660
19. Schluchter MD, ed. BMDP Statistical Software. Technical report no 86. BMDP 5V: Unbalanced repeated measures. Models with structured covariance matrices. Los Angeles: BMDP Statistical Software, 1988. 20. Krolewski AS, Warram JH, Rand LI, Kahn CR. Epidemiologic approach to the etiology of Type I diabetes and its complications. N Engl J Med 1987; 317: 1390-98. 21. Karjalainen J, Salmela P, Ilonen J, Surgel H-M, Knip M. A comparison of childhood and adult type I diabetes mellitus. N Engl J Med 1989; 320: 881-86.
22. Tuomilehto J, Reunanen A, Lounamaa R, Rewers M, Åkerblom HK, and the DIME Study Group. Differences in epidemiology of diabetes between Finnish males and females, 0-14 years. Diabetologia 1990; 33 (suppl): A197. 23. Shah SC, Malone JI, Simpson NE. A randomized trial of intensive insulin therapy in newly diagnosed insulin-dependent diabetes mellitus. N Engl J Med 1989; 320: 550-54. 24. Diabetic honeymoon: prolonged at a price? Editorial. Lancet 1989; i: 1235-36.
VIEWPOINT
Hospital management of voluntary total fasting among political prisoners
In 1989 20
political detainees, held without trial for to were admitted, on hunger strike, to 32 months, up the Johannesburg Hospital, South Africa. Most were held under the regulations of the State of Emergency (since revoked) and 5 were held incommunicado under section 29 of the Internal Security Act (still in force). Guidelines for ethical management were based on the Declaration of Tokyo, which included the understanding that such detentions constituted mental torture. Conditions of detention in hospital were complicated by police interference in medical and nursing care, and by the chaining of some prisoners to their beds. Doctors are in a unique position to protest against inhuman treatment of prisoners, and should use this authority. Lancet 1991; 337: 660-62.
Introduction Since the first state of emergency in South Africa was declared after the Sharpville shootings in 1960, between 70 000 and 80 000 people have been detained without triaJ.1 Most have been held since 1986 in the recent states of emergency. Early in 1989 nearly 800 of these emergency detainees, imprisoned throughout the country, started a hunger strike (voluntary total fast, VTF). This event was an unprecedented, desperate protest by individuals who had been indefinitely detained without charge or due process of law. At about that time a smaller number of individuals who were held under section 29 of the Internal Security Act (ISA), 1982, also began hunger strikes. Section 29 allows for the indefinite detention of individuals for interrogation. The health care of political prisoners on hunger strike is complicated by medical, ethical, and individual factors?-5 This report summaries the management of emergency and section 29 detainees admitted to Johannesburg Hospital, South Africa, in 1989.
The detainees 15 men (aged 17-37 years, mean 25) who had been held in detention for an average of 16 months (range 4-32) were admitted to Johannesburg Hospital. The fasts were usually begun by detainees sharing cells, who thus had a high level of motivation and mutual support. Reported daily intake
typically consisted of a jug of tap
water, sometimes with a teaspoon of sugar and salt. The fasts lasted for a total of 6-27 days. 5 other detainees who had been held under section 29 of the I SA for up to 7 months were admitted in the next few weeks. Under this law prisoners are held without access to
family, friends, or lawyers, reading or writing materials (except the Bible), or the media; they are, however, visited at least once in 2 weeks by a district surgeon and a magistrate, and by an inspector of detainees. Such prisoners are subjected to sensory deprivation and have made allegations of threats and physical and verbal abuse before the courts, where, nevertheless, confessions and statements by them have often been accepted as evidence. All section 29 detainees had been on hunger strike once or twice before for a few days to about 2 weeks. On every occasion, it was claimed, the authorities had made promises that had led these prisoners to break their fasts, but their material conditions had not changed. On admission they had been fasting for 10-12 days, and fasting continued for up to 23 days in hospital.
