On Friday, June 18, the CIA Inspector General's report from May 2004 will be released, hopefully in an unredacted form. This report is anticipated to reveal the consequences of harsh detainee treatment that helped lead to the withdrawal of the Yoo-Bybee torture memos in 2004.
Last Friday, the ACLU obtained previously classified transcripts from the 2007 Guantanamo military tribunals (CSRTs) detailing the charges against several "high value" detainees, including the three known to be waterboarded, Abu Zubaydah, Abd al-Rahim al-Nashiri (al-Nashiri), and Khalid Sheik Mohammed (KSM).
In this diary, I examine (as a physician) the CSRT testimony, in order to explore further the reason why al-Nashiri was waterboarded only two times, versus 83 and 183 times for Zubaydah and KSM, respectively. I hope everyone will recognize that this merely is informed speculation. We will likely have a much better idea of the details of the medical outcomes of torture on Friday.
Marcy Wheeler and I have previously noted that of the three detainees known to have been waterboarded by the CIA, al-Nashiri's experience was very different. His waterboarding was stopped after two applications, as opposed to the 83 or 183 applications Zubaydah and KSM underwent.
I have pointed out that following al-Nashiri's waterboarding, the CIA made dramatic changes to the "enhanced interrogation" program. Specifically, they:
- Ended all videotaping of interrogations.
- Changed the rules for interrogation (two memos in January, 2003), requiring more headquarters control over when the harsh techniques could be used, and required field agents to sign the policy.
- Added requirements for medical and psychological personnel on scene.
- Initiated an internal Inspector General review of the program.
These and other hints discussed previously, strongly suggest that al-Nashiri suffered an adverse outcome from his two waterboarding applications. I am going to add a few other details that point us toward the possible medical underpinnings of the bad outcome.
- Phillip Zelikow, a former top adviser to Condaleeza Rice, wrote a memo strongly opposing the legal "justification" of the harsh techniques. In response, The Bush Administration ordered that all of the copies of the memo be collected and destroyed. In television interviews, Zelikow has pointed to sleep deprivation as being particularly heinous.
- Sleep deprivation, as practiced by the CIA, means shackling to the wall in the standing position, with the arms outstretched to the sides in a crucifixion posture, for up to 7.5 days. From the 2005 "Techniques Memo":
...shackles are only used as a passive means to keep the detainee standing and thus to prevent him from falling asleep; should the detainee begin to fall asleep, he will lose his balance and awaken, either because of the sensation of losing his balance or because of the restraining tension of the shackles.
- Emails written by former Deputy Attorney General James Comey have recently come to light. Comey resisted many of the Bush "War on Terror" policies, and was one of a group of DOJ lawyers who opposed versions of the OLC memos that reapproved harsh interrogation techniques in 2005. Comey's main problem was with a memo that employed combinations of harsh techniques (Stephen Bradbury's May 10, 2005 "Combined" memo.) In particular, Comey objected to the "abstract" discussion of combinations as opposed to providing specific guidelines. He asked the OLC to evaluate a RETROSPECTIVE case to define limits to the technique combinations:
Some weeks ago [OLC Lawyer Patrick Philbin] alerted me to his serious concerns about the adequacy of the "combined effects" analysis, particularly as it relates to the category of "severe physical suffering," which the December 30 opinion had, for the first time,
concluded was a separate category that needed to be considered in
decided whether something amounted to torture.
He mentioned at one point that OLC didn't feel like it could accede to my request to make the opinion focused on one person because they don't give retrospective advice. I said I understood that, but that the
treatment of that person had been the subject of oral advice, which OLC
would simply be confirming in writing, something they do quite often.
Since combinations of enhanced techniques were not described in the original Bybee/Yoo Memos, any use of combinations on Zubaydah, al-Nashiri, or KSM would have been oral approvals. I believe it likely that Comey is asking the OLC to consider a prior bad outcome (dealing with severe physical suffering) in defining limits of the interrogation program, but the CIA is resisting. To this refusal, Comey issues the startling analysis:
In stark terms, I explained to [Attorney General Alberto Gonzales] what this would look like some day and what it would mean for the President and the government. I sketched out for him the "summation" that could be made to demonstrate that some of this stuff is simply awful. I told him it would all come out some day and be presented in the way I was presenting it. I mentioned that I had heard there was a video of an early session, which would come out eventually.
The only 2 detainees videotaped were Zubaydah and al-Nashiri.
- The ACLU's posting of al-Nashiri's CSRT testimony was largely still censored in the sections dealing with his treatment as a detainee. However, the following statement was declassified on 6/12/09:
Before I was arrested I used to be able to run about ten kilometers. Now, I cannot walk for more than ten minutes. My nerves are now swollen in my body. Swollen too.
Following his detention and interrogation by the CIA, al-Nashiri experiences a "nerve" problem that leads to difficulty walking. It is impossible to make a reasonable medical diagnosis based on this description. There is an issue of poor translation. There is also the fact that besides leprosy, there is not much that makes the nerves "swollen."
What Happened to al-Nashiri?
