Author: Dominique Leth-Sørensen
The definition of torture can have slight variations, but it is important to distinguish it from other forms of ill-treatment. Torture is an act that does not only aim to hurt but also to dehumanise a person and strip them of their dignity. According to the UN’s 1984 Convention, an act is torture if it has a coercive purpose (such as retrieving information or ‘keeping someone quiet’), and if it is inflicted by a public or official figure.
Torture can be physical, psychological and sexual. Although these are three different categories, they often overlap and the health consequences of each are not necessarily distinct. Torture can lead to chronic pain, reduced mobility, and brain damage as well as PTSD and flashbacks, anxiety, depression and other long-term effects.
There is no centralised record of the number of investigations and prosecutions relating to torture. Yet Dignity – the Danish Institute Against Torture – found that 30% of refugees have been subjected to torture. In Denmark alone, 50 000 refugees suffer from torture-related anxiety or depression, either through primary or secondary trauma. Where primary trauma refers to the direct trauma torture victims suffer as a result of the harm inflicted on them, secondary trauma occurs when family members or care-givers experience the same adverse psychological symptoms of torture as the victims due to close contact with them. The lack of torture documentation does not only reflect the difficulty in prosecuting cases, but also the near impunity of those responsible – often because of the official positions they may hold. Beyond the immediate challenges of the current global migrant and refugee crisis, the considerable number of individuals that may have been subjected to torture around the world exposes the relevance and necessity of dealing with the health consequences of torture in the field of Global and Public Health.
Despite having significant health, social and political implications, torture is not prominent in the general Global Health agenda. The WHO does not have any web pages dedicated to torture, even less its health implications. This lack of attention in the global leading health institution sets the tone for its priority worldwide. The Sustainable Development Goals mention torture once in their targets under Goal 16: Peace, Justice and Strong Institutions. However, it is in reference to “end abuse, exploitation, trafficking and all forms of violence against, and torture of children”. While this target’s necessity is indisputable, the mention of torture only in the context of children is questionable. The Human Rights Watch dedicates a page to torture on its website (constituting one paragraph), where it assures readers of its strong stance against torture, but with no additional information on the matter – no numbers, figures, or reports.
The apparent lack of global health focus on torture could have serious ramifications. For instance, on one hand, health professionals may not have acquired the necessary knowledge and sensitivity to treat patients who present with signs of torture, and on the other, victims of torture may not know what health services to access if needed. In Denmark, patients who have been subjected – or who are suspected of having been subjected – to torture are referred to Dignity’s rehabilitation clinic. However, few countries worldwide have such an organisation dedicated to treating torture consequences outside of their health system.
Prison Health is closely linked to the field of torture because places of detention are where most torture cases occur, and therefore where many subsequent health ramifications are treated. Despite this area having received more attention from the field of Global Health, the quality of healthcare for detainees around the world is below acceptable standards. The UN’s basic principles for the treatment of detainees states that “Prisoners shall have access to the health services available (…) without discrimination on the grounds of their legal situation”. However, according to the WHO, health in prisons is consistently worse compared to that of the general population. Rates of HIV, hepatitis B and C, and TB are significantly higher in detainees globally. Similarly, mental health disorders, cardio-vascular diseases and some cancer rates are also higher among the prison population. Globally, at least 10 million people are estimated to being incarcerated at any given moment. Prison Health is important to Global Health because this number represents a population around the world whose chance for good health is systematically diminished. While an individual’s right to freedom should never interfere with their right to health, this is not always reflected in practice.
One fundamental structural issue within Prison Health may be responsible for poorer access to health care. While some countries have Prison Health integrated within their general Health System under the Ministry of Health – such as Norway or the UK’s NHS (National Health Service) –, for most states worldwide, Prison Health is under the Ministry of Justice (MoJ). Having health issues under the jurisdiction of the MoJ is problematic because for one, it categorises detainees as prisoners before patients, which allows for interference between legal status and health. Furthermore, this structure may influence the work of prison health staff by forcing them to have dual loyalty: to the patient and the prison management. This is especially dangerous in cases of torture, where prisoners that confide in their doctors may suffer reprisals from the prison management. Current research suggests prison health professionals play an important role in preventing torture through documentation and contact with victims. However, this may prove difficult if prison staff have a conflict of interest.
In Denmark, for example, Prison Health falls under the Prison Delegation (Direktoratet for Kriminalforsorgen) and ultimately the MoJ. Because of its structure, health staff are employed by the individual prisons and only work there part-time. Furthermore, it is each prison’s, ward’s and/or staff’s responsibility to organise their own specific health system. Practically, this means there are no general guidelines for health workers to follow in prisons – making accountability difficult –, and because health staff do not work full time, there are barriers to continuity of care. Overall, health conditions in Danish Prisons are high compared to many countries, but this may be a reflection of the nation’s overarching wealth, rather than a functional system. Another state with more financial restrictions may find less funds for Prison Health if costs are shared within the entire MoJ. Detainees are part of the public and as such, should receive the same funding for their health as the general population.
Last year I interned with Dignity in their Public Health team, and am now employed by them as a student-worker. From the beginning, it was surprising the see the vast amount of on-going research and published literature on torture – in terms of torture methods, health consequences, populations affected and testimonies. The intersections between torture and Prison Health also quickly became apparent. Given the amount of available literature on these topics and their clear relevance to Public/Global Health, it was astounding – and worrying – to discover a whole field that was so under-represented in our master’s course. If leading health institutions are not focusing on these issues, academia should, at the very least, better disseminate the existing knowledge to students across all health disciplines (medicine, psychology, nursing, public and global health). With this awareness, we can begin to educate ourselves on how to assist people needing specialised treatment and ensure that our work does not contribute to the marginalisation of already vulnerable populations.