Implementation of Istanbul Protocol for effective documentation of torture - review of Sri Lankan perspectives

Documentation of torture is a multidisciplinary, multistage scientific procedure evolved over the past decades through the experience of various strata in medical and related fields. It plays a key role in effective corroboration of facts, providing redress to victims and also has a long term regulatory impact on prevention of torture in a society. The UN endorsed Istanbul protocol serves as the model for effective documentation of torture in the present context and there were many attempts in the recent years to create a systematic and uniform approach among professional bodies to document torture by adopting it to the local medico-legal and legal systems in some less resourced countries. The post independent Sri Lanka is widely known in international human rights forums for the prevalence of torture and its endemicity since 1970s. The long term struggle to ensure justice to torture victims in Sri Lanka has been greatly enhanced by the submission of detailed medico-legal reports on them to relevant courts. As strengthening of medico-legal and legal reporting strategies were more focused towards the end of twentieth century the medico-legal and legal professionals in consensus attempted to use Istanbul Protocol for documentation of torture since 2004. However Sri Lankan experience on application of Istanbul protocol for documentation of torture signifies that unless and until a political commitment is shown by the government to internalize Istanbul Protocol into legal and medico-legal systems locally the expected outcome of effective documentation would not be evident.     

Intentional burn injury: Assessment of allegations of self-infliction

This study investigates the question of whether there is evidence that suggests the possibility of self-infliction, or self-infliction by proxy, of burn injury among a group of asylum claimants in the UK who have attributed such injuries to torture, and how such evidence might be assessed. The question arose from the observations of doctors at the UK-based charity Freedom from Torture that increasing numbers of individuals from Sri Lanka who described a history of torture had suffered severe and disfiguring burn injuries from heated metal objects, and the suggestion from asylum decision-makers that in some cases such injuries could have been acquired deliberately by self-infliction or self-infliction by proxy rather than by torture as claimed. This suggestion has not been confined to Sri Lankan cases, but due to the large numbers of Sri Lankan asylum claimants referred to Freedom from Torture in recent years, including many with this type of injury, the case set for this study was drawn from this population. As many of these injuries are found to be on the back, where self-infliction would be extremely difficult, the possibility of self-infliction by proxy was specifically investigated.An observational data set was examined in detail, comprising medico-legal reports for Sri Lankans with heated metal object burn injuries documented in 2011–14 by the Medico-Legal Reports Service at Freedom from Torture. All had described detention in Sri Lanka since the end of the civil war in 2009. The study reviewed the documented evidence of these injuries alongside other physical and psychological evidence attributed to torture and relevant contextual factors documented in each case. Findings were compared with previous research on torture in Sri Lanka and patterns of injury identified in forensic medicine for both self-infliction and self-infliction by proxy. Thorough examination of the evidence found no indication in this data set to suggest the possibility of self-infliction or self-infliction by proxy and supported the view that, as indicated in the Istanbul Protocol, the overall conclusion on likelihood of torture should be made on evaluation of all the physical and psychological evidence over and above the scrutiny of an individual lesion.     

Review of initiatives adopted for effective documentation of torture in a developing country

Effective documentation of torture is the key to successful interrogation and redress of torture victims. However the facilities available for such documentation to the forensic practitioners in less resourced countries are far from satisfactory. The emphasis on accurate and detailed documentation of examination findings of torture victims is currently necessary in Sri Lanka as the courts are relying heavily on medical reports for interrogation. In a situation where most of the torture victims are examined by unskilled medical officers who are not full time forensic practitioners, deficiencies of various degrees are commonly observed pertaining to depth of examination and documentation of examination findings. Therefore it was attempted in 2004, to introduce uniformity to existing documentation procedures by implementing Istanbul Protocol on island wide basis. However it was revealed that the adoption of the Istanbul Protocol could not be done as a whole in a short period due to variable degree of compliance from medical officers and further it need to be modified according to domestic requirements. The documentation of torture is a distinct multistage and multidisciplinary process. Therefore unless and until a cohesive collaboration is established between all disciplines concerned, a positive development on documentation process cannot be anticipated.     

