement is longer and crueler. Solitary confinement is nothing but a specific form of torture. People do not die from solitary confinement; they only lose their minds.

FROM THE PERSONAL TO THE POLITICAL: The involvement of Israeli physicians in the torture and ill-treatment of detainees

(Speech given as part of the “Human Security in the Middle East” Seminar Series, Brown University, March 13, 2012)

Medical professionals hold in their hands the power-knowledge of healing and curing body and soul, but that same power-knowledge can also be used to cause harm. The medical system functions as an agent of social oversight, regulation and control. It also determines social norms as society gives health professionals the power to judge and punish. Hence, for example, physicians determine a person’s fitness to work, fitness to stand trial, and the fitness of a patient to decide on the medical treatment that will or will not be administered to him or her. Physicians possess the power to determine how we enter this world and how we depart it.

Israel Prison Service physicians provide medical authorization for the solitary confinement and isolation of prisoners. Psychiatrists, who until recently gave their medical opinions to the courts via “isolation committees,” have brought about the continued incarceration of detainees in solitary confinement, causing unequivocal, and sometimes irreversible, harm to their health.

The decisions of these physicians are often influenced by extraneous considerations that undermine their commitment to act, first and foremost, for the benefit of the patient, as required by the rules of medical ethics.

The critical question is what causes someone who studied the profession of healing, the very foundation of which is to benefit mankind, to ignore and not protest against harm caused to a patient under his or her care, or—even worse—to be a complicit partner in inflicting this harm on behalf of an organization or a state?

Detainees and prisoners comprise a vulnerable population. Their rights are violated in many respects, including with regard to the medical care and treatment that is provided to them by physicians. Furthermore, when detainees are members of a cultural and national group that is different from that of the medical caregivers, this difference may significantly affect the quality of the diagnosis and care they receive. The reason is that, whether consciously or unconsciously, the medical professional brings into the interaction of diagnosis or treatment his or her own view of social-political reality, which contributes significantly to the way in which he or she understands the patient and interprets his or her complaints. In too many cases, this interaction entails the diminution of the humanity of the patient—the detainee/prisoner—in accordance with the subjective psychological needs of the physician. One can argue that the doctor reduces the patient to a single aspect of the qualities attributed to him or her.

The medical caregiver, in a blindness that serves parts of his subjectivity, perceives only a part of the object (the patient), yet considers it to be the whole. The object is thus seen as nothing more than a “criminal,” an “Arab,” a “terrorist,” a “woman.” This view eliminates the object’s individuality and transforms him into nothing more than the representative of a group with stereotypical characteristics, which stem from the physician’s prejudices. It happens both inside and outside the prison.

Psychiatry has classically positioned itself in the intra-personal dimension. During the latter decades of the twentieth century, the inter-personal dimension was added to the field. From the perspective of classical psychiatry—according to which everything occurs in the intrapersonal dimension—the social-political dimension has been rejected from the confines of its discourse, disregarding the fact that the exclusion of this dimension is, in and of itself, a political stance. However, there is indeed legitimate scope within psychiatry for this social-political dimension in addition to the interpersonal and intrapersonal dimensions, as a supra-personal dimension, one that goes beyond the personal. The inclusion of the social-political dimension in the discourse of psychiatry serves to introduce what has been missing from psychiatry for such a long period of time: the awareness and theoretical tools needed to both conceptualize a person as a social-political being and recognize human rights as a vital part of it.

These elements—human rights and an inclusive concept of the person—should be integral components of all branches of medicine if we are to implement the rules of medical ethics.

The therapist-physician must be aware of his or her own subjectivity, recognize that it is always present, and not fall back on the classic theory, which supposedly equips him or her with objectivity and neutrality. This will give the patient a chance to stand alongside the caregiver, not automatically opposite him. The patient will then cease to be an “object,” which implies “standing opposite,” and which in turn carries connotations of enmity and a state of war. Thus, the time-honored concept of the therapist as an objective and neutral person who stands opposite the patient is undermined.

However, this advice cannot apply when the therapist is in no way interested in looking inwards at his or her personal-social-cultural-political perspective, or at his or her own concerns. In this case the therapist may prefer “outsight” to insight. Within the political power game that the state plays in order to silence and repress the other, physicians can have a blind spot when it comes to recognizing the extent of their own cooperation with it. This blind spot allows physicians to disregard their professional-ethical role to protect the rights of the patient, the detainee, the other, defined as anyone whom the social order consciously silences. “Outsight” is a system of ideas and viewpoints that come from the outside—in this case from the social systems of the ruling power. This specific blindness allows physicians to regard themselves as “apolitical” and to view anyone who opposes or does not identify with the regime’s point of view as acting out of “political motives,” which stand in opposition to the purity of the medical profession. This form of identification by the psychiatrist with the ruling power has been repeated many times in history. We are familiar with cases from the twentieth century, when the medical world served as an instrument of oppressive, despotic regimes, such as those in Germany, the Soviet Union, Argentina, Chile, the U.S.A., Israel and others.

