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Home , Asphyxia, Cage (organisation), Drowning

25

”Not waving, ”. and : the myth of simulated drowning and other forms of torture

Jonathan Beynon, MD

Abstract in which intake to the can be The article will give a brief introduction to what mechanically restricted: by obstruction of we understand by the term Asphyxiation. The the external respiratory passage (the mouth, main focus will then turn to how Asphyxiation is nose, oropharynx); by on the neck used as a method of torture, (often euphemisti- producing compression of the as cally called a “method of interrogation”) with an well as the neck vessels, or by pressure overview of wet methods such as immersion in on the thoracic cage which restricts the me- water or the pouring of water over the mouth and nose, and dry methods such as the use of bags/ chanical mechanism of . sacks/masks and how exacerbating factors such as In all cases, the restriction of oxygen the use of contaminants or irritants are used. The intake can lead to , ultimately through recently published International Forensic Expert , but it should be noted that Group Statement on Hooding1 will be introduced the fear and stress associated with the as- and the notion will be explored that during so- phyxia, may in themselves produce cardiac called ‘enhanced interrogation’ asphyxiation or and sudden death through re- drowning can be “simulated.” flex cardiac arrest. This cardiac arrest is through vagal inhibition, which may also Keywords: drowning, asphyxia, torture, be produced by pressure on the neck (spe- interrogation cifically on the baroreceptors of the internal carotid artery), water striking the glottis, or Although the term Asphyxia stems from the

sudden immersion in icy water. T Greek for the lack of a pulse (a sphyxis), it ORTURE The ‘classic signs’ of asphyxia are said is commonly understood to mean a lack of

to be petechiae, congestion, oedema and Volume 22, Supplementum 1, 2012 oxygen, either from a restriction of its intake, . Petechiae may be present on the or a restriction of its use, or uptake, by the eyelids, conjunctivae, sclera, the face, includ- body. When the lack of oxygen results in ing the lips and mucous membranes, as well death it is termed suffocation. For the pur- as behind the ears, on the neck, and on the poses of this workshop the discussion will chest. A struggle may accentuate these signs, be limited to ways in which oxygen intake but then one might also expect to see other is impaired. There are broadly three ways signs of the struggle such as abrasions and on the face, neck or chest. But the ‘classic signs’ are actually non- Correspondence to: [email protected] specific, and may be caused by other mecha- 26

nisms other than asphyxia. If there is no elephant, this method is sometimes termed struggle, or if death is sudden through reflex “the elephant.” cardiac arrest, then these signs may also be The material that is used to block the absent. Petechiae have been found to be air passages may be contaminated from caused by mechanical mechanisms (rupture previous use with the saliva, sweat, vomit or of capillaries and venules due to increased blood of other victims. But other contami- vascular pressure) and not purely by the hy- nants may be deliberately introduced, such poxia associated with asphyxia. Thus if there as faeces, chillies or volatile liquids such as is asphyxia without a mechanical component petrol or in the case of the gas mask smoke such as compression of the neck or chest, or other noxious substances may be intro- then petechiae may be absent.2 duced through the filter hole. These irritants may directly affect the mucous membranes, Methods produce , airway or pulmo- In this discussion on the use of asphyxia nary inflammation or oedema as well as the in torture, if we exclude mechanisms that noxious effects of the contaminant itself. would interfere with oxygen exchange in Hooding, the practice of fully covering the blood itself, we can look at external the head of a person, usually with a perme- mechanisms that impede the mechanism of able material such as sacking or cloth, has respiration, namely, obstruction of the exter- in itself been found by various international nal respiratory orifices (nose and/or mouth), bodies, including the United Nations Com- obstruction of the air passages (pharynx, mittee Against Torture, to be torture or larynx, trachea), pressure on the neck and cruel, inhuman or degrading treatment. A pressure on the chest. statement by the International Forensic Ex- pert Group on how the practice of hooding Obstruction of the respiratory passages during arrest and interrogation may consti- Obstruction of the external respiratory pas- tute torture or cruel inhuman or degrading sages, or smothering, may be with a material treatment was published in 2011.1 As well as or with an object such as a pillow, hand or impeding air flow, the hooding will produce other body parts of the perpetrator.3 In what sensory deprivation by interfering with sight, is often termed “dry submarino” any imper- hearing and smell, produce disorientation, meable material, such as a plastic bag, held fear, stress and may exacerbate pre-existing over the face or head produces asphyxia. medical conditions, particularly respiratory It does not simulate asphyxia, it produces or cardiac illness and psychological disor- asphyxia. Since there is direct pressure over ders. the face and neck, and since the victim is likely to struggle, it may be that the classical Restraint or Positional Asphyxia signs of asphyxia are more evident, but not Restraint or positional/mechanical asphyxia necessarily, as may be other signs of struggle is a term used to describe the restriction of such as abrasions and bruising around the the mechanical process of respiration which face and neck. In parts of Central Asia, a gas leads to asphyxia. mask with the filter blocked has been used Restraint may be through holding an