Management Ethical considerations and care in
hospital
The medical and nursing staff decided to regard the hunger strikers as ordinary patients, as far as possible. On the basis of the Declaration of Tokyo (1975)6 on the treatment of prisoners, three guidelines were followed. First, the principle of full patient participation and consent in all clinical decisions was applied. Secondly, the ethical provisions with respect to hunger strike (article 5 of the Declaration) and the consequences of VTF were explained objectively. The patients were not pressurised to end their fast, and the confidentiality of all discussions was emphasised. Thirdly, it was decided to try to prevent police interference in patient care. The hospital staff agreed that the conditions of detention, ADDRESS: Department of Medicine, University of the Witwatersrand Medical School, and National and Medical Dental Association Detainees Service, Parktown 2193 Johannesburg, South Africa (Prof W. J. Kalk, FRCP), and Department of Medicine, Coronation Hospital and University of Witwatersrand Medical School, Johannesburg (Dr Yosuf Veriava, FCPSA) Correspondence to Prof W. J Kalk.
661
especially those of the I SA, constituted torture as defined in the Declaration of
Tokyo "...
torture
is defined
as
the
deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, make a confession, or for any other reason". Staff attitudes were also governed by article 1: "The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including conflict and civil strife". Therefore doctors caring for these patients refused to discharge them to prison on recovery, on the grounds that indefinite remand in custody without trial is torture. The board of the Faculty of Medicine of the University of the Witwatersrand later endorsed this policy.’7
Conditions of detention in hospital
prisoners were guarded continuously by two armed policemen; senior officers made frequent inspections. The police also had written instructions that allowed them to impede hospital practices and to enforce prison conditions of detention. Hospital staff continually negotiated these conditions with senior police officers, and several regulations were initially tacitly ignored. Thus radios, newspapers, books, and frequent family visits, all judged therapeutic, were allowed. Once the patients had recovered from the effects of VTF, occupational therapy was arranged. Most police officers behaved correctly and professionally, but those who did not (generally non-commissioned officers, but also an officer in the security police) generated considerable friction, usually by the seemingly capricious enforcement of regulations. Relations between the police and hospital staff deteriorated after a few prisoners had escaped from another hospital, once it became known that the emergency prisoners were to be released from custody, and with the arrival of the section 29 detainees, who were regarded as serious security risks. Relations reached a nadir with three developments. The police decreed that the doctor-patient relationship was no longer privileged and that a policeman All
had
to
be present
at
all doctor attendances
on
detainee-
patients (under the I SA medical visits to detainees are privileged). A week later, after vehement protest, this regulation was rescinded. The police attempted to restrict nursing contact with the detainee-patients. Protest to senior officers ended this interference. Patients were denied personal privacy-the prisoner had always to be in direct sight of a policeman. The rationale offered for this was the possibility of suicide among these patients. The culmination of these events was the chaining of 2 prisoners to their beds "to prevent escape". The regional Divisional Commissioner of Police disclaimed authority to remove the chains. A week later the shackles were removed without comment. During the ensuing weeks in hospital these prisoners, who were now awaiting trial, were arbitrarily chained or handcuffed to their beds for short periods, or were threatened with chaining. Objections to this practice, lodged with the Ministers of Law and Order and of Health and Population Development proved fruitless. The Minister of Law and Order justified chaining by citing such practice in the USA,8 and by alleging that our patients were "murderers or potential murderers", although their cases were subjudice.