It is fundamentally important, both in theory and in practice, that physicians recognize that they are on the side of the forces that are in power in the given political-social-cultural reality: the healthy versus the ill, Israeli versus Palestinian, the free versus the imprisoned, the white collar person versus the convicted criminal, at times the educated person with means versus the uneducated person without, and often, despite the many recent advances, man versus woman.

What is the physician’s personal stance when the person he or she examines is not from his or her own culture or national group? And, in the context of Israel, what is the personal stance of the physician when he or she examines a Palestinian, who is not only a stranger but also perceived as an enemy? Is the medical system aware of its subjective biases, whereby it views the person under examination as a “terrorist” who poses a real security threat to the society? This perspective may be so all-encompassing that it obscures any other element of the patient’s humanity. The health system’s role in protecting “public security” in certain circumstances (for example, in cases of danger to the public to incarcerate the patient, contagious illnesses that necessitate reporting, compulsory hospitalization, etc.) and the real power that comes with this may blur the boundaries between the system’s political and professional stance. In the Israeli context the absence of sufficient awareness of the physician's personal stance means the Palestinian patient, in too many cases, is perceived as a terrorist and indeed as a threat to the public security rather than as a patient in need of medical care. This increases the likelihood that Palestinian detainees who complain of torture, ill-treatment or harmful detention conditions will not receive the appropriate treatment and protection from their doctor.

For instance, J.M. was arrested in 2008. After three months in detention and interrogation by the Shabak, he was taken to an interrogation unit where he was brutally beaten until his head and face were bleeding and he felt that he was losing consciousness. A doctor examined him and told the interrogators that J.M. should be taken to a hospital. The interrogator in charge told everyone present (the two men who had beaten J.M., the doctor and the ambulance crew) not to talk about what had happened. If asked, they were to say that J.M. had fallen down some stairs. All present agreed to adhere to this version of events. In the public hospital to which J.M. was later taken, he was examined by three different doctors, each of whom refused to listen to his claims of being beaten. They all appeared to accept the story that he had fallen down stairs. One of them told J.M. that what happened to him was not her concern, that her role was merely to treat him, and that the cause of his injury was of no interest to her. After some three hours, stitches to the head and an X-ray, J.M. was released from hospital and returned to the interrogation center. There he met a doctor employed by the Israeli Prison Service, who again ignored his attempts to report the abuse, gave him pain killers, and allowed the security guards to escort him to a solitary confinement cell.

On the basis of J.M.’s affidavit and the hospital’s medical documentation, it is clear that all the doctors who examined him after the beating ignored his complaints and did not properly document them. They did not report the injuries and allowed J.M. to be returned to a setting where he may be tortured again.

Following the case of J.M., PHR-IL contacted the hospital at which he was treated, the Ministry of Health, and the Israel Medical Association to request an investigation into the involvement of various physicians in this case. PHR-IL further requested, not for the first time, that copies of the rules of medical ethics and obligations regarding the treatment and protection of imprisoned persons who are subjected to torture or ill-treatment be distributed to medical professionals, and that the Ministry of Health announce legal and financial support for medical professionals who report and bring an end to incidents of torture and ill-treatment in case they encounter mistreatment by their employers.

(It is the position of PHR-IL that doctors should not be employed by the IPS or the GSS, and that they should not work in GSS interrogation facilities.)

In July 2011, following additional complaints by PHR-IL against the involvement of medical teams in the torture and ill-treatment of imprisoned persons, and the publication of a report by the Public Committee against Torture in Israel (PCATI) and PHR-IL,⁵ the Ministry of Health announced that it had appointed a “Committee for Medical Staff Reporting Harm to Interrogatees’ Medical Condition.” Unfortunately, questions addressed to the Ministry of Health regarding the staffing and function of the committee and how one should approach it have gone unanswered, giving us reason to fear it is not actually operating.

