Of all of the CIA "enhanced interrogation techniques" waterboarding has gotten the most attention, fitting most people's definition of torture. I have previously diaried that when the CIA's doctors (Office of Medical Services, OMS) finally were consulted on the enhanced interrogation techniques in December 2004, they imposed several restrictions on the program to try to ensure that the detainees would not die as a result of interrogation. One of the changes was a requirement for a physician with a tracheotomy kit to be present during waterboarding.

I have also written about how waterboarding combined with other techniques could lead to a medical complication that could cause painful and severe nerve injury to the legs, a condition that may affect one of the detainees, Abd al-Rahim al-Nashiri (al-Nashiri).

At the suggestion of Marcy Wheeler, I have spent time reviewing the Autopsy reports of the detainees known to have died in US custody in Iraq and Afghanistan. Of these 44 detainee deaths, 21 were determined by US military pathologists to be homicides. Most of the autopsies reveal the handiwork of pure cruelty. The autopsies are replete with descriptions of linear bruises caused by batons or other blunt objects, patterned abrasions ("brush burns") on the back from dragging, cuts and bruises at the wrists from shackling, boot prints in the flesh, head injuries that cause blood vessels in the brain to rupture.... This link to an ACLU press release provides several telling excerpts.

Aside from the unadulterated cruelty evident in many of the autopsies, one autopsy reveals a death that was exacerbated by the medical experimentation of the early torture program. One of the homicide victims, an Afghani Mullah named Habibullah, was clearly beaten while in captivity (Autopsy Link PDF). Indeed, his torture and that of another detainee who died a week after him, is detailed in the excellent reporting of Tim Golden. However, despite the severity of his injuries, Habibullah's autopsy suggests that his beating was not alone in causing his death. It is likely that "enhanced interrogation techniques" the DOJ approved for use by the CIA in August 2002 and which Donald Rumsfeld approved for Military use on December 2, 2002 caused or contributed to his death.



The Beating

According to the autopsy report (PDF), Habibullah was not injured when he first arrived at the Bagram detention facility:

MEDICAL RECORD REVIEW: Copies of the inprocessing evaluation are reviewed in full. The clinical portion documents the decedent as "appearing well", without injuries and offering "moderate resistance to inprocessing". The decedent was "dead on arrival" per the Medical Treatment Facility (MTF) Emergency Room record which was otherwise non-contributory.

On autopsy, however, Habibullah's body bore the stigmata of torture (Graphic content warning):

Head and Neck: Multiple abrasions and contusions and evidence of ligature or other instrument applied to the neck:

On the right side of the neck there are two parallel, faint, linear abraded contusions. each averaging 1 1/4 x 1/4 inches with 1/2 inch separation between the two. They average approximately 10 inches below the top of the head and three inches to the right of the anterior midline. Just to the left of these is a similar, fainter, patchy abraded contusion in

approximately the same dimensions.

Torso: Multiple contusions and abrasions including "brush burn" injuries consistent with being dragged on the ground.

Extremities: Multiple contusions and abrasions, including injuries around the wrists consistent with shackling. On the thighs were linear contusions likely made from being struck with blunt objects. The patterns in the skin of the left calf revealed the likely source of the injuries- combat boots:

On the back of the left knee and calf is a 11 x 7 1/2 inch red-dark purple contusion which extends upwards above the back of the knee in a linear fashion. On internal examination, confluent hemorrhage extends deep within the muscle which is focally necrotic. On the left calf, centrally located, is a patterned abrasion consisting of multiple parallel horizontal linear abrasions the largest averaging 1 1/2 x 1/4 inches, these are closely spaced.



The Killer

Despite the violence inflicted upon his extremities, what killed Habibullah was found when they cut open his chest:

Examination of the pulmonary artery in-situ reveals a large branching embolus (blood clot) extending into both the right and left pulmonary arteries. The embolus is mildly firm. focally coiled, and smaller than the circumference of the pulmonary vessels.

