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Human Rights Watch has reported on a wide range of abuses against patients and individuals under medical supervision - in medical facilities, juvenile detention centers, orphanages, drug treatment centers, and social rehabilitation centers. Often in these settings, health providers may be forced to withhold care or engage in treatment that intentionally or negligently inflicts severe pain or suffering for no legitimate medical purpose.

Medical care that causes severe suffering for no justifiable reason can be considered cruel and inhuman, and in some cases, where there is state involvement and specific intent, it can be considered torture.

Prohibitions in international human rights law forbidding torture and other cruel, inhuman or degrading treatment (CIDT) or punishment apply to conditions of confinement, including in medical and other institutions. The International Covenant on Civil and Political Rights (ICCPR), the first international treaty to address torture and CIDT explicitly, provides, in article 7, that: "No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation."

The UN Human Rights Committee emphasizes that article 7 "protects, in particular ... patients in teaching and medical institutions." The UN Manual on Reporting also notes: "Article 7 protects not only detainees from ill-treatment by public authorities or by persons acting outside or without any official authority but also in general any person. This point is of particular relevance in situations concerning ... patients in ... medical institutions, whether public or private."

The United Nations Human Rights Committee has stated that prohibitions against torture and CIDT apply "not only to acts that cause physical pain but also to acts that cause mental suffering to the victim."[1] Article 16 of the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Convention against Torture), and interpretations by the European Court of Human Rights and the United Nations special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment suggest that, at a minimum, CIDT covers "treatment as deliberately caus[ing] severe suffering, mental or physical, which in the particular situation is unjustifiable."[2] The special rapporteur, Manfred Nowak, suggests that CIDT is distinguished from torture in that it may occur out of intentional and negligent actions."[3]

Human Rights Watch research into torture and CIDT in health settings includes  health care providers' involvement in forcible anal and vaginal exams, female genital mutilation, and failure to provide life-saving abortion, palliative care and treatment for drug dependency.

The Human Rights Watch 2010 World Report essay, "Abusing Patients: Health Providers' Complicity in Torture and Cruel, Inhuman or Degrading Treatment" summarizes recent research by Human Rights Watch on the abuse of patients in health settings.

Other Human Rights Watch research related to this theme, in various institutional settings:

Prisons/Pre-Trial Detention

"Barred from Treatment: Punishment of Drug Users in New York State Prisons," March 2009: Details lack of drug dependence treatment, Medication-Assisted Therapy, and harm reduction services in New York state prisons.

"Torture and Impunity in Jordan's Prisons: Reforms Fail to Tackle Widespread Abuse," October 2008: Documents torture in Jordan's prisons and notes lack of adequate health care, especially psychiatric care.

"Locked Up Alone: Detention Conditions and Mental Health at Guantanamo," June 2008: Describes deteriorating mental health of detainees held at Guantanamo Bay, Cuba, as a result of conditions of confinement.

"In a Time of Torture," February 2004: Documents the human rights abuses suffered in Egypt  by men suspected of engaging in homosexual activity, which is unlawful under Egyptian moral codes. The systematic abuse imposed on suspected individuals  by police officials includes forcible "anal exams," conducted by forensic physicians. These exams, which involve anal molestation and penetration, are used to establish whether an individual has violated the moral code against "debauchery." But examining physicians admitted to HRW that the tests are not conclusive despite official reliance on results for conviction.

[See also: News Release, "Egypt: Court Upholds HIV Sentences, Reinforces Intolerance," May 2008; News Release, "Egypt: New Indictments in HIV Crackdown," March 2008; News Release, "Egypt: Spreading Crackdown on HIV Endangers Public Health," February 2008; News Release, "Egypt: Stop Criminalizing HIV," February 2008: Series of pieces detailing abuses suffered by men arrested and tried on the basis of suspected HIV positive status, including HIV testing without consent by Ministry of Health doctors and forced forensic anal examinations designed to "prove" that they had engaged in homosexual conduct].

"Undue Punishment: Abuses Against Prisoners in Georgia," September 2006: Details conditions of detention in Georgian prisons and substandard or absent medical care, including lack of medicines and other treatment and wholly inadequate mental health care.

"Guinea - "The Perverse Side of Things": Torture, Inadequate Conditions, and Excessive Use of Force by Guinean Security Forces," August 2006: Describes prison conditions in Guinea, including severe overcrowding, and policy of releasing individuals who are near death so that they do not die in custody.

