Friday, August 20, 2004

Abu Ghraib: its legacy for military medicine

The Corpus Callosum was shocked into a state of total dysfunction today.  This resulted in complete loss of communication between the left and right hemispheres.  CC has noticed that the two sides have not been getting along lately.  Perhaps there are no Red States or Blue States, but there are abusers in the military along with their accomplices; and then there is the rest of humanity.  It was not just "a few bad apples." 

I really can't convey how upsetting this is.  I turned the background here all black.  I am not going to get to sleep at night.  I was in a pretty good mood when I got home from work.  My wife told me about her father's recent experience at the VA hospital.  We had a nice talk.  I felt inspired to blog about my support for a national health care service.  Then I spent part of the evening setting up a two-monitor configuration. 

The idea is that I can edit blog entries on one screen, and have the sources (news articles, etc.) on the other.  I couldn't get it to show two separate screens under Linux; all I could do was get it to echo one screen on both monitors.  That was irritating, but not really a big deal.  The two-monitor configuration works fine under Windows XP. 

So I sit down, fire up my browser.  My home page is Google News.  Immediately, I see the headline:

US Army Doctors Had Role in Abu Ghraib Abuse -Lancet
Reuters - 5 minutes ago
LONDON (Reuters) - US military doctors working in Iraq collaborated with interrogators in the abuse of prisoners at Abu Ghraib prison outside Baghdad, an article in the British medical journal The Lancet said on Friday.

Gasp.  I scan the Reuters article, then go to the source at The Lancet.  For those of you unfamiliar with it, The Lancet  is a medical journal published in the UK.  It arguably is the most prestigious -- not to mention conservative -- medical journal in the world. 

Abu Ghraib: its legacy for military medicine
The complicity of US military medical personnel during abuses of detainees in Iraq, Afghanistan, and Guantanamo Bay is of great importance to human rights, medical ethics, and military medicine. Government documents show that the US military medical system failed to protect detainees' human rights, sometimes collaborated with interrogators or abusive guards, and failed to properly report injuries or deaths caused by beatings.  [see refs. 1-23 in the original article]  An inquiry into the behaviour of medical personnel in places such as Abu Ghraib could lead to valuable reforms within military medicine. [...]

In late 2002, the Secretary of Defense approved "Counter Resistance Techniques" including nudity, isolation, and exploiting fear of dogs for interrogating al-Qaeda suspects at Guantanamo.  In April, he revised those techniques and advised those devising interrogation plans to give consideration to the view of other countries that some of the authorised techniques such as threats, insults, or intimidation violate the Geneva Convention. He added, "Nothing in this memorandum in any way restricts your existing authority to maintain good order and discipline among detainees." [see ref. 6] [...]

Although US military personnel receive at least 36 minutes of basic training on human rights, Abu Ghraib military personnel did not receive additional human rights training and did not train civilian interrogators working there. [1,15,17] Military medical personnel in charge of detainees in Iraq and Afghanistan denied being trained in Army human rights policies.[17] Local commanding officers were unfamiliar with the Geneva Convention or Army Regulations regarding abuses.[13-15] Arab language synopses of Geneva protections were not posted in the cellblocks in Iraq and Afghanistan as required by Army regulation.[2,10,13,17] [...]

US Army investigators concluded that Abu Ghraib's medical system for detainees was inadequately staffed and equipped.[8,11,13,16,17] The International Committee of the Red Cross (ICRC) found that the medical system failed to maintain internment cards with medical information necessary to protect the detainees' health as required by the Geneva Convention; this reportedly was due to a policy of not officially processing (ie, recording their presence in the prison) new detainees.[16,34] Few units in Iraq and Afghanistan complied with the Geneva obligation to provide monthly health inspections.[17] [...]

The medical system collaborated with designing and implementing psychologically and physically coercive interrogations. Army officials stated that a physician and a psychiatrist helped design, approve, and monitor interrogations at Abu Ghraib. [15] This echoes the Secretary of Defense's 2003 memo ordering interrogators to ensure that detainees are "medically and operationally evaluated as suitable" for interrogation plans.[6] In one example of a compromised medically monitored interrogation, a detainee collapsed and was apparently unconscious after a beating, medical staff revived the detainee and left, and the abuse continued.[22] There are isolated reports that medical personnel directly abused detainees. Two detainees' depositions describe an incident where a doctor allowed a medically untrained guard to suture a prisoner's laceration from being beaten.[22,23]

The medical system failed to accurately report illnesses and injuries.[34] Abu Ghraib authorities did not notify families of deaths, sicknesses, or transfers to medical facilities as required by the Convention.[34,36] A medic inserted a intravenous catheter into the corpse of a detainee who died under torture in order to create evidence that he was alive at the hospital.[37] [...]

Death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months.[24,39] Medical investigators either failed to investigate unexpected deaths of detainees in Iraq and Afghanistan or performed cursory evaluations and physicians routinely attributed detainee deaths on death certificates to heart attacks, heat stroke, or natural causes without noting the unnatural aetiology of the death.[40,41] In one example, soldiers tied a beaten detainee to the top of his cell door and gagged him. The death certificate indicated that he died of "natural causes . . . during his sleep." After news media coverage, the Pentagon revised the certificate to say that the death was a "homicide" caused by "blunt force injuries and asphyxia." [24] [...]

Finally, although knowledge of torture and degrading treatment was widespread at Abu Ghraib and known to medical personnel,[13,41,44] there is no report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture. [...]

