Policemen and people walk in front of the main gate of Tora prison in Cairo on June 4, 2012.

(New York) – Scores of Egyptians died in government custody in 2014, many of them packed into police stations in life-threatening conditions. Yet the authorities have taken no serious steps either to improve detention conditions or to independently investigate detainees’ deaths.

Some detainees appear to have died after being tortured or physically abused, Human Rights Watch found. But many appear to have died because they were held in severely overcrowded cells or did not receive adequate medical care for serious ailments.

Egypt’s prisons and police stations are bursting at the seams with opposition supporters rounded up by the authorities,” said Sarah Leah Whitson, Middle East and North Africa director. “People are being held in grossly overcrowded and inhumane conditions, and the mounting death toll is the wholly predictable consequence.”

Human Rights Watch independently documented nine deaths in custody since mid-2013 based on evidence from the victims’ relatives and lawyers, as well as medical documents. In one case, the detainee appeared to have been beaten and then died in a severely overcrowded police cell. In the other cases, detainees who had heart disease, cancer, or other ailments were either denied necessary medical treatment or release on medical grounds, and in some cases were held in overcrowded conditions that exacerbated their health problems.

A broad arrest campaign targeting the Muslim Brotherhood, which the government has labeled a terrorist organization, and others who oppose the government of President Abdel Fattah al-Sisi has strained Egypt’s prisons. The influx of tens of thousands of people has led authorities to house many suspects in temporary detention sites.

According to an investigation published in December by Al Watan newspaper that drew on statistics of the Justice Ministry’s Forensic Medical Authority (FMA), at least 90 detainees held in police facilities in just the governorates of Cairo and Giza died in custody in the first ten and a half months of 2014.

A report by the Nadeem Center for the Rehabilitation of Victims of Violence, an Egyptian NGO that examined the first 100 days of al-Sisi’s administration, found that at least 35 people had died in custody – most in police stations – between early June and early September. In the 15 cases for which the center identified a cause of death, 13 involved overcrowding or failure to provide medical care, and two involved physical abuse.

The government has not disclosed the number of deaths in custody countrywide, but those recorded by the FMA in Cairo and Giza were a nearly 40 percent increase over the 65 deaths recorded by the same authority in 2013, Al Watan reported. The newspaper quoted FMA spokesman Hisham Abd al-Hamid as saying that overcrowding from the wave of new detainees was the primary reason for the rise in deaths. News organizations have regularly reported deaths in detention facilities in other governorates, suggesting that the total number nationally could be significantly higher.

Egyptian authorities are obliged under international law to provide detainees with the same health care available to people who are at liberty and, under international standards, pretrial detention should only be used as a last resort.

Article 55 of Egypt’s constitution, passed in 2014, forbids torturing or physically harming detainees, and requires authorities to treat all detainees “in a manner that maintains their dignity” and hold them in facilities that are “adequate on human and health levels.” It states that violating those provisions is a crime. Article 56 states that prisons and places of detention should be subject to judicial supervision and that “actions inconsistent with human dignity or that endanger human health shall be prohibited.”

Despite the rising number of deaths and widespread reports of mistreatment, lack of medical care, and severe overcrowding, prosecutors have filed only one case against police linked to detainees’ deaths since mid-2013. This stemmed from an August 18, 2013 incident in which 37 detainees died after police fired a tear gas canister into a prison van in which they were confined at Abu Zaabal Prison. A judge convicted four officers but, in July, an appeals court ordered them retried. The next hearing will be held on January 22.

In a message to Human Rights Watch smuggled out of Tora Prison in March 2014, one prisoner said teams of prosecutors regularly visited prisons but refused to listen to prisoners’ complaints. “All they did was enter each cell, take a quick glance, count beds, and note names in each cell,” this prisoner said.