"Ill-Equipped: U.S. Prisons and Offenders with Mental Illness," October 2003: Documents the disproportionate number of mentally ill individuals in prisons. Three times as many  mentally ill people are in prisons as in mental health hospitals; and prisoners have rates of mental illness  two-to-four times greater than the rates for the general public. Seriously ill prisoners often receive little or no meaningful treatment because prison mental health services are woefully deficient, crippled by understaffing, insufficient facilities, and limited programs. The role of psychiatric personnel is limited, and includes stabilizing those who suffer psychotic episodes so that they can be returned to the conditions that provoked the attack.

[See also: Letter to Representative Julie Hamos, "Human Rights Watch Supports HB 2633," April 2009; Article, Jamie Fellner, "Prevalence and Policy," Correctional Mental Health Report, January 2007; News Release, "U.S.: Number of Mentally Ill in Prisons Quadrupled," September 2006; News Release, "Prisons No Place for Mentally Ill," February 2004].

"Long Term Solitary Confinement for Political Prisoners," July 2004: Describes Tunisia's prolonged isolation of selected inmates, most of them leaders of the banned Nahdha Party, which seems driven less by legitimate penological motives than by a political will to punish and demoralize these individuals and to crush the Islamist trend they represent.

"Nowhere to Hide: Retaliation against Women in MI State Prisons," September 1998: Describes  retaliation by attackers against  women inmates who have been raped by guards in Michigan prisons.

"Cold Storage: Super Maximum Security Confinement in Indiana," October 1997: The first comprehensive assessment under international human rights law of super-maximum security facilities in the United States, which house prisoners who will someday be released back into society.

Immigration Detention

Report, "On the Margins: Rights Violations against Migrants and Asylum Seekers at the New Eastern Border of the European Union," November 2005: Describes detention conditions  for migrants in Ukraine, including lack of access to medical services.

"Chronic Indifference," December 2007: Documents HIV/AIDS care for detained immigrants; death of HIV-positive detainee in federal custody immigration facility; and failures in the system that lead to insufficient medical care, discrimination and harassment.

 "Detained and Dismissed," March 2009: Documents health care conditions in  US immigration and Customs Enforcement Service facilities, where as of 2007,  more than 320,000 people were in its custody. Individuals are detained for administrative infraction but suffer health care conditions worse than prison settings. Documents  many instances of facilities ignoring sick call requests, not delivering necessary medication, losing medical records, failing to provide translation services, impeding access to specialist care, and  denying access to needed treatment. Documents instances in which women were denied gynecological care, mammograms and adequate care during pregnancy.

Health Care Institutions/Hospitals

"Please, do not make us suffer any more...," March 2009: Examines the chronic  worldwide problem of under-treatment for pain. Despite the universal consensus that palliative care should be  part of the national response to AIDS and cancer treatment, 80 percent of the world's people do not receive adequate pain treatment. Government passivity is a key reason for under-treatment  in both the developed and developing world.

"A High Price to Pay: The Detention of Poor Patients in Hospitals," September 2006: Examines the effects of user fees and the practice of routinely detaining poor patients who are unable to pay their hospital bills in Burundi, one of the poorest countries in the world.  Documents inadequate, often inhumane, living conditions for  detained patients, who often go hungry, sleep on the floor and are refused appropriate medical treatment. The abuses  discourage similarly situated people from seeking health care and exacerbate health problems of recovering patients.

"Hated to Death: Homophobia, Violence, and Jamaica's HIV/AIDS Epidemic," November 2004: Notes discrimination faced by men who have sex with men in Jamaica by health workers, who refuse to treat the men, make abusive comments and disclose their sexual orientation, putting them at risk of homophobic violence.

"Over Their Dead Bodies," October 2007:  Documents  deaths that result from a blanket ban on abortion in Nicaragua, one of three remaining countries that ban abortion for women in all circumstances and a country in which a doctor who performs abortions may face criminal charges. The deaths include those that result from the "chilling effect" of the law, described by women reluctant  to seek medical care for obstetric emergencies, including heavy bleeding, for fear of being suspected of inducing abortion.

