Several readers of my post earlier today New Doubts Regarding the Lancet Iraq Mortality Study have raised the question as to why the lapse committed by Burnham et al. in this study warrants dismissing the entire study. After all, they argue, the lapse of recording names was an ethical lapse, perhaps, but recording extra information should not affect the results. Let me take this opportunity to clarify my reasoning.
The faith one has in the results of any study depends largely on the quality of the research design and on how carefully that design is followed. In the case of a population-based epidemiological survey like the 2006 Lancet study (Lancet II), even minor deviations from the survey design can have large effects on the results. (Survey research depends crucially on every person in the population having an equal chance of being selected.) As one example, if interviewers used discretion – beyond that mandated by safety considerations – in selecting households, it could introduce (probably unintentional and unconscious) bias that would make the findings unreliable. For this reason, survey researchers attempt to maintain strict control over the procedures actually used by those collecting data in the field.
We have been assured for years that the design of Lancet II was carefully followed. Now we hear that the specified design was not followed in a crucial way that may have put participants at risk. Furthermore, the Lancet researchers have for years pointed to those very risks as reasons to deny access to raw data and to withhold crucial methodological information when questioned. The fact that the protocol wasn’t followed in a central aspect severely reduces the confidence we can have that the study procedures were carefully monitored.
The Baltimore Sun reported:
“Because of the difficulty of carrying out research in Iraq during the war, Burnham and his team partnered with Iraqi doctors at a university in Iraq. Burnham, working out of Jordan, said he made it clear to the doctors that they could collect the first names of children and adults, to help keep the information straight, but that last names could not be collected.
“When the surveys came back to him in Jordan, it appeared that some had last names. Many were in Arabic. Burnham said he asked his Iraqi partners and was told that the names were not complete, which he accepted. But Hopkins, in its investigation, found that the data form used in the surveys was different from what was originally proposed, and included space for names of respondents. Hopkins found that full names were collected.”
This description, if true, supports the assumption that Burham was in no position to carefully monitor the details of data collection for the study. Further, at its most charitable, it indicates severe communication difficulties with the Iraqi staff that may easily have left him unaware of other possible deviations in procedures. If one is not so charitable, one may wonder why Burham was told a falsehood, that the names were only first names, and thus what else was distorted. In any case, in the absence of this confidence in the study procedures, we cannot maintain confidence in the study’s results.
There is yet another troubling aspect of this incident. The lapse that occurred, recording of full names of respondents reporting deaths from violence in a country undergoing civil war after the Johns Hopkins ethics committee and the respondents were told no names or unique identifiers would be collected, is no trifling error. As Johns Hopkins Magazine reported in its February 2007 issue:
“Concern for the safety of interviewers and respondents alike produced two more decisions. First, they would not record identifiers like the names and addresses of people interviewed. Burnham feared retribution if a hostile militia at a checkpoint found a record of households visited by the Iraqi survey teams.”
Thus, the researchers were well aware that collecting names of respondents could put them at grave risk. Burnham owed it to the people in his study to have enquired further when he noticed names on the forms and not so easily accepted false reassurances. That he did not suggests that he may have (perhaps unconsciously) looked the other way at other possible deviations from protocol.
Since the study was released over two years ago, it has been subjected to severe criticism. While much of this criticism was likely motivated by concern for the political implications of the study, and some of the criticism was clearly unwarranted, that does not give the study a free pass on criticism. And we shouldn’t look the other way to its potential problems just because its findings support our antiwar position.
In response to the criticism, the Lancet study authors have been less than forthcoming with key details, such as their exact sampling procedure for selecting streets, which, under criticism, they admitted was not accurately described in the published paper. That we now know that another crucial detail, the collection of identifiable information, deviated from the published record, and that the authors failed to correct the public record on the matter until forced to, raises questions about what other aspects of the study may not have been conducted as described. As long as these questions remain, the study cannot be considered reliable.
March 16th, 2009
The World Federation for Mental Health has issued the following statement:
WFMH STATEMENT ON THE MENTAL HEALTH CONSEQUENCES OF WAR AND CIVIL CONFLICT
“The World Federation for Mental Health (WFMH), while making it absolutely clear that it does not take sides in armed conflicts, must express its grave concern at the present escalation of conflict around the world in which civilians are the principal victims.
This statement is a response to the horrific circumstances in Gaza, Darfur, Sri Lanka, the Congo and many other areas where conflict is having serious mental health consequences both for the participants and those they involve.
Promoting and protecting the mental health and the well being of the population must be a high priority for governments . Paying attention to the mental and emotional health of a nation’s people must be given added priority during times of stress and conflict such as the world is currently experiencing.
Tension, disruption and uncertainty caused by war and civil strife have major and lasting consequences in the daily lives and routines of children and adults in areas of ongoing violence. Anger and worries about terrorism and military conflicts, the very real fear for safety and survival of civilians and military personnel – all heighten stress and anxiety for everyone. For some, they bring strong feelings of hopelessness and depression, and may result in post-traumatic stress with constant nightmares and panic. They add further stress for those already living with a major illness. The overwhelming and constant connection to military and political conflicts created by the worldwide media lend a sense of “virtual reality” to unfolding events that is inescapable.