The authorities should investigate deaths in custody and prosecute police officers and other officials suspected of negligence or abuse, Human Rights Watch said. Egypt’s prosecutor general should release all detainees held solely for exercising their constitutionally protected rights to peaceful protest or political expression. The prosecutor should create a process to review pretrial detention practices, with a presumption against pretrial detention in all cases, and ensure the immediate release of all those who need medical care unavailable in detention.

“The Egyptian authorities have appeared shockingly complacent in the face of so many detainee deaths,” Whitson said. “They need to ensure that all such deaths, as well as abuse allegations, are independently investigated, and rapidly put in place and enforce effective safeguards to protect everyone in state custody.”

Deaths in Detention
Though Egyptian authorities do not publish prison population statistics, it is likely that the number of prisoners has risen significantly since the military overthrew Mohamed Morsy, Egypt’s first freely elected president, in July 2013 and began a crackdown on the Muslim Brotherhood. The authorities have detained at least 41,000 people, according to a count based on media reports by the Egyptian Center for Economic and Social Rights, an independent group. The Brotherhood estimates that 29,000 members or suspected supporters of its movement have been arrested.

In December, an Interior Ministry official announced that in 2014, authorities had arrested 10,000 people accused of rioting, attacking police stations, belonging to terrorist groups or sabotaging rail lines, and suggested that all were tied to the Brotherhood. In July, the Interior Ministry told a presidential fact-finding commission investigating the events surrounding Morsy’s removal that more than 7,000 people arrested during those events remained in pretrial detention.

Al-Watan reported that Hisham Abd al-Hamid, the spokesman for the Forensic Medical Authority, said a team from his agency had surveyed Cairo and Giza police stations and found that overcrowding was the main cause of the increase in deaths. Abd al-Hamid said that prisons lacked capacity to hold an influx of short-term prisoners and so the authorities had to hold the prisoners in cramped police stations and other facilities where, on average, each was allocated only half a square meter of space.

Abd al-Hamid was quoted as saying that rising summer temperatures and the spread of disease in the winter led to a “natural” increase in detainees’ deaths, and that they resulted from “medical conditions” and did not give rise to “criminal suspicion.” Al Watan said an anonymous source within the Cairo Security Directorate had told the newspaper that authorities had installed air conditioners to alleviate conditions in some Cairo and Giza police facilities.

Abd al-Hamid, reached by telephone in December, declined to respond to requests from Human Rights Watch for information about detainees’ deaths in custody and abuse of detainees. The office of Prosecutor General Hisham Barakat did not respond to a July 8 letter from Human Rights Watch requesting information about any existing investigations into deaths in custody or the abuse of detainees over the past year. On July 1, an Interior Ministry spokesperson, General Abd al-Fattah Othman, said on a TV talk show that accounts of police rape and other torture of prisoners circulating on social media had “no basis in truth” and described Egyptian prisons as “like hotels.”

Compensation for detainees who have been abused or mistreated is seldom reported. On January 14, in a rare ruling, an Alexandria administrative court ordered the Interior Ministry to pay a former prisoner 75,000 Egyptian pounds (US$10,341) for lost wages as a result of having his arm amputated after it became infected from receiving an injection from a contaminated syringe. In past years, the Arab Organization for Penal Reform has won similar rulings, but the Interior Ministry has, in some of those cases, failed to pay, according to Al-Ahram newspaper.

Right to Health
Despite the Abu Zaabal incident and some accounts of death in custody that involved torture or physical abuse, a large number of the deaths reviewed by Human Rights Watch in media and reports from nongovernmental groups – in addition to the majority of the nine cases independently verified – appear to be the result of inadequate medical care, exacerbated by overcrowded conditions.

The United Nations Basic Principles for the Treatment of Prisoners, adopted by the General Assembly in 1990, provide that prisoners “shall have access to the health services available in the country without discrimination on the grounds of their legal situation.” The universal right to “the enjoyment of the highest attainable standard of health,” as recognized and described in various international treaties, including the African Charter on Human and Peoples’ Rights, and the International Covenant on Economic, Social and Cultural Rights, both ratified by Egypt, also applies to prisoners.