Homicidal firearm injuries: a study from Sri Lanka

Stabbing, mechanical asphyxia, blunt head injury and shooting are the most common methods of homicides, with firearm homicides on the increase throughout the world. This study was a retrospective study carried out by the Department of Forensic Medicine, University of Kelaniya, Sri Lanka over a 1 year period on firearm homicides examined at two principal forensic institutions in the western province (Office of the Judicial Medical Officer Colombo and Ragama) of Sri Lanka. During the period of the study (June 2005 to July 2006) 3100 medicolegal autopsies were carried out at these two institutions with 265 representing alleged homicides. Eighty-three cases (31%) were identified as homicides due to fatal firearm injuries. The majority of the victims (N = 76) were young adult males (aged 18–40 years). Almost half of the firearm homicides (47%; N = 39) were associated with previous enmity, while 33% (N = 27) were due to ethnic rebel killings in the North and East. Daylight hours (6.00 a.m. to 6.00 p.m.) were preferred by rebels, while there was no relation to the time of day in the other firearm deaths. The weapon of choice was a rifled firearm (98%). While 70% of war-related deaths had one or two fatal shots, either to the head or chest, homicides motivated by personal enmity had multiple wounds, with an average of 5.7 fatal shots per victim. This study demonstrates that firearm homicides in Sri Lanka mainly involve young men, and that when related to armed conflict the fatal injury usually consists of a single shot to the head or chest.     

DNS-Laborstrategie zur Identifizierung von Katastrophenopfern

More than 400 samples from 101 Tsunami victims from Sri Lanka were sent to our laboratory. Barcoded sampling kits were used to collect 2 swabs from internal body regions, a 4 cm piece of long bone and 2 teeth, which were all shipped on ice. A high throughput DNA extraction and STR analysis procedure for the swabs was developed in order to provide STR profiles within 24 h. For the skeletal remains and teeth a highly sensitive DNA extraction procedure was applied Both processes included electronic accessioning to maintain the numbering system of the DVI team in Sri Lanka and data exchange via Interpol and Plass Data software. DNA profiling of swabs was successful in 42% of the cases. For the remaining cases skeletal remains had to be typed and produced useful results in 65% for teeth and in 94% for bone. A sufficient profile was obtained from each victim, so the overall success rate was 100%. Until now DNA matching procedures in Innsbruck facilitated by using DNAVIEW software enabled DNA-based identification of 24 victims from 9 countries.     

Helping victims of violence in Uganda

We report on a project to assist victims of war and violence in Uganda. The original aim of this project, set up by the Medical Foundation for the Care of Victims of Torture, was to establish a centre for the assessment and treatment of torture victims who had suffered during previous regimes in that country. We found, however, that a specialist centre was not the most appropriate response in a country like Uganda. We argue for the need to respect local initiatives and systems of support and against the notion that there is a single model of care which is universally relevant. Following much investigation and involvement with local personnel, we have developed a programme of training and discussion for health workers, and a service to reach the many women who have suffered rape, and whose suffering has continued, largely ignored.     

Practice of clinical forensic medicine in Sri Lanka: Does it need a new era?

Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.     

Scars of torture: a Sri Lankan study

Interpretation of scars of torture is not an easy task as our understanding of evolution of scars of different methods of torture is still in its infancy. The objectives of this study were to produce the features of a typical scar of a few selected methods of torture and determine their characteristic distribution. To achieve this, 100 medico-legal records of victims of torture examined at the Judicial Medical Officer's Office, Colombo between 1998 and 2001 were perused. Scars caused by seven selected methods of torture were taken into consideration. They were, assault with both non-pliable and pliable blunt objects, cigarette burns, burns with heated solid objects and molten plastic, ligature application with different forms of suspension and cuts with sharp objects. Total number of scars analyzed in this study was 1846, which included 740 scars of non-pliable blunt weapons, 182 of pliable blunt weapons, 102 of ligature, 59 of molten polythene, 55 of heated objects and 82 of razor blades and knives. Typical scars of each method of torture and their characteristic distribution were determined.     