Of major concern to the World Federation for Mental Health (WFMH) is that the mental health consequences of the hardship and trauma created by violence and disruption are generally being ignored, by combatants on both sides of these conflicts.
The social, emotional, physical and economic impact of armed conflict add tremendously to the daily challenges of survival for those caught up in the violence of war and civil strife. Psychological scars, it must be remembered, will remain for many years after the physical ones have healed and will impair the ability of many people to work and contribute to economic recovery. In general, government policies and resources allocated to mental ill-health across the world are grossly inadequate, and these inadequacies become glaringly obvious during periods of crisis and disaster.
The World Federation for Mental Health calls urgently
* On all nations involved in conflict, and to those contributing aid to support such conflict, to respond specifically to these issues and to consider the serious immediate and long term mental health consequences of continuing armed conflict;
* On the international mental health community including professional associations and NGOs concerned with health to intervene with respective governments to insist on upholding the Geneva conventions concerned with the health consequences of war and to provide immediate financial support to the mental health services located in conflict areas; and
* On those major humanitarian organisations that traditionally have not prioritised mental health, to provide the means to support established organisations like WFMH to expand training and services according to the new Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings. The Guidelines are now available, their message is clear, but the resources for implementation are still hopelessly lacking.”
Emeritus Professor John R M Copeland MD ScD
PRESIDENT, WORLD FEDERATION FOR MENTAL HEALTH
University of Liverpool Department of Psychiatry,
Section of Old Age Psychiatry,
St Catherine’s Hospital,
Birkenhead, Wirral, CH42 0LQ, UK
TEL + 44 151 604-7333
FAX+ 44 151 653-3441
09 FEBRUARY 2009
March 16th, 2009
Reporter and attorney Mark Danner has obtained a copy of the International Committee of the red Cross’ report on the torture at the CIA’s black sites. The report was based upon extensive interviews with 14 “high value” detainees who were transferred from CIA custody to Guantanamo in 2006. Danner has written an extended piece based on the report in the New York Review of Books and has excerpted a small portion of the article as an op-ed in the New York Times. As Danner points out, the 14 detainees had been kept isolated from each other since their capture. Thus they had no opportunity to coordinate their stories. The fact that many of the details were repeated by multiple detainees thus constitutes strong evidence for the veracity of the reports.
Here is one excerpt of what the detainees relate, as told by Abu Zubaydah:
After the beating I was then placed in the small box. They placed a cloth or cover over the box to cut out all light and restrict my air supply. As it was not high enough even to sit upright, I had to crouch down. It was very difficult because of my wounds. The stress on my legs held in this position meant my wounds both in the leg and stomach became very painful. I think this occurred about 3 months after my last operation. It was always cold in the room, but when the cover was placed over the box it made it hot and sweaty inside. The wound on my leg began to open and started to bleed. I don’t know how long I remained in the small box, I think I may have slept or maybe fainted.
I was then dragged from the small box, unable to walk properly and put on what looked like a hospital bed, and strapped down very tightly with belts. A black cloth was then placed over my face and the interrogators used a mineral water bottle to pour water on the cloth so that I could not breathe. After a few minutes the cloth was removed and the bed was rotated into an upright position. The pressure of the straps on my wounds was very painful. I vomited. The bed was then again lowered to horizontal position and the same torture carried out again with the black cloth over my face and water poured on from a bottle. On this occasion my head was in a more backward, downwards position and the water was poured on for a longer time. I struggled against the straps, trying to breathe, but it was hopeless. I thought I was going to die. I lost control of my urine. Since then I still lose control of my urine when under stress.
I was then placed again in the tall box. While I was inside the box loud music was played again and somebody kept banging repeatedly on the box from the outside. I tried to sit down on the floor, but because of the small space the bucket with urine tipped over and spilt over me…. I was then taken out and again a towel was wrapped around my neck and I was smashed into the wall with the plywood covering and repeatedly slapped in the face by the same two interrogators as before.
I was then made to sit on the floor with a black hood over my head until the next session of torture began. The room was always kept very cold.
This went on for approximately one week. During this time the whole procedure was repeated five times. On each occasion, apart from one, I was suffocated once or twice and was put in the vertical position on the bed in between. On one occasion the suffocation was repeated three times. I vomited each time I was put in the vertical position between the suffocation.
During that week I was not given any solid food. I was only given Ensure to drink. My head and beard were shaved everyday.
I collapsed and lost consciousness on several occasions. Eventually the torture was stopped by the intervention of the doctor.
I was told during this period that I was one of the first to receive these interrogation techniques, so no rules applied. It felt like they were experimenting and trying out techniques to be used later on other people.
