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.

A population-based assessment of human rights abuses committed against ethnic Albanian refugees from Kosovo.

OBJECTIVES: This study assessed patterns of displacement and human rights abuses among Kosovar refugees in Macedonia and Albania. METHODS: Between April 19 and May 3, 1999, 1180 ethnic Albanian refugees living in 31 refugee camps and collective centers in Macedonia and Albania were interviewed. RESULTS: The majority (68%) of participants reported that their families were directly expelled from their homes by Serb forces. Overall, 50% of participants saw Serb police or soldiers burning the houses of others, 16% saw Serb police or soldiers burn their own home, and 14% witnessed Serb police or soldiers killing someone. Large percentages of participants saw destroyed mosques, schools, or medical facilities. Thirty-one percent of respondents reported human rights abuses committed against their household members, including beatings, killings, torture, forced separation and disappearances, gunshot wounds, and sexual assault. CONCLUSIONS: The present findings confirm that Serb forces engaged in a systematic and brutal campaign to forcibly expel the ethnic Albanian population of Kosovo. In the course of these mass deportations, Serb forces committed widespread abuses of human rights against ethnic Albanians.

Health and human rights of adolescent girls in Afghanistan.

Physicians for Human Rights (PHR) conducted a study in early 1998 to assess the health and human rights conditions of Afghan women and girls living under the Taliban regime in Kabul. This paper highlights the concerns and experiences of adolescent girls in Kabul, includes a brief overview of the political situation in Afghanistan and Taliban policies toward women and girls, and presents findings from interviews with adolescent girls and women with adolescent daughters. It concludes with a discussion of current international standards for the protection of women's and girls' rights and the crucial role of health professionals in helping defend these rights.

Virginity examinations in Turkey: role of forensic physicians in controlling female sexuality.

CONTEXT: Although the Turkish Medical Association has deemed "virginity examinations" a form of gender-based violence, women in Turkey are often subjected to such examinations by forensic physicians for both legal and social reasons. Little is known about these physicians' role and attitudes in this practice. OBJECTIVES: To assess forensic physicians' experiences and attitudes regarding virginity examinations in Turkey and suggest potential solutions to the problems identified. DESIGN: Cross-sectional self-administered survey. SETTING: Surveys were completed during the Forensic Science Congress held in Kusadasi in April 1998 as well as in urban academic and medical practice settings between April and October 1998. PARTICIPANTS: Of 158 physicians who practice, are formally trained in, or are in training for forensic medicine, 118 completed the survey (response rate, 74.7%). MAIN OUTCOME MEASURES: Frequency and circumstances of conducting virginity examinations, opinions regarding beneficial and adverse consequences of these examinations, and recommendations for changing the practice, as measured by a 100-item questionnaire. RESULTS: Overall, survey respondents reported conducting 5901 examinations in the previous 12 months; 4045 were conducted because of alleged sexual assault and 1856 for social reasons. Although 68% of forensic physicians indicated that they believed virginity examinations are inappropriate in the absence of an allegation of sexual assault, 45% had conducted examinations for social reasons. The majority of the respondents (93%) agreed that the examinations are psychologically traumatic for the patient. In addition, more than half (58%) reported that at least 50% of patients undergo examinations against their will. CONCLUSIONS: Nearly half of forensic physicians in Turkey conduct virginity examinations for social reasons despite beliefs that such examinations are inappropriate, traumatic to the patient, and often performed against the patient's will. Physicians' participation in such practices is inconsistent with principles of bioethics and international human rights.

Women's health and human rights in Afghanistan.

