(New York) - A Jordanian prosecutor ordered the pre-trial detention of a woman accused of a minor offense despite her life-threatening infection with necrotizing fasciitis, also known as "flesh-eating" bacteria, Human Rights Watch said today.
The detention was ordered despite the fact that she was scheduled for surgery the same day and that, medical authorities say, the condition can worsen rapidly and cause death. Prison authorities finally sent her for surgery elsewhere but offered inadequate treatment after she was returned to prison. She was held for almost three months, when Human Rights Watch spoke to Nuri.
"The prosecutor's detention warrant could well have been Nuri's death warrant if not for the intervention of prison authorities who transferred her to the hospital," said Christoph Wilcke, senior Middle East researcher at Human Rights Watch. "But then they held her for three months without the treatment she needed for her condition or pain."
A suspect's health, and the ability of the prison system to provide adequate care, should be a basic consideration for pre-trial detention, especially for a minor offense, Human Rights Watch said.
Ruba ‘Atta Nuri, a 34-year old Jordanian living in Amman, had scheduled surgery at Amman's al-Hanan private hospital on August 5, 2010, for her condition, but police officers arrested her on the night of August 4 and interrogated her regarding charges of fraud against her.
The police then transferred her overnight to the Juwaida holding facility for women, before presenting her to a South Amman prosecutor, Muhammad Hashim al-Hijazi, on the morning of August 5. Al-Hijazi issued a detention warrant for Nuri valid until August 12, apparently without taking into consideration her medical condition or the surgery scheduled for that day. Fraud does not require pre-trial detention in Jordan, and in light of her planned surgery, there was no obvious reason to seek detention, such as risk of flight or interference with the course of justice, Human Rights Watch said.
The staff at the Juwaida holding facility refused to re-admit Nuri, following the prosecutor's decision, when they detected her condition. Instead of sending her to al-Hanan hospital for her scheduled surgery, though, they sent her to al-Bashir Government Hospital in Amman, where doctors performed surgery a few days later.
The US National Library of Medicine refers in a December 2009 entry to "necrotizing soft tissue infection [as] a rare but very severe type of bacterial infection that can destroy the muscles, skin, and underlying tissue...Without treatment, death can occur rapidly."
A 2009 scholarly article in the American Journal of College Surgeons on necrotizing fasciitis found that, "Twenty-five to thirty-five percent of patients with necrotizing fasciitis die from the disease, [which presents itself with] classic symptoms [of] pain, anxiety, and diaphoresis, which worsen rapidly."
In addition, methicillin-resistant staphylococcus aureus (MRSA) infection, which is one cause of necrotizing fasciitis, can be quickly transmitted in prisons and difficult to contain.
Nuri said she suffered severe pain without treatment after being sent back to the Juwaida holding center on August 29, following three-and-a-half weeks under police guard at al-Bashir Hospital. She continued to be held, under order from the administrative governor. From then until September 25, prison staff on several occasions took Nuri to al-Bashir Hospital, Hawuz Government Hospital in Zarqa, and Tutanji Government Hospital in Sahab, all of which refused to admit her despite acknowledging that she needed urgent treatment, Nuri told Human Rights Watch. Prison authorities did not endeavor further to provide her access to medical care.
Nuri said she saw the prison doctor, but he did not examine her while there. A prison nurse only provided her with two pain relieving injections of ibuprofen, around September 11 and 12, despite her frequent complaints about severe pain.
The prison doctor also provides services at Juwaida's prison for men, which is close by, and only visits the women's facility three times a week for a short time. The nurse is available during working hours only, prison staff confirmed to Human Rights Watch. The organization inspected Juwaida men's and women's prisons in 2008 and found health care services inadequate.
The Juwaida women's prison director, Col. Hana al-Afghani, told Human Rights Watch that the Health Ministry is responsible for the health care of prisoners, but that prison staff can decide to transfer inmates to receive outside care and that an ambulance is available on a 24-hour basis. Al-Afghani said she had medical reports referring to Nuri's condition as "stable" while she was in Juwaida. Human Rights Watch has seen a report by the prison doctor, Bashar Ahmad, describing her as "stable," although Nuri says he never examined her.
Prison authorities are obliged under international law to provide inmates with the level of health care available in the community, not just life-saving or stabilizing measures. Failure to provide pain treatment may amount to cruel treatment.
Nuri also told Human Rights Watch that she was unable to shower or bathe for over a month due to her wounds, and that the prison had only some wipes for her to clean herself. She said she felt humiliated in front of fellow prisoners, who she said nevertheless showed understanding. She said relatives brought her antibiotics she paid for herself, but that pain medication was not available. She said she gave a guard money to buy her the bandages she needed to change the dressing on her wound daily.
"Prison authorities are fully responsible for the health of their detainees," Wilcke said. "Their failure to give Nuri appropriate care for her infection or to treat her severe pain could be considered cruel, inhuman, and degrading treatment."
On Nuri's first court date, October 28, the judge released her on bail of 10,000 Jordanian Dinars (JOD); around US$15,000. Medical reports to the judge indicate he was informed of her medical state. However, police took her to the administrative governor, who released her on a further financial guarantee of JOD30,000, for which she presented securities and paid fees. Human Rights Watch has previously detailed in a report how governors abuse their powers to detain criminal suspects administratively, even those released on judicial bail. Nuri remains at liberty as her trial continues and is currently undergoing treatment.
The UN Body of Principles of 1988 stipulate that all detainees must be treated "in a humane manner and with respect for the inherent dignity" (principle 1), and that free "medical care and treatment shall be provided whenever necessary" (principle 24). The UN Standard Minimum Rules of 1955 also stipulate that toiletries must be "adequate" for "health and cleanliness" (rules 12 and 15).
Jordan is a party to the International Covenant on Civil and Political Rights, which requires that governments provide "adequate medical care during detention" and the Convention against Torture and other Cruel, Inhuman, or Degrading Treatment or Punishment (CAT), which prohibits torture and ill- treatment. The Committee against Torture-the monitoring body of the Convention against Torture-has found that failure to provide adequate medical care for detainees can violate the CAT's absolute prohibition of cruel, inhuman, or degrading treatment. In 2007 Jordan amended article 208 of its penal code to criminalize torture, but not ill-treatment. Furthermore, pre-trial detention by order of the prosecutor of nearly three months before the first court session is in violation of ICCPR article 9(3) which requires the authorities to "promptly" bring a suspect before a judge. Jordan is also a party to the International Covenant on Economic, Social, and Cultural Rights (ICESCR), which guarantees the right to the highest attainable standard of health.
The Human Rights Committee, which interprets the ICCPR, in its General Comment 21 of 1992, clarified that detainees "may [not] be subjected to any hardship or constraint other than that resulting from the deprivation of liberty," and that humane treatment "cannot be dependent on the material resources available in the State party" (paras 3 and 4).
The Committee for Economic, Social, and Cultural Rights, interpreting the ICESCR in its General Comment 14 of 2000, found that "States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees" (para 34). The General Comment also makes clear that states must fulfill the right to health care "when individuals or a group are unable, for reasons beyond their control, to realize that right themselves by the means at their disposal" (para 37).