Habibullah died of pulmonary embolism. A pulmonary embolus is a blood clot that is passed from the veins to the heart, then pumped into the lungs. Blood clots in the pulmonary arteries block blood flow to the lungs. Because the lungs oxygenate the blood needed for life, if large enough, pulmonary emboli lead to death.



Analysis

The Autopsy listed the cause of death as "Pulmonary embolism due to blunt force injuries", and the manner of death as homicide. Whereas I concur this was a homicide, and Habibullah was clearly beaten severely, I strongly doubt that blunt force injuries were the sole cause of the pulmonary embolism. Pulmonary embolism is most often caused by immobility, which lets blood clots form in the deep veins (usually of the legs). When trauma is a cause of pulmonary embolism, it is almost always associated with immobility. For example, head injuries leading to coma and leg fractures both result in immobility and high risk of pulmonary embolism. In the hospital, such patients would get preventative treatment, such as with a blood thinner to prevent blood clots from forming in the veins of the immobile extremities. But in Afghanistan in December 2002, immobility was exactly what was in store for a detainee.

Habibullah was being interrogated by the military. Upon autopsy he was clothed only in an adult diaper. Because he was taken from his cell to the Bagram medical facility "dead on arrival" it is likely he was wearing a diaper when he was found "unresponsive, restrained in his cell" (hanging shackled from the ceiling). This is consistent with the nudity and use of diapering during "sleep deprivation" approved by Rumsfeld and described as part of the protocols for CIA interrogation during one technique: sleep deprivation- in which the detainee is shackled standing or sitting for up to 7 1/2 days straight. We have learned from the 2005 Bradbury memos that sleep deprivation causes venous stasis in the legs and has led to severe leg edema. We know that Habibullah was shackled to the ceiling of his cell for sleep deprivation, where he was ultimately found dead. This scenario is reinforced by a citation of a DOD criminal investigation report in the recently released Senate Armed Services Committee Report on Detainee Treatment (PDF). This citation noted that "the use of stress positions and sleep deprivation combined with other mistreatment at the hands of Bagram personnel, caused or were direct contributing factors in the two homicides [Habibullah and Dilawar]."



Postscript

In addition renewed attention to blatant and banal cruelty evident in the deaths of detainees in the "War on Terror", I wanted to point out again that the detainees were subjected to medical experimentation.

Although it is widely known that immobility can lead to blood clots and risk of life-threatening pulmonary embolism (See Dan Quayle and David Bloom [h/t Clytemnestra]) this risk was apparently not entertained in the initial crafting of the CIA and DOD interrogation programs.

It is interesting to note that another enhanced interrogation technique that forces immobility, "Cramped Confinement", was approved for use by the CIA in 2002 and initially allowed 18 hours of confinement in a box that "restrict[s] the individual's movement." An important change to cramped confinement was made in the 2005 DOJ memo for the CIA; Confinement time was limited to 8 hour sessions and the time limit was now subject to input from OMS officers. These changes suggest awareness of the potential complications of immobility, and suggest bad experience necessitated the change. Habibullah's death by pulmonary embolism is likely one of the events reviewed by the OMS in imposing limits on immobility.

I suspect that the CIA IG report to be released tomorrow will detail many of the "failed experiments" with torture that led to detainee injury or death. It is important to remember that torture is still torture even if the wonders of modern medicine are employed to keep the torture victims alive.



Update

See Emptywheel today for another detailed exploration of an autopsy report revealing death by torture in US custody. Other bloggers will also be focusing on torture today, and I will try to link them when they post.

bmaz on torture and the Rule of Law.

Teacherken on Bob Hebert on torture.

Glenn Greenwald on NPR's inability to say "torture".

More death by torture covered by Glenn.

(Valtin) Jeff Kaye's excellent post on Drugs used on detaineeds.

And our own mcjoan with a beautiful synthesis.