The fact that the medical establishment in Israel refrains from discussing the involvement of physicians and other medical personnel in the torture and ill-treatment of imprisoned persons testifies to a common political-social need of both many individual physicians and of the organization that binds them. This need is that of the Israeli-Zionist to view the Palestinian as an enemy, a terrorist, an agent of danger. It is so frequently expressed that it can be viewed as a coherent system, one that does not allow a Palestinian who is being tortured or ill-treated to transcend the sole role that has been assigned to him: a terrorist. This attitude has been adopted by junior as well as senior physicians, department heads and district physicians, new immigrants and people born in Israel, and inhabitants of the north, center and south of the country. They, doctors, all live among their people. One should not assume, however, that physicians act out of malice for malice’s sake or out of professional ignorance. The violation of human rights and the rights of the patient is not the goal; rather, the goal is to sustain a single, uniform image for all Palestinians—that of the enemy—which helps to preserve the social fiber of the Israeli Zionists as a coherent group with a common ideology and purpose. The presence of an enemy is vital to maintain both the affinity and the reciprocal relations between the patriotic-Zionist discourse and actions that derive from this discourse, which include the occupation and the repression, arrest and torture of Palestinians.

Therefore, it is what the security forces portray as the political “crimes” of the patient—the Palestinian detainee – and not his or her medical condition, that too often determine the medical diagnosis and treatment that he or she receives.

We at PHR-IL are often accused by physicians and the medical establishment at large of taking a political stance, of being “too political.” We answer these claims with the words of Stephen Mitchell: “Is not the posture of not taking sides itself a partisan position, a side one is taking?”⁶

The problem is not one of “taking sides.” The problem is when we do not see that we are taking a side, because all of us take a side. The question is how aware we are, as physicians, that we, like anyone else, are subjective and political. When we take the side of the establishment, there is a tendency to blindness that fosters the comfortable thought that we are not political. Concurrence with the establishment, and avoiding casting doubts on its deeds, is perceived as an objective, not a political, attitude. And yet protesting these deeds is considered a political stance. Elucidating the blind spot is considered a one-sided, extreme act that vilifies one’s colleagues.

The recognition that we are all “tainted” by a political viewpoint makes it possible to open up a discourse within the medical profession that can develop insight among its members. Progressing in this direction will make it possible for the medical profession to protect human rights. By contrast, a lack of openness will result in a perversion of the power of medical professionals, and will necessarily lead to ongoing human rights violations.

Hamisa Muhana, half-blind, stabbed a Border Police officer, who shot her in the right leg. She was sentenced to 10 years in prison. The prison spokesperson responded to our letters after lengthy delays, describing Muhana’s conditions in such general terms that the responses were useless. Muhana was released from prison in 1997, following the Oslo Agreements, some three years before her time was up.
Hava Keller was a volunteer with the organization Women for Women Prisoners.
Administrative detention does not require that any charge be made against the prisoner.
Coffin or closet is a narrow cell, 90×90 cm., also used as refrigerator by cooling it to freezing temperature by cool air. The banana tie is used in two forms/methods: the legs of the tortured person are tied to the legs of a stool and his hands to the other stool's legs, his body is bent backward. The body is arched in a banana form. The second form is tying the torture's hands to his feet creating an arch banana like shape. The "al-shabach" tie is used often as preparation for interrogation. The detainee's hands are tied behind and over the head. The bound hands are also tied to bars or pipes embedded in the wall. The hands are usually fixed so high that the tortured person finds it very difficult to stand on his legs, which are also bound. Usually the tortured person is blindfolded or hooded. "al-shabach" lasts for 6-9 hours between interrogation or during the night. In many cases the “al-shabach” is used as a preparation period before investigation. The prisoner will be tied like this for 2-5 days. Other methods of torture are: gambaz – sitting in a frog like position, hands tied behind the back. It is painful and harmful to knees and feet. Might cause rectal bleeding. Tightening handcuff – painful and harmful to hands or legs. Might stop blood flow, swelling of limb and harm to the nerves. Shaking – rapid enforced movements of head and shoulders. Might cause brain hemorrhage including death. Strangling by pressure to throat. Sensory deprivation by hooding with a heavy stinking sack on head and neck for many hours. The same effect is obtained when the tortured person is hold in the coffin/closet for long hours. Loud music for long periods of time. Sleep deprivation. Food and water deprivation.
The Public Committee Against Torture in Israel and Physicians for Human Rights – Israel, Doctoring the Evidence, Abandoning the Victim, October 2011: http://www.phr.org.il/uploaded/Doctoring%20the%20Evidence%20Abandoning%20the%20Victim_November2011.pdf .
Stephen Mitchell, Influence and Autonomy in Psychoanalysis, 1997, London: Hillsdale, pp. 183.