Danner gives us the Table of Contents of the report, which clearly evokes the nature of the CIA program:
1. Main Elements of the CIA Detention Program
1.1 Arrest and Transfer
1.2 Continuous Solitary Confinement and Incommunicado Detention
1.3 Other Methods of Ill-treatment
1.3.1 Suffocation by water
1.3.2 Prolonged Stress Standing
1.3.3 Beatings by use of a collar
1.3.4 Beating and kicking
1.3.5 Confinement in a box
1.3.6 Prolonged nudity
1.3.7 Sleep deprivation and use of loud music
1.3.8 Exposure to cold temperature/cold water
1.3.9 Prolonged use of handcuffs and shackles
1.3.11 Forced shaving
1.3.12 Deprivation/restricted provision of solid food
1.4 Further elements of the detention regime….
He also gives its conclusion which makes it unequivocall that, in the ICRC’s view, the United States government committed major crimes through its “enhanced interrogation” program:
The allegations of ill-treatment of the detainees indicate that, in many cases, the ill-treatment to which they were subjected while held in the CIA program, either singly or in combination, constituted torture. In addition, many other elements of the ill-treatment, either singly or in combination, constituted cruel, inhuman or degrading treatment.
Danner places the report in the context of the lies and disinformation continually told us by our leaders, President Bush foremost among them:
“This debate is occurring,” as President Bush told reporters in the Rose Garden the week after he delivered his East Room speech,
because of the Supreme Court’s ruling that said that we must conduct ourselves under the Common Article III of the Geneva Convention. And that Common Article III says that, you know, there will be no outrages upon human dignity. It’s like—it’s very vague. What does that mean, “outrages upon human dignity”?
In allowing Abu Zubaydah and the other thirteen “high-value detainees” to tell their own stories, this report manages to answer, with great power and authority, the President’s question.
Now that the President’s question has been answered, the question now remains what we, the American people, will do with this answer. Will we demand further answers, the who, what, why and when? Will we insist on making public all these sordid details? Will we demand punishment? What steps will we take to make sure this never happens again? Or will we, perhaps, continue our complicity in these abuses committed in our name?
As a psychologist, I am well aware that the techniques documented in this report were created and monitored by psychologists James Mitchell and Bruce Jessen, as Jane Mayer, Katherine Eban, and Mark Benjamin have documented. As Mayer reports in her book, The Dark Side, Mitchell and Jessen apparently adopted ideas on “learned helplessness” from former American Psychological Association President Martin Seligman, who lectured, under CIA auspices, to the Navy Survival Evasion, Resistance, and Escape school, with Mitchell and Jessen in the audience. [An earlier version of the following comments were made by me yesterday on a listerve and were quoted by Daily Kos blogger Valtin in his commentary on the Danner article.] These psychologists were present at the APA-CIA-Rand conference on the Science of Deception. Among the topics discussed at this conference were:
What pharmacological agents are known to affect apparent truth-telling behavior?….
What are sensory overloads on the maintenance of deceptive behaviors? How might we overload the system or overwhelm the senses and see how it affects deceptive behaviors?
Is it plausible that no APA official in attendance considered or has since considered the possibility that discussion of these topics at a CIA workshop was connected to the CIA’s “enhanced interrogation,” a.k.a. torture program? If such thought ever occurred to any APA leaders, they have never been expressed publicly. Rather, the APA has never explained why these torturers were invited to this conference, what they said or what was said to them. Nor have the APA leaders who invited and participated with these torturers expressed any remorse that they may have aided their torture. Rather, these leaders tried to hide the attendance list for this conference, just as they later tried to hide the membership of their “ethics” task force, and even claimed to have “misplaced” it. And these leaders repeatedly have tried to change the subject to whether or not these torturers were “APA members”, as if its fine to aid torturers if they aren’t members of the association.
APA leaders also have given recognition and awards to a military psychologist who helped design the Guantanamo interrogation system, while refusing to disciple those psychologists whose participation in US abuses was reported to them.
But, perhaps most disturbingly, when the APA created a task force to formulate ethics policy regarding interrogations, they chose psychologists who had been involved in the U.S. government’s interrogation programs at the CIA’s black sites, Guantanamo, and Afghanistan to form the majority of that task force and then refused to reveal the task force membership. One member of the task force was even reportedly present at the torture of Abu Zubaydah, a fact he neglected to mention during the task force proceedings. Not surprisingly, the task force report echoed the government’s cover story that the participation of psychologists in these interrogations “puts psychologists in a unique position to assist in ensuring that such processes are safe and ethical for all participants.”
Accountability for US torture MUST include accountability for those who aided the torturers, including those in the APA leadership who, wittingly or unwittingly, helped provide cover for the torture program. Continued silence is not acceptable. The truth must come out. We must pressure any Truth Commission or other accountability process to explore the role of the APA, other psychologists, and other health professionals, in the US torture program. It is up to psychologists, along with other citizens concerned with human rights and human decency, to demand accountability from our leaders.
March 16th, 2009