Volume 22, Supplementum 1, 2012 Volume to obstruct the external airways. Since the individual in an arm lock (or “choke hold”) type of gas mask often has a long tube that which is employed by some law enforcement ORTURE

T houses the filter, resembling the trunk of an authorities in order to detain an individual. 27

There may be a combination of compression can produce asphyxia as the of the of the chest, impairment of cerebral blood abdominal contents pushes down on the flow through partial neck compression, and diaphragm thus restricting its movement. compression of the airway.4 Since you might The asphyxia can be exacerbated by the expect the victim to struggle, as in cases of wrists being tied behind the back which will strangulation, there is a likelihood of pe- impede chest movement. Suspension by the techiae on the conjunctivae, face or trunk, as wrists either tied above the head or behind well as congestion and oedema. the back so that the head remains upwards In using restraint asphyxia as a method will similarly produce some degree of as- of torture the person may be tied in con- phyxia as chest movements are restricted as torted positions such as the so-called ”Hog the weight of the body passes through the tie” or ”Banana tie” in which the wrists are shoulders and arms, more so as the indi- bound behind the back, the ankles are tied vidual becomes exhausted. and then the spine forced into hyperexten- sion by pulling the wrists back toward the Drowning ankles. Sitting on the chest or back of a Following a process of international con- person will similarly impair respiratory chest sensus on a new definition of drowning, van movement. Forcing prisoners to pile on top Beeck5 provided that the definition should of each other clearly risks some form of include both cases of fatal and non-fatal positional asphyxia, in particular for those drowning, and thus adopted the following: crushed at the bottom of the pile. “Drowning is the process of experiencing It must be remembered that victims of respiratory impairment from submersion/im- torture who are restrained in one of the mersion in liquid.” Thus drowning is not above manners, are commonly simultane- simply a terminal event, but is a process. The ously or cumulatively subjected to other process is not simply one of induced forms of violence such as beatings, electric but a complex process involving breath hold- shocks, extremes, stress posi- ing, struggling, physical exhaustion, rising tions, insults, threats and hooding. In the levels, the inhalation and case of Baha Mousa, a civilian Iraqi National ingestion of the liquid, coughing, , who died in ’under interrogation’ by the loss of consciousness, respiratory failure, car- British Army in 2003, an inquiry found that diac arrest, culminating in death. Therefore

the cause of death was restraint positional if the process is interrupted at some stage T asphyxia. Mr Mousa was hooded, beaten, prior to death we can logically have cases of ORTURE

forced to remain in stress positions, deprived non-fatal drowning. Volume 22, Supplementum 1, 2012 of food and water, held in extremely hot in either salt or fresh water conditions and died within 24 hours of be- impairs respiratory exchange and produces ing detained. Just prior to his death one or hypoxia. Inhalation of fresh water, since it two soldiers had been sitting on his back is hypotonic, produces rapid hypervolae- while he was face down, clearly a method of mia, hypoxaemia due to the haemodilution, restraint that can produce asphyxia, espe- cardiac stress, haemolysis and electrolyte cially in an already exhausted victim. changes, and can produce death in four to Suspension can also produce positional five minutes. Inhalation of sea water, which asphyxia. Suspension in the inverted position is hypertonic, produces pulmonary oedema by ropes or chains fixed around the ankles as water passes from the plasma into the air 28