Furthermore, under international standards, pretrial detention should only be used when it is absolutely necessary to ensure the integrity of the criminal proceedings and should take into consideration the likelihood that the detainee will flee. A suspect’s health, and the ability of the prison system to provide adequate care, should be a basic consideration for pretrial detention.

Egypt’s Prisons Act of 1956 and Interior Ministry Decree 79 of 1961 mandate adequate care by prison doctors and a bed for each inmate, including pre-trial detainees, to avoid overcrowding. But in the nine cases verified by Human Rights Watch, the authorities routinely ignored and violated these prescriptions. Prison authorities also routinely ignored the requirement to notify relatives immediately if a prisoner dies, and they flouted the requirement that they inform prosecutors whenever a prisoner dies “suddenly” or as a result of an accident or criminal act.

A 2014 report on health care in prisons and detention facilities by the Egyptian Initiative for Personal Rights (EIPR) found that conditions generally did not meet the minimum requirements of the right to health guaranteed by international law – although the quality of care varied by location – and that speedy emergency services were “typically very limited.”

Former detainees EIPR interviewed said that they rarely, if ever, received medical attention from the overburdened and inexperienced general practitioners who serve as prison doctors. The detainees said they treated themselves with medicine brought by family members or recommended by fellow inmates. Wardens also often interfered with prison doctors’ advice and recommendations when they were available, the prisoners said.

Overcrowding, combined with poor ventilation, left cells and prison wards cold in the winter and unbearably hot in summer, prisoners told the EIPR.

In September, the Interior Ministry amended its 1961 decree, but the amendments fell short of Egyptian and international standards, the EIPR said. They did not require the number of doctors in each prison to be proportionate to the number of inmates or specify the maximum number of prisoners who can be held in each cell. They also did not remedy other flaws the EIPR has identified in prison regulations, such as the fact that prison wardens and other administrators hold approval power over doctors’ recommendations for treatment or release.

Deaths in Custody

Ahmed Ibrahim: Signs of a Beating
Ahmed Ibrahim, 23, died early in the morning of June 15, 2014, at a police station in Cairo’s Matariya district. Ibrahim had been learning how to install heating and air conditioning systems before he was given a three-year prison sentence for theft in 2012. Prison authorities had transferred him to the Matariya police station on June 14 to finalize his early release. His father, Mohamed Ibrahim, told Human Rights Watch that he last saw Ahmed alive when he took some food to the police station for him that evening. His son, he said, was held in an uncomfortably hot cell of about 4 by 4 meters that was so packed that prisoners were forced to remain standing.

Mohamed Ibrahim told Human Rights Watch that he complained to the police captain in charge of the station that the conditions were inhumane but that the officer punched him and told him to find a doctor if he thought so. Ibrahim spoke briefly to his son, who assured him that he would survive until his expected release. At around 1 a.m., however, Ibrahim received a mobile phone call from Ahmed, who said, “Dad, I’m dying,” the father told Human Rights Watch.

Ibrahim called an ambulance, he said, but when he went to the station the next morning, the police told him that Ahmed had died while being taken by ambulance to a hospital only a short distance from the station. At the morgue, Ibrahim saw blood on his son’s lips and bruising on his face and head – injuries noted in a forensic medical report that also found that Ibrahim’s lungs were swollen and had hemorrhaged.

Ibrahim told Human Rights Watch that he suspects police beat his son. He said he had filed a complaint with the local prosecutor, who has not filed charges. According to the December investigation by Al-Watan newspaper, eight detainees died at the Matariya Police Station in 2014, the most of any location in Cairo or Giza.

Dr. Tarek Mahmoud al-Ghandour: Refusal to Provide Life-Saving Care
Dr. Tarek Mahmoud al-Ghandour, a dermatology professor at Cairo’s Ain Shams University and local leader of the Muslim Brotherhood, died on the morning of November 12 in the intensive care unit of the National Liver Institute at Menoufia University, where he had been moved only hours before.