"No Bright Future," July 2006: Details the practical impossibilities for HIV-positive individuals in Zimbabwe  in accessing necessary antiretroviral therapy (ART), whose cost can be prohibitive. The government grants waivers for health user fees  but the  system is rife with flaws. Hospitals turn away patients who have been granted exemptions, for example,  requiring payment  up front instead. Such provider abuse denies life-saving care  and disrupts ART, which can result in the patient's developing drug resistence.

"Decision Denied," June 2006: Documents the difficulties  Argentinian women have gaining access to abortion.

"Mexico: The Second Assault," March 2006: Documents difficulties girls and women face in Mexico if they seek abortions  as a result of rape. Mexico's laws permit legal abortion after rape. But for many rape survivors, actual access to safe abortion procedures is made virtually impossible by a maze of administrative hurdles as well as official negligence and obstruction. At the core of this issue is a generalized failure of the Mexican justice system to provide a solution for rampant domestic and sexual violence, including incest and marital rape.

"Rhetoric and Risk," March 2006: Describes discrimination by health  care providers  against people living with and at high risk of HIV/AIDS in Ukraine. People living with HIV/AIDS and injection drug users have been turned away from hospitals, summarily discharged when their HIV status became known, or provided poor quality care that was both dehumanizing and debilitating to their already fragile health status.

"Positively Abandoned," July 2005: Documents discrimination for HIV-positive mothers and their children in healthcare settings (as well as in other sectors).

Psychiatric Institutions

News Release, "Speaking Up for Vietnam," June 2008: Notes the legally sanctioned practice in Vietnam of committing political dissidents to "social protection centers" and psychiatric facilities involuntarily without trial.

News Release, "Turkmenistan: New Leader Should End Rights Abuses," December 2006: Urges Turkmenistan to end practice of forcible detention of political prisoners in psychiatric hospitals

News Release, "Uzbek Activist in Eighth Day of Detention," November 2005: Describes arrest of Elena Urlaeva, a member of the Human Rights Society of Uzbekistan,  in the waiting room of the office of the human rights Ombudsman in Tashkent while trying to deliver a complaint.

News Release, "Uzbekistan: Dissident Forced into Psychiatric Detention," September 2005: Describes  politically motivated detention of individuals in psychiatric facilities and forced psychiatric treatment as punishment.

[See also: News Release, "Uzbekistan: Dissident in Psychiatric Detention," April 2001].

News Release, "Russia: EU Policy Should Address Human Rights," March 2004: Notes need for reform of psychiatric institutions given serious problems with procedures for committal for involuntary treatment.

"Dangerous Minds: Political Psychiatry in China Today and Its Origins in the Mao Era," August 2002: Details the practice of politically motivated psychiatric diagnosis and institutionalization in China. Inside a secret network of state run psychiatric facilities, accused political dissidents are detained indefinitely, alongside those who are truly mentally ill. Political dissidents receive "treatment" for disobedience in the form of electroshocks, public humiliation, force feeding, and forcible injections of anti-psychotic drugs.

[See also: News Release, "China: No Medical Reason to Hold Dissident," March 2006; News Release, "China: Political Prisoner Exposes Brutality in Police-Run Mental Hospital," October 2005; News Release, "China: WPA Action on Psychiatric Abuse Falls Short," August 2002; News Release, "China: End Political Abuse of Psychiatry," August 2002].

Drug Treatment Facilities

"‘Skin on the Cable':The Illegal Arrest, Arbitrary Detention and Torture of People Who Use Drugs in Cambodia," January 2010: Documents the treatment of   people who use drugs  by law enforcement officials and staff  at government drug detention centers  claiming to provide drug "treatment" and "rehabilitation."  These centers  hold  people rounded up by police or arrested at  the request of family members, who sometimes pay for their care,   without  judicial oversight.  In 2008 over 2,300 people were detained in such centers, including many children under 15 and people with mental illnesses.

"Where Darkness Knows No Limits," January 2010: Documents how China's June 2008 Anti-Drug Law compounds the health risks of suspected illicit drug users by allowing government officials and security forces to incarcerate them for up to seven years without trial or judicial oversight.  The law fails to  define clearly mechanisms for legal appeals or to report abusive conduct and does not ensure evidence-based drug dependency treatment.