Although the US Armed Forces' medical services are mainly staffed by humane and skilled personnel, the described offences do not merely fall short of medical ideals; some constitute grave breaches of international or US law. Various voices call for courts martial, a special prosecutor, or compensation. Such measures will be inadequate if unaccompanied by even more ardently pursued reform.

Such reform must begin with a comprehensive investigation. At this time, it is not possible to know the absolute or relative prevalence of the various abuses or fully assess the performance of military medical personnel with regard to human rights abuses. Army investigations have looked at a small set of human rights abuses, but have not investigated reports from human rights organisations, nor have they focused on the role of medical personnel or examined detention centres that were not operated by the Army.[13-17] Six more investigations are underway.[59] The Army's Miller and Ryder Investigations remain classified.[17] Several thousand pages of the Army's Taguba Investigation appendices are unavailable.[13] Several secret detention centres that remain unmonitored. The US military medical services, human rights groups, legal and medical academics, and health professional associations should jointly and comprehensively review this material in light of US and international law, medical ethics, the military code of justice, military training, the system for handling reports of human rights abuses, and standards for the treatment of detainees. Reforms stemming from such an inquiry could yet create a valuable legacy from the ruins of Abu Ghraib.

I edited out several of the specific cases they cited, since I only wanted to cite enough to make a point.  The article in The Lancet  contains many more documented incidents; there are fifty-nine references.  They make note of the fact that there are thousands of additional pages of documents that have not been released. 

The article was researched and written as carefully as any medical study report.  This is not the kind of casual journalism that gets researched, written, and published in a 24-hour news cycle.  This cannot be dismissed.  It is a very serious problem for our country. 

And my fellow physicians were part of the whole god damned mess. 

(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
E-mail a link that points to this post:
Comments (1)

Wednesday, August 18, 2004

Gene Therapy With Behavioral Consequences...(?)

...In monkeys, anyway, sort of.  Recently, news@nature.com reported on a study, in which the behavior of monkeys was altered by injecting DNA into their brains.  The original article is available, open access, at PNAS.  The title of the Nature news report got my attention: Gene therapy cures monkeys of laziness.  Did the scientists find a way to alter the genetic makeup of monkeys, such that they were better workers?  Could this work for humans?  Could we actually make people into better workers?  Maybe then we could all get a little injection into our skulls and boost the GDP!  Maybe no child will be left behind, for real.  Just get them all to stand in a line, before they take the SAT or whatever, give them a little needle in the skull, hand out some sharp #2 pencils, and let 'em at it!

It turns out that the title is a bit of an exaggeration.  What the researchers did is not really gene therapy, and it did not cure the monkeys of anything.  This degree of hyperbole is unusual for a journal known more generally for being understated.

Gene therapy cures monkeys of laziness
Published online: 11 August 2004; | doi:10.1038/news040809-10
Helen Pilcher

Switching off key gene turns layabout primates into keen workers.

Procrastinating primates can be turned into workaholics, thanks to gene therapy. The discovery, which sheds light on the workings of the brain's reward centre, may further our understanding of mood disorders, such as depression and obsessive-compulsive disorder.

Like many humans, monkeys tend to slack off when their goal is distant, then work harder as a deadline looms. But when a key gene is turned off, the primates work hard from the word go, researchers report in PNAS Online1.

"The gene knockdown triggered a remarkable transformation in the simian work ethic," says Barry Richmond of the National Institute of Mental Health in Bethesda, Maryland, who studied the animals. [...]

The scientists set up a study in which monkeys had to perform a boring, repetitive task.  During the task, the monkeys could see an indicator that showed how long they had to keep going before they would get a reward.   The system monitored how often the monkeys made errors.  It turns out that they make a lot of errors when the reward was a long way off.  As the time for the reward got closer, they started to pay more attention, and made fewer errors. 

Then, they took some monkeys and injected a specially-prepared DNA solution into their brains.  The DNA was an antisense analogue of the region that codes for one kind of dopamine receptor.  The injected DNA would bind to the DNA in the nuclei of the monkeys' brain cells, preventing it from functioning.  This effectively stopped the production of D2 receptors, thereby decreasing the number of such receptors in the brain. 

It turns out that monkeys treated in this way make fewer errors during the early part of the test, when the reward is still a long way off. 

Now, what they did to the monkeys is not really "gene therapy."  They did not insert new genetic material into the functioning nuclei of the monkeys.  They used a nonfunctioning kind of DNA to turn off (temporarily) a normal gene that had been functioning properly.  Furthermore, the treatment did not cure anything.  All it did was to make the monkeys more able to tolerate boredom. 

Ok, so they exaggerated.  Still, is there any chance that this kind of thing could be beneficial for people?  I mean, if you could somehow get past the obvious ethical issues, could we make people better workers? 

First, we can't  get past the ethical issues.  Gene therapy is risky, and could be justified only for treatment of a life-threatening condition.  Also, we already have a way to block D2 receptors without putting a needle inside the skull.  Antipsychotic medications block D2 receptors.  So it turns out that the research cited above really has no hope of ever evolving directly into anything of clinical utility.  It could be important, it that it could help us to develop a better understanding of the connection between genetic constitution and behavior.  Or perhaps it could lead to new targets for drug development.  But something like that would take at least a few decades. 

(Note: The Rest of the Story/Corpus Callosum has moved. Visit the new site here.)
E-mail a link that points to this post:
Comments (0)