His death from liver disease occurred following nearly a year of detention during which prison authorities denied him access to necessary medical care, according to al-Ghandour’s family and friends.

Police arrested al-Ghandour on December 18, 2013, at his home in Cairo’s Nasr City neighborhood. Prosecutors charged him with several offenses related to his membership in the Muslim Brotherhood and, in April, a judge convicted him of participating in an illegal protest and sentenced him to five years in prison, despite evidence that he had been at the headquarters of the national Doctors Syndicate throughout the day of the protest in question, his wife told Human Rights Watch.

Though al-Ghandour suffered from Hepatitis C, liver cirrhosis, and other problems and needed a liver transplant from a donor that his family had identified, the authorities kept him detained pending his appeal of his five-year sentence and did not transfer him to a hospital where he could receive the transplant. According to the EIPR and witnesses interviewed by Human Rights Watch, Egyptian prison hospitals are not equipped for surgery, and authorities often put pressure on regular hospitals to return admitted prisoners as quickly as possible, sometimes preventing follow-up treatment or recovery time.

Al-Ghandour’s family informed the prosecutor about his medical condition and requested his release for the liver transplant, and his wife wrote similar appeals to the presidency and the quasi-governmental National Council for Human Rights (NCHR).

On April 28, the office of the East Cairo General Prosecutor wrote to prison authorities requesting that al-Ghandour undergo medical examinations to see if he needed to have surgery and that further steps be taken “in accordance with the law,” according to a letter provided by al-Ghandour’s family. On May 4, a prison doctor sent a medical report to prison authorities recommending that al-Ghandour be transferred to Ain Shams University Specialized Hospital to receive a liver transplant and warning that his health would deteriorate if he was not. The report was smuggled to al-Ghandour’s family, who provided it to Human Rights Watch.

Eventually, prison administrators said they would investigate, al-Ghandour’s family said, but by then they had moved al-Ghandour first to one prison, then another. In late October, authorities moved him to Shibin al-Kom Prison in the governorate of Menoufia because of its proximity to the National Liver Institute. The prison authorities allowed him to have an operation in the Liver Institute necessitated by his cirrhosis but insisted that he be immediately returned to prison after surgery without allowing time for recovery. Al-Ghandour’s cousin, also a dermatologist, told Human Rights Watch that he should have stayed longer.

“I know that all hospitals in general don’t admit political prisoners easily. They receive instructions not to admit them,” he told Human Rights Watch. “The doctor at that time said it’s difficult for them to admit political prisoners because it means a lot of problems for them and the hospital.”

On November 9, nearly a year after his arrest, a prison medical committee reviewed al-Ghandour’s case and asked for an ultrasound of his cirrhosis, his wife said. Al-Ghandour received the ultrasound on November 10. Early the next morning, he began to vomit blood. Prison authorities transferred him to the Menoufia University Hospital, where he was placed under police guard and for roughly three hours received little treatment aside from a blood infusion, family members who saw him there told Human Rights Watch. Al-Ghandour’s brother and cousin, who arrived at the hospital from Cairo after the family received a call from a doctor, said they found him conscious and that he told them, “I threw up a bucket of blood.”

Police refused to transport al-Ghandour to the Liver Institute, so his brother and cousin helped him make the roughly 10-minute walk. A manager agreed to admit him, and doctors began giving him an endoscopy, but he continued to bleed heavily, suffered cardiac arrest, and fell into a coma. Doctors transferred him to the intensive care unit, where he died the next morning.

Two days later, Hafez Abu Saada, a member of the NCHR, called on the interior minister and prosecutor general to investigate al-Ghandour’s death. Neither has announced an investigation.