spaces of the lungs, and with less cardiac the inversion would also produce a form of disturbance, death may occur in eight to positional asphyxia as the abdominal organs twelve minutes. It is however important to pressed down on the diaphragm. note that in either fresh or salt water, death The description given of ‘waterboard- may in some cases be rapid from cardiac ar- ing’, the supposed interrogation method rest probably due to vagal inhibitory reflex. employed in the so-called ‘’ is The victim of the drowning process who identical to those just given for the methods survives may also show pneumonia from the employed by the Khmer Rouge and others. inhaled water and contaminants, gastroin- An individual is strapped to a board or table, testinal disturbances from ingesting water a cloth placed over the face covering the and contaminants, and other physiological nose and mouth and water poured over the disturbances such as haemolysis leading to cloth saturating it and blocking off the flow haemoglobinuria and even renal failure. of air. As a method of torture, the use of wa- But we are now told that in fact, the ter to impede respiration has been used for Inquisitors, the Khmer Rouge, the perpetra- centuries. In the Inquisition of the 15th tors of the ‘Dirty Wars’ of Latin America and 16th centuries, individuals were tightly and other countless interrogators across bound to a wooden frame or table, the head the world, were not actually using a torture end lowered and a cloth forced into the method but were in fact just practicing “en- mouth onto which water was poured. The hanced interrogation.” We are now told that cloth would prevent the person from spitting they were not in fact employing drowning out the water, but also obstruct the oro as a method of torture, but were actually pharynx as it was forced back into the just “simulating drowning”. This presup- throat by the water. The individual would poses that drowning someone must result both swallow and inhale the water while all in death, whereas from the proposed new the time being interrogated. As the water is international definition of drowning, it is not poured over the mouth at intervals, the sub- necessarily the end result, but drowning is a mersion is intermittent, as it may be in cases process, a continuum which includes cases of accidental drowning where a victim may of non-fatal drowning. be conscious. Therefore, when it comes to employing Under the Khmer Rouge, between 1974 asphyxia through drowning as a so-called and 1979 a similar method of torture was method of interrogation, there can be no employed whereby a prisoner was shackled simulation, either you are subjected to, by the wrists and ankles to a wide platform and experience asphyxia and the process of while water was doused over a cloth cover- drowning, or you are not. If I put a plastic ing the face. Across Latin America in the bag over your head and hold it in position 1970’s and 1980’s political prisoners would until you experience difficulty breathing, am be bound and have their heads submersed in I simulating depriving you of oxygen, or am drums, baths or other vessels of often fetid I depriving you of oxygen? Self-evidently it water, either while kneeling or lying over, is the latter. The person subjected to sub- or in, the container, or while suspended marino or is not waving,

Volume 22, Supplementum 1, 2012 Volume upside down by their bound ankles. While but drowning; they are being involuntarily the submersion in water produced (mostly) subjected to the severe and suffering of ORTURE

T non-fatal drowning, as already mentioned the process of drowning for the purpose of 29

interrogation. They are being subjected to References: torture. 1. International Forensic Expert Group. Statement on hooding. Torture 2011;21:186-9. Would anyone really like to claim that 2. Ely SF, Hirsch CS. Asphyxial and pe- Comrade Duch, recently convicted by the techiae: a review. J Forensic Sci 2000;45:1274–7. special tribunal in Cambodia of war crimes 3. Morentin B, Callado LF, Idoyaga MI. A follow (including torture) and crimes against hu- up study of allegations of ill-treatment/torture in incommunicado detainees in Spain. Torture manity (including torture), was not actu- 2008;18:87–98. ally ordering the torture by “submarino” 4. O'Halloran R, Frank JG. Asphyxial death during of countless victims at the Khmer Rouge prone restraint revisited: a report of 21 cases. Am prison S-21 in Phnom Penh, but was actu- J Forensic Med Pathol 2000;21:39-52. 5. van Beeck EF, Branche CM, Szpilman D, Modell ally only “simulating the drowning” of these JH, Bierens JJ. A new definition of drowning: to- individuals through the use of “waterboard- wards documentation and prevention of a global ing”? Because S-21 was actually an inter- public health problem. Bull World Health Organ rogation centre, would another plausible 2005;83:853-6. defence be that Comrade Duch was merely using enhanced interrogation techniques such as “waterboarding” since indeed, apart from being a part of the Khmer Rouge ‘propaganda’ machine, the purpose of S-21 was intelligence gathering and the aim was certainly not to kill the prisoner (execution specifically came separately). T ORTURE Volume 22, Supplementum 1, 2012