CONTEXT: During the past 20 years, social and political upheavals have disrupted the way of life in Afghanistan. The Taliban regime, a radical Islamic movement that took control of Kabul in September 1996, has had extraordinary health consequences for Afghan women. OBJECTIVE: To assess the health and human rights concerns and conditions of women living in Kabul under the Taliban regime. SETTING: Residences in Kabul; refugee camps and residences in Pakistan. DESIGN: A cross-sectional survey of women who lived in Kabul, prior to September 1996, when the Taliban took control. PARTICIPANTS: A total of 160 women participated, including 80 women currently living in Kabul and 80 Afghan women who had recently migrated to Pakistan. MAIN OUTCOME MEASURES: Self-reported changes in physical and mental health, access to health care, war-related trauma, human rights abuses, and attitudes toward women's human rights. RESULTS: The median age of respondents was 32 years (range, 17-70 years); median formal education was 12 years, and 136 (85%) of respondents had lived in Kabul for at least 19 years. Sixty-two percent (99/180) reported that they were employed before the Taliban takeover; only 32 (20%) were employed during their last year in Kabul. The majority of all women reported a decline in physical and mental health status (71% [113/160] and 81% [129/160], respectively) and reported a decline in access to health care (62% [99/160]) during the last 2 years living in Kabul. Many of the women reported symptoms that met diagnostic criteria for posttraumatic stress disorder (42% [67/160]), demonstrated evidence of major depression (97% [155/160]), and had significant anxiety symptoms (86% [137/160]). Eighty-four percent (134/160) of women reported 1 family member or more killed in war. Sixty-nine percent (111/160) reported that they or a family member had been detained and abused by Taliban militia, and 68% (108/160) reported extremely restricted social activities. Almost all (96%) expressed support for women's human rights. CONCLUSIONS: The current health and human rights status of women described in this report suggests that the combined effects of war-related trauma and human rights abuses by Taliban officials have had a profound effect on Afghan women's health. Moreover, support for women's human rights by Afghan women suggests that Taliban policies regarding women are incommensurate with the interests, needs, and health of Afghan women.

Education, a Health Imperative: The Case of Afghanistan.

Education is not only a right, but an essential condition for the health and well-being of individuals and the communities in which they live. Despite strong authority within Islamic law and traditions affirmatively promoting the education of both girls and boys, the Taliban regime has denied women this right in the name of religion and culture. Physicians for Human Rights (PHR) recently surveyed the health and human rights concerns of Afghan women. The case of Afghanistan dramatically illustrates that education is a health imperative. Taliban policies of systematic discrimination against women, including restrictions on education, undermine the physical, psychological and social well-being of Afghan women. Such discrimination and the suffering it causes constitute an affront to the dignity and worth of Afghan women, and humanity as a whole.

Torture and war trauma survivors in primary care practice.

Close to 1 million refugees from around the world have entered the United States, fleeing repression, war, terrorism, and disease. It has been estimated that among these are thousands who have experienced torture. Many refugees and immigrants will appear in the offices of health care professionals with symptoms that may be related either directly or indirectly to torture. Both physical and psychological torture may result in long-term sequelae. Physical effects may be found in every organ system, but psychological effects are most commonly manifest in the symptoms of the post-traumatic stress disorder. For physicians to recognize how torture can affect health status, it is important to understand that history taking may be difficult and that little information may emerge that would explain the origins of scars, fractures, or disabilities. Recognizing the clues to a torture history allows physicians to assist patients in describing the trauma. In addition, knowing the subacute and chronic signs and symptoms of torture enables physicians to diagnose and treat often obscure symptoms with a much clearer understanding of the sources of the difficulty. Paying special attention to the interview process will support torture survivors in detailing often horrific events.

Physician complicity in misrepresentation and omission of evidence of torture in postdetention medical examinations in Turkey.

Between June 1994 and October 1995, representatives of Physicians for Human Rights studied the problem of physician complicity in torture (ie, misrepresentation and omission of medical evidence in postdetention examinations of detainees) in Turkey. The research consisted of a survey of forensic documentation of torture, interviews with individual physicians who examine detainees, analyses of official medical reports of detainees, and interviews with survivors of torture. Results from the survey, interviews, and medical report analyses provide evidence that torture of political and criminal detainees continues to occur in Turkey and that Turkish physicians are coerced to ignore, misrepresent, and omit evidence of torture in their examinations of detainees to certify that there are no physical signs of torture.

Life-threatening babesiosis in a women from Wisconsin.