Uneventful recovery from suicidal hanging: a case report

Although hanging accounts for a considerable number of suicidal deaths in Sri Lanka, on rare occasions the victims survive. A few cases have been reported in the literature where victims survived after varying periods of unconsciousness. It has been observed that death does not necessarily result from hanging, provided the victim is brought down promptly and resuscitated actively and vigorously. This paper focuses on an unusual case of a 39-year-old male who survived after resuscitation, without any adverse neurological outcome, after a suicide attempt by hanging.     

Female victims of torture

Torture is common today and is practised in over 100 countries according to Amnesty International. A substantial number of refugees coming to Europe have been tortured including females. Documentation of physical injuries due to torture is done by forensic pathologists often in collaboration with psychiatrists. In Sweden, the majority of torture documentations is done by an organization (KTC) which have specialized in documenting torture, and in short-term therapy of refugees and other crime victims suffering from post-traumatic stress. From the KTC archives of 500 documented alleged torture victims, the records of 63 females were studied separately. Age, nationality, asylum motive, social situation, torture methods, number of injuries, and sequels to torture were among the variables studied. Female torture victims differed from their male counterparts studied previously in the following: (i) The most common reason for seeking asylum was persecution because of the political activity of their husbands or some other close relative. (ii) Rape often both anal and vaginal, several times, and by different persons, was reported by 76% of the women. Physical abuse by use of blunt force was alleged by 95% but (iii) other types of force and specific torture methods was reported infrequently. (iv) A high frequency of PTSD -- 87% was diagnosed.     

Suicide by electrocution

Electrocution is a rare mode of suicide. In Sri Lanka, where the suicide rate is extremely high, ingestion of liquid pesticides is the commonest method used. The case of a 34-year-old labourer of the Electricity Board, who committed suicide using 220-240 volt domestic electricity supply is described. He had been suffering from a depressive illness for some time. Suicide by electrocution has not been documented in Sri Lanka before.     

Torture: Diagnosis and rehabilitation

This article describes psychological and physical methods of torture, the general stress‐related sequelae that are unrelated to the method used, and some examples of clinical effects that are related to specific methods. The approach to the rehabilitation of victims of torture practised at RCT is outlined. Two illustrative case histories are given.     

Mental health initiatives as peace initiatives in Sri Lankan schoolchildren affected by armed conflict

The Health Reach Sri Lanka project (1993-96) is described. It was a school-based assessment of children's exposure to war-related events and the presence of psychological distress, undertaken in six communities in parts of Sri Lanka variously affected by armed conflict. Its objectives, methods and results are presented. The research project aimed to raise national awareness of the psychosocial effects of armed conflict on children, using a community-development approach to local capacity building, based on the 'health initiative as peace initiative' model. As a follow-up to the study, a locally run programme, based on creative play and trauma-healing, was established, initially for the children involved in the study. This was later extended to other children in the district affected by armed conflict.     

Radiology of torture

PURPOSE: Although there are different definitions of torture, there is no contradiction that torture exists. Changes resulting from torture are shown to demonstrate which findings can be visualized with X-rays. MATERIAL: The findings come from rehabilitation centers for victims of torture, collections of others and from personal observations. They are documented with plain films, scintigraphy, computed tomography, and MRI. RESULTS: On fingers, hand, and arm, and on toes, foot and leg, imaging can visualize changes and pathologies which are characteristic for preceding torture. On head, neck, and trunk, this is only rarely the case; this is understandable, when one considers that force having been directed against these regions of the body will more often be deadly than that applied on limbs only. Special forms of torture with the use of water and electricity are also described. It is pointed out that multiple forms of torture do not leave traces, which might be made visible by diagnostic imaging. The cases are part of a selection: the victims have survived (which means that these types of torture permitted survival; injuries of hand and foot do not endanger the survival as opposed to stab wounds to the head, chest, and abdomen, into the anus and the genitals, which are often mortal. Mutilation by torture motivates the torturer to eliminate any proof of his actions and to kill the victim. Public interest induces a selection of methods, which leave no traces. Possibly (and hopefully) some special forms of torture, which use chemical substances that act on the psyche and the central nervous system, might become visible by functional MRI in the near future. CONCLUSION: Torture is likely to occur when findings are seen to be typical or characteristic forms of torture, when age of fractures and pattern of beatings and other injuries corroborate the indications of the victim, and when these findings correspond to the procedures known from the region of application the organization/group/militia, which is said to have executed the torture.     