Mahmoud Abd al-Rahman al-Mahdi: Repeated Heart Attacks
Mahmoud Abd al-Rahman al-Mahdi, 51, a government employee, died in custody at Suez General Hospital on November 3 after being held for months in an overcrowded prison cell and suffering apparent heart attacks.

National Security officers arrested al-Mahdi, a supporter of the ousted president, on January 19, 2014, at his office in Suez. Prosecutors accused him of carrying firearms, inciting violence, and belonging to a banned group – the Muslim Brotherhood. They ordered him detained for 15 days pending investigation and repeatedly renewed the order until August, when a judge acquitted him. The prosecutor appealed, and the judge ordered al-Mahdi released on a 10,000-pound (US$1,400) bail. However, National Security officers made new allegations that led prosecutors to file new charges against him and keep him in pretrial detention.

Authorities held al-Mahdi in Ataka Prison in Suez, in a cell with nearly 50 other inmates that was so small they had to sleep in shifts, al-Mahdi’s daughter told Human Rights Watch. Al-Mahdi began suffering chest pains and was transferred to Suez General Hospital three times, his daughter said. The family arranged for a Health Ministry inspector to visit al-Mahdi in prison, and the inspector recommended his immediate transfer to a hospital, though the hospital declined to admit him. Many doctors seem reluctant to admit those viewed as political prisoners because they do not want to be legally responsible, al-Mahdi’s daughter said.

“Actually, in the last period my father sometimes refused to go to hospital when he felt sick because he thought it would be a lot of useless effort,” she said.

One afternoon in late October, a few days before he died, al-Mahdi’s pain became so severe that fellow prisoners began banging on the cell bars to attract help, his daughter said, but it took 10 hours before prison officials moved al-Mahdi to Suez General Hospital, where doctors diagnosed high blood pressure and elevated blood sugar and said he was probably having a heart attack. They admitted al-Mahdi to the intensive care unit for fewer than 12 hours and then transferred him to the hospital’s prison ward, a facility that seemed to lack basic equipment, including an oxygen mask, al-Mahdi’s daughter said.

On November 2, al-Mahdi suffered another bout of chest pain, and doctors took him to the intensive care unit for an oxygen mask and electrocardiogram. Though al-Mahdi said he was sick and could not breathe, nurses and others told his daughter, doctors returned him to the prisoner ward, where he died a few hours later.

Under the United Nations Standard Minimum Rules for the Treatment of Prisoners, sick prisoners who require specialist treatment must be transferred to specialized institutions or civil hospitals. The refusal of a hospital to admit a sick prisoner does not relieve prison authorities of their duty to provide the prisoner with adequate care, such as transferring the prisoner to another hospital, Human Rights Watch said.

Abu Bakr Ahmed Hanafi: Continued Detention Despite Terminal Illness
Abu Bakr Ahmed Hanafi, an accountant and Brotherhood leader in the Qena governorate, died in Assiut Prison on November 13 after more than 10 months in detention. Police arrested him on January 1, 2014, at his office in Qena governorate and charged him with involvement in a riot that damaged Qena’s main train station in July 2013.

Prosecutors ordered him held, pending trial. In July, while at Qena Prison, he began suffering stomach pain and vomiting, his wife told Human Rights Watch. After several weeks, a prison doctor sent him to Qena University Hospital for tests. A doctor there said his symptoms were psychosomatic and ordered him returned to prison.

Prison authorities moved him to the prison hospital when he continued to vomit and fed him intravenously because he could not eat, his wife said. They then returned him to the university hospital, where doctors diagnosed liver and pancreatic cancer, and estimated that he had only three months to live, his brother, a prisoner in the same facility, told Hanafi’s wife.

On September 7, prison authorities approved Hanafi’s transfer to Assiut University Hospital for an MRI scan, but his transfer took 10 days. The MRI confirmed the earlier tests, but doctors asked for a biopsy. Meanwhile, Hanafi’s lawyer requested that Hanafi, likely suffering from a terminal illness, be released for treatment. At a September 20 court session after trial began, the judge ordered further medical examination. On October 26, rather than release Hanafi, he ordered him transferred to a hospital.