A 63-year-old women from Wisconsin presented with severe hemolytic anemia and was found to have babesiosis by red blood cell morphologic appearance and serologic testing. Despite having an intact spleen, she developed adult respiratory distress syndrome, which required prolonged mechanical ventilation. An unusually high level of parasitemia was noted and resolved completely following treatment with quinine, clindamycin, and exchange transfusion. This case illustrates that the geographic distribution and clinical severity of babesiosis may be greater than previously recognized and that reduction in parasitemia may be achieved with exchange transfusion, quinine, and clindamycin.

Responses to leukotriene C4 in the perfused rat lung.

The isolated rat lung was used to study both the effect of leukotriene C4 on pulmonary perfusion pressure and the synthesis and release of cyclooxygenase products in the pulmonary circulation. A cell-free perfusate was passed only once through the pulmonary circulation or was recirculated. During single transit, leukotriene C4 produced dose-dependent increases in pulmonary perfusion pressure that were abolished by FPL-55712, a leukotriene receptor antagonist, but were not altered significantly by indomethacin. The duration of the pulmonary pressor response to leukotriene C4 was markedly prolonged during recirculation compared to single transit. Leukotriene C4 also induced dose-dependent increases in effluent levels of 6-keto-prostaglandin F1 alpha and thromboxane B2 that were attenuated by indomethacin or FPL-55712 pretreatment. We conclude that leukotriene C4 directly constricts the pulmonary vasculature independent of cyclooxygenase products, is not rapidly degraded by the pulmonary circulation and stimulates the release of cyclooxygenase products in the pulmonary circulation that can be attenuated by pretreatment with indomethacin or FPL-55712.

Cardiovascular responses to leukotriene C4 in the rat.

Bolus injections of leukotriene C4, (LTC4; 0.1 to 10 micrograms/kg) were administered to anesthetized closed-chest rats i.v., before and min after administration of indomethacin (2 mg/kg). Systemic arterial pressure (SAP) and pulmonary arterial pressure (PAP) were monitored continuously. LTC4 produced dose-dependent changes in SAP and PAP. The characteristic SAP response to LTC4 (4 micrograms/kg) consisted of an initial transient rise (16 mm Hg), followed by a sustained decrease (18 mm Hg). LTC4 produced only a decrease in PAP (4 mm Hg). Cardiac output (CO) and heart rate (HR) were measured in the control period and during the maximum increase and decrease in SAP. Decreases in CO (32 ml/min) and HR (15 beats/min) occurred during the initial rise in SAP and further declined (36 ml/min and 21 beats/min, respectively) during the systemic hypotensive phase. Total peripheral resistance markedly increased during the transient rise in SAP (67%). Indomethacin potentiated the transient rise in SAP and attenuated systemic and pulmonary hypotensive responses induced by LTC4. Decreases in CO and HR induced by LTC4 were also attenuated by indomethacin, but total peripheral resistance was not significantly altered. These observations describe a characteristic hemodynamic response to LTC4 in the rat that reflects the composite actions of LTC4 as well as those of prostanoate compounds that may be synthesized and released after LTC4 administration.

Catheterization of the pulmonary artery in the closed-chest rat.

A simple technique has been devised to catheterize the pulmonary artery in rats for measurement of pulmonary artery pressure. A no. 3 1/2 French umbilical vessel catheter (Argyle), angled to 90 degrees over the distal 1 cm, was introduced into the right external jugular vein of the anesthetized (50 mg/kg pentobarbital sodium, ip) rat (male Wistar, 250-350 g). With the angle directed anteriorly, the catheter was inserted 2.5 cm proximally, which placed the catheter in the right atrium. The catheter was rotated 90 degrees counterclockwise and inserted 1.0 cm further, which placed the catheter in the right ventricle. Advancement of the catheter an additional 1.5 cm allowed placement in the pulmonary artery. Placement at each stage was confirmed by the respective pressure contours. This technique is easily and rapidly performed and has many potential applications in measuring parameters of the pulmonary circulation in a variety of small laboratory animals.