Folter

During the past decades international rules against every form of torture have been established based on the United Nations (UN) “Declaration of Human Rights” from 1948. Torture is defined in the “Convention against torture and other cruel, inhuman or degrading treatment or punishment: United Nations Convention against Torture” from 1987. Muslim nations also consented to the “Cairo Declaration on Human Rights in Islam” from 2000. In 1999 a manual that came known as the “Istanbul protocol” was submitted to the UN High Commission for Human Rights and contains details on how to perform a thorough physical examination of torture victims taking all body regions into account. Different types of torture are described as well as injuries due to torture and additionally the participation of physicians involved in abuse and torture is dealt with.     

Challenges of war surgery in Mallavi,Sri Lanka

Northern Sri Lanka has been separated by an active front line from the remainder of the country and has lacked basic facilities, including hospital care, because of the war between the government and the Tamil Tigers. This article reports on the resulting situation in one district hospital in the region and on the work of Médecins sans Frontières in providing specialist hospital care under such difficulties.     

III: Mental health initiatives as peace initiatives in Sri Lankan schoolchildren affected by armed conflict

The Health Reach Sri Lanka project (1993–96) is described. It was a school‐based assessment of children's exposure to war‐related events and the presence of psychological distress, undertaken in six communities in parts of Sri Lanka variously affected by armed conflict. Its objectives, methods and results are presented. The research project aimed to raise national awareness of the psychosocial effects of armed conflict on children, using a community‐development approach to local capacity building, based on the ‘health initiative as peace initiative’ model. As a follow‐up to the study, a locally run programme, based on creative play and trauma‐healing, was established, initially for the children involved in the study. This was later extended to other children in the district affected by armed conflict.     

Identifizierung der Tsunami-Opfer im Einsatzabschnitt Sri Lanka

Sri Lanka was extensively devastated by the Tsunami on 26 December 2004. At the command of the Foreign Ministry, a forerunner of the disaster victim identification (DVI) team was deployed by the German Federal Criminal Police Office (Bundeskriminalamt, BKA) to Columbo. The capital of Sri Lanka then served as the central point for communication and organization. An office with equipment for communication and data handling was set up in the German embassy and a network with other affected nations was established. The identification measures were carried out in the Institute of Forensic Medicine in Columbo. Identification of corpses was complicated in most cases by a state of advanced decomposition, skeletonization from animal bites and several bodies had been embalmed. Corpses of suspected foreigners were located in hospitals, local funeral parlours, swamps or provisional graves, the latter of which were exhumed. The success of this extraordinary and challenging mission was based on the benevolent support of the local authorities and the commitment of each member of the multidisciplinary teams from all the different nations working together for a common purpose.     

Statement on access to relevant medical and other health records and relevant legal records for forensic medical evaluations of alleged torture and other cruel,inhuman or degrading treatment or punishment

In some jurisdictions attempts have been made to limit or deny access to medical records for victims of torture seeking remedy or reparations or for individuals who have been accused of crimes based on confessions allegedly extracted under torture. The following article describes the importance of full disclosure of all medical and other health records, as well as legal documents, in any case in which an individual alleges that they have been subjected to torture or other forms of cruel, inhuman or degrading treatment of punishment. A broad definition of what must be included in the terms medical and health records is put forward, and an overview of why their full disclosure is an integral part of international standards for the investigation and documentation of torture (the Istanbul Protocol). The fact that medical records may reveal the complicity or direct participation of healthcare professionals in acts of torture and other ill-treatment is discussed. A summary of international law and medical ethics surrounding the right of access to personal information, especially health information in connection with allegations of torture is also given.