"An Unbreakable Cycle: Drug Dependency Treatment, Mandatory Confinement, and HIV/AIDS in China's Guangxi Province," December 2008: Details the range of human rights abuses suffered by identified drug users in China. Detained in drug rehabilitation centers for indefinite periods of time, drug users are forced into unpaid labor, exposed to environments with  an unnecessary and heightened risk of disease infection, inadequate medical services and rampant abuse  by prison guards.   Describes human rights violations resulting from a  national drug policy that shirks universally recommended methods for rehabilitation in favor of a punitive system.

"Rehabilitation Required: Russia's Human Rights Obligation to Provide Evidence-based Drug Dependence Treatment," November 2007: Finds that treatment offered at state drug treatment clinics in Russia is so poor as to constitute a violation of the right to health and further notes breaches of confidentiality.

"Deadly Denial," November 2007:Documents the repeated failures of the Thai government in extending the success of its universal ART program to HIV- infected drug users. Although the law has extended  provision of  ART to drug users, discriminatory practice continues without state censure. Health care  providers interviewed admitted  they did not know of a change in the law, were uncertain about potential interactions between ART and methadone or other illicit drugs, or feared that extension of ART to drug users would be "asteful" given the group's "unreliability."

"Not Enough Graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights," July 2004: Details inadequacy of drug treatment and HIV prevention programs in prisons in Thailand, coerced substandard drug treatment, discrimination in hospitals, and drug users' exclusion from government-sponsored HIV/AIDS treatment programs.

"Locked Doors," September 2003: Documents the urgent needs of persons living with HIV in China  for healthcare, legal aid and community support.  Instead, widespread discrimination by state and private actors and the lack of redress are forcing many people with HIV/AIDS to live like fugitives. 

Social Rehabilitation Facilities

"Libya: A Threat to Society? Arbitrary Detention of Women and Girls for ‘Social Rehabilitation'" February 2006: Details the inhuman and degrading treatment of women  suspected of transgressing moral codes - often involving extramarital sex and rape -  in state run "rehabilitation centers." Women and girls identified as "vulnerable to engaging in moral misconduct" can be detained indefinitely at these  centers. A majority of women interviewed reported undergoing invasive "virginity exams," by health care personnel when they entered  the facility. Results from such exams not only inform the prosecutorial process but also affect the family's decision on whether to abandon the woman to the facility's care.

Orphanages/Juvenile Detention Centers

"Real Dungeons: Juvenile Detention in the State of Rio de Janeiro," December 2004: Describes abuse and inhumane conditions in Rio de Janeiro's state juvenile detention centers, including poor hygiene and healthcare (lack of water and frequent scabies outbreaks).

"Abandoned to the State: Cruelty and Neglect in Russian Orphanages," December 1998: Details the egregious abuse and inhumane conditions that abandoned and orphan Russian children experience in state-run orphanages. . Inhumane conditions include prolonged use of restraints and light deprivation, inadequate medical attention, isolation, and abuse by supervising medical staff.

"Custody and Control," September 2006: Examines two large, prison-like facilities in which girls in New York state are confined, and concludes that, far too often, girls experience abusive physical restraints and other forms of abuse and neglect and are denied the mental health, educational and other rehabilitative services they need.

"Death by Default: A Policy of Fatal Neglect in China's State Orphanages," January 1996: Documents the pattern of cruelty, abuse, and malign neglect which has dominated child welfare work in China since the early 1950s, and that constitutes one of the country's gravest human rights problems.

"Romania's Orphans: A Legacy of Repression," December 1990: Shortly after Nicolae Ceaucescu was overthrown on December 22, 1989, the world was exposed for the first time to the shocking images of Romania's orphans, expecially its handicapped children and babies with AIDS. These children, numbering over 100,000, lived for the most part in Dickensian institutions - bleak, understaffed orphanages built by the Ceaucescu government to deal with the consequences of its policy of coercively raising the birth rate. The orphans are the grisly legacy of an oppressive regime in a country that lacks both democratic traditions and independent associations of professionals.

[1] United Nations Human Rights Committee, General Comment 20,  Article 7 (forty-fourth session, 1992). Compilation of general comments and general recommendations adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.1 at 30, paragraph 5.

[2]M. Nowak, "What Practices Constitute Torture?" Human Rights Quarterly 28(2006), p. 821, quoting from A. Boulesbaa, The UN Convention on Torture and the Prospects for Enforcement (Martinus Nijhoff Publishers, 1999).

[3]M. Nowak and E. McArthur, The United Nations Convention Against Torture. A Commentary (New York: Oxford University Press, 2008), p. 553.

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