Two days later, authorities sent him first to Qena University Hospital and then to Assiut University Hospital, where the doctor kept him for 13 days in the prisoners’ ward, where he was under guard and almost always handcuffed, his wife said. He underwent a biopsy, but because prison officials confused his results with those of another prisoner, Hanafi had to return for a second session. This delayed the release of the biopsy results until the second week of November.

On November 12, doctors discharged Hanafi, prescribed medication, and ordered him transferred to Qena University Hospital. But a prison officer insisted on taking him first to Assiut Prison where, according to Hanafi’s wife, the officer and the warden debated whether he should still be held. Eventually, the warden ordered him held while awaiting transfer to Qena.

On November 13, prison guards told Hanafi’s wife that she could not visit him. The next day, they allowed Hanafi’s nephew to enter, and he discovered that Hanafi had died. Hanafi’s brother, the prisoner, said guards had found Hanafi dead in his cell and moved his body to an ambulance. On his death certificate, they wrote that he had died in a hospital.

Returning a critically ill prisoner like Hanafi to prison despite doctors’ recommendations to send him to another hospital likely amounted to inhuman and degrading treatment under international law.

Abd al-Rahman al-Razahi: Failure to Allow Care in Prison
Abd al-Rahman al-Razahi, a 43-year-old school employee and Muslim Brotherhood leader from Assiut governorate, died on or shortly before October 13, 2013, in Tora Prison in Cairo.

Police arrested al-Razahi on August 17, 2013, three days after security forces brutally dispersed pro-Morsy sit-ins in the capital and killed more than 800 people, mostly Muslim Brotherhood supporters. Prosecutors accused al-Razahi of spying for the Palestinian movement Hamas and of escaping during the 2011 revolution from Wadi al-Natroun Prison – where many Muslim Brotherhood leaders had been held during the January 2011 uprising.

The authorities initially held him in solitary confinement in a high security section of Tora Prison. When his wife saw him more than a month after his arrest, al-Razahi had lost weight and was ill and vomiting, she said. She said that Khairat al-Shater, a top Brotherhood leader detained with al-Razahi, had asked the prison authorities to let a doctor see al-Razahi but that the warden had refused, and she added that prison guards sometimes threw away medicines taken to al-Razahi by his brother. As al-Razahi’s health deteriorated, his wife said, an ophthalmologist sharing his cell asked the authorities to transfer al-Razahi to a hospital. The authorities refused and only allowed the ophthalmologist to order blood tests for al-Razahi. The tests did not reveal anything abnormal, she said.

His wife told Human Rights Watch that she believed prosecutors would release al-Razahi because they had no evidence that he had ever been a prisoner in Wadi al-Natroun but that National Security officers provided testimony to prevent his release. On October 12, 2013, the investigating judge ordered al-Razahi released without bail for health reasons, and an ambulance arrived to transport him back to his home in Assiut. But the prosecutor appealed the release order, and the judge ordered al-Razahi held for another 45 days pending investigation, his wife said.

On October 13, al-Razahi’s brother arrived at the prison for a visit and found the facility in chaos. Guards told him that a prisoner had died and ordered him to leave. Al-Razahi’s brother called the family’s lawyers, who discovered that al-Razahi had died and that authorities had already transferred his body to Cairo’s Zeinhom Morgue. Al-Razahi’s brother said that morgue workers told him that National Security officers had instructed them not to confirm that the body was there. When al-Razahi’s brother was finally allowed to take the body, morgue officials asked him what he wanted written as the cause of death. He responded that it did not matter, and they wrote “acute circulatory failure.”

Al-Razahi’s wife told Human Rights Watch that Tora Prison officials had never conducted medical tests on her husband, but the prison doctor told her that he suspected he suffered from a stomach ulcer.