Knowing full well that the CIA OIG report is coming in 3 days that may clarify al-Nashiri's condition, I am going to use my medical training and knowledge of the memos to try to provide an informed guess as to what may have happened during the al-Nashiri interrogation that might be the "bad outcome" we suspect.
- The 2005 "Techniques" memo contains numerous references to edema, swelling of the legs due to prolonged standing during "sleep deprivation". In fact, the memo notes "severe edema" in three detainees.
- Edema is cause by transudation of fluid out of the vascular system and into the tissue of the legs. The fluid is essentially "filtered" out of the blood, swelling the skin, muscles, and subcutaneous tissues. I have seen some patients in whom the edema is so bad that the skin "weeps" and is prone to splitting or tearing, but usually edema is not painful and is resolved by elevating the legs.
- The fluid filling the tissues is the same salt concentration as the blood.
- After the early waterboarding experiences, the CIA doctors required saline to be used for waterboarding (same salt concentration as blood and edema fluid).
- Prior to this, waterboarding was done with bottled water, which has no salt.
- In the body, water moves across membranes (such as connections between cells in capillaries) faster than salts, so free water will move between compartments (like blood vessels and surrounding tissues) until salt concentrations are equal.
- Per the memos, waterboarding can results in aspiration and swallowing large amounts of water. This can cause acute water intoxication with extremely low salt concentrations in the blood.
- In water intoxication, free water leaves the blood vessels into the tissues to try to equilibrate the salt concentrations. Of all the tissues, the brain is most sensitive to these fluid shifts, because the cells are bathed in salty fluid (spinal fluid) that the free water will rush to join.
- Enter the problem with severe edema. Based on a May 30, 2005 memo (CAT memo), we know that al Nashiri was waterboarded on the 12th day of his interrogation. It is likely that he had been subjected to sleep deprivation for the days prior to this event, and may have had severe edema of the legs. Basically, acute water intoxication in a person with severe edema would be predicted to result in massive fluid shifts of free water from the blood vessels into the already edematous legs.
- Massive fluid shifts into already edematous legs might cause splitting of the skin, no doubt painful and a bloody mess. But more germane to al-Nashiri's CSRT testimony, this could cause swelling of leg muscles that damages the nerves.
- Compartment Syndrome- Basically in the legs (and arms) there are muscles, arteries and veins and nerves that run for a section through a "compartment" that encloses the structures in a water impermeable fibrous sheath. The capillaries within the muscles in this compartment allow water and ions to exchange with the blood. If the blood suddenly becomes dilute from water intoxication, the free water will egress from the blood vessles into the muscles to equilibrate the salts in the muslces. Because there is way for the increased water in the muscle to expand the compartment against the fibrous sheath, pressure builds up. If the pressure becomes high enough, then adequate blood can’t flow into the compartment. The nerves and muscles can be permanently damaged from the lack of blood flow.
- Compartment syndrome is exquisitely painful. I have seen patients with compartment syndrome screaming in agony despite massive amounts of narcotics. If this is what happened to al-Nashiri, it could very well explain why they stopped videotaping the interrogation sessions.
- Compartment syndrome can result in such severe injury that amputation is required. Less dramatic outcomes include nerve damage. In the legs, compartment syndrome can result in compression of the common peroneal nerves or their branches, which control the extension of the foot and toes, as well as some of the sensation on the feet. Nerve injury from compartment syndrome thus often results in "foot drop" and leads to difficulty walking.
- Nerve injury from compartment syndrome is consistent with al-Nashiri's CSRT testimony of a "nerve problem" that leads to difficulty walking.
I don't know whether the speculation presented above is true. I am just a Cheetoh-eating blogger in pajamas, albeit one who is also a board-certified physician. There is a lot to put together- the memos, the testimony of the accused terrorists, the emails of conscientious objectors within the DOJ, the destroyed videotapes. Al-Nashiri may not have been injured in the way I speculate here- we will find out Friday.
Regardless, I think the "summation" that Comey warned Gonzales about may go something like this:
They stripped him naked and put a diaper on him. They chained him to the wall, arms outstretched, in the position of Jesus on the Cross. They withheld food and gave him barely enough water to whet his cracked and bleeding lips. After seven days positioned as such, and despite the dehydration, his legs swelled with fluid so that they were like doughy tree trunks. When they finally laid him down, it was to pour water down into his nose and throat to simulate drowning. He desperately gulped the water, out of an attempt to breathe more than his severe thirst. The water, unfortunately, went straight into his swollen legs, restricting blood flow to the muscles and nerves of the legs and resulting in screaming that, although erased from the day's videotape, was never really forgotten by those who heard it.
Cited Memos (PDFs)
"Techniques" May 10, 2005: Memo from Steven Bradbury, Acting Assistant Attorney General, OLC, to John A. Rizzo, General Counsel CIA
"Combined" May 10, 2005: Memo from Steven Bradbury, Acting Assistant Attorney General, OLC, to John A. Rizzo, General Counsel CIA
"CAT" May 30, 2005: Memo from Steven Bradbury, Acting Assistant Attorney General, OLC, to John A. Rizzo, General Counsel CIA