Ending of hunger strikes Once the continuing hunger strike among emergency detainees had spread to hundreds of people, the Minister of Law and Order agreed to see legal representatives and to review the need for detention. Thus nearly all prisoners were released from detention, many with greatly restricted freedom. Some prisoners broke their fast soon after admission; others did so only when they had been assured by their lawyers of their release. Management of the section 29 detainees was far more difficult than the remand prisoners. They refused to eat until they were either charged or released. District surgeons were informed of the prisoners’ condition and were requested to urge the police to complete their investigation rapidly, to prevent patients’ further deterioration. In most cases these appeals seemed to have no effect. In one instance, a direct appeal to the Attorney General was unsuccessful. What did succeed in hastening official responses was a medical report indicating that the detainee-patients’ condition had seriously deteriorated, and that the fast was entering the stage of potential complications, usually during the fourth week.3 Several patients continued their fasts for three additional weeks, before such action could be taken. These periods of waiting proved highly stressful for the patients and for the health care team, whose efforts to influence the authorities proved futile. Only when the detainee-patients had been formally charged in court, with an automatic change in their section 29 status, did any individual agree to eat. On one previous occasion after such a report the authorities formulated charges (later dropped) and convened a court in the hospital ward, within a few hours. 3 patients remained in hospital for several months after recovery, for treatment of depression. Bail had been refused and psychiatric assessment indicated a risk of relapse if they were returned to prison. At the time of formal trial, the courts ordered the imprisonment of 2 detainees, against medical and psychiatric advice. The remaining patient voluntarily agreed to return to prison to stand trial. two to
Discussion The scale of the hunger strikes and the large numbers of prisoners admitted to public hospitals confronted many health workers with situations that they had not experienced. Through their patients, they were directly exposed to the damaging effects of prolonged detention without trial, and of solitary confinement. Previously only the few doctors caring for detainee-prisoners had witnessed the destructive effects of such practices; their public silence on these issues raises the question of their complicity in -
torture.9 The ethical principles in the Declaration of Tokyo were introduced in the hospital regimen with the admission of emergency detainees, whose fasts soon ended. The guidelines proved invaluable in the management of hunger strikers held under section 29, who had suffered extreme privation and who had become very ill during their second or third VTF. The Faculty of Medicine’s acceptance of working guidelines for the management of these prisoners..’ and the condemnation ofdetentions by virtually all independent medical organisations provided additional moral support for hospital staff. The legal conditions of detention without trial in South Africa are in conflict with medical ethics. These have been subverted by the legalisation of unacceptable, unethical
662
practices, to which there must be open and resolute objections." The experience at Johannesburg Hospital has clear messages for all health workers who have to care for such prisoners. The carers’ prime responsibility is to the patient. They must insist on complete clinical independence, resist attempts to undermine it, and withstand the development of a "security mentality". To gain the detainee-patient’s trust, he must be convinced that the doctor is working in the patients’ best interests. Health personnel should not be, and not be perceived to be, subservient to the security forces. Doctors should be prepared to appeal to the courts if the health of their patients is threatened." There are still some 100 section 29 detainees in South Africa, and new hunger strikes have started. Doctors are in a unique position to help to alleviate some of the worst aspects of detention without trial. They, and all other health workers, should be in the forefront of public efforts to expose harmful practices and to create mechanisms to prevent torture and other forms of inhumane and degrading treatment of prisoners.s
OCCASIONAL
REFERENCES 1. Human Rights Commission. Weekly Mail: March 3, 1989. 2. The handbook of medical ethics. London: British Medical Association 1981. 3. Frommel D, Grautier M, Questiaux E, Schworzenberg L. Voluntary total fasting: a challenge for the medical community. Lancet 1984, i: 1451-52. 4. Editorial. Shackled, shameful, and shoddy. Lancet 1988; ii: 1402-04. 5. Harding TW. Prevention of torture and inhuman or degrading treatment: medical implications of a new European convention. Lancet 1989, i: 1191-93. 6. Declaration of Tokyo. Guidelines for medical doctors concerning
torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. World Med J 1975; 22: 87. 7. Voluntary total fasting: ethical-medical considerations. Faculty of Medicine, University of the Witwatersrand, Johannesburg, 1989. Document S89/278. 8. Natal Mercury Oct 28, 1989. 9. Veriava Y. Torture and the medical profession in South Africa: complicity or concern. Critical Hlth 1989; 26: 39-52. 10. Levin J. Intervention in detention: psychological, ethical and professional aspects. S Afr Med J 1988; 74: 460-63. 11. Y Mohamed vs the Minister of Law and Order and the Commissioner of Police (case no 90/24318). Johannesburg, September-October, 1990.
BOOK
Drugs and demagogues
"Along with much of the world, Canada has been swept a ’War on Drugs’ that clouds its values, brutalizes its actions, and, in the end, exacerbates the problems it was
into
intended to solve." So opens the introduction to Alexander’s Peaceful Measures-a disturbing and thought-provoking analysis of modern approaches to the social problems of psychoactive drug use. It is no news that a state of war exists against illicit drugs, declared by Canada’s southern neighbour and waged throughout the world with a commitment that fully justifies the most bellicose metaphor. But how much has the associated propaganda penetrated our thinking and subverted rational approaches to the very real problems and suffering associated with drug use? This war has been waged for the past two centuries; the drug disapproved of may have changed several times but the war-like measures, and especially the propaganda, have been remarkably constant. Alexander argues that, in stark contrast to normal peacetime practice, these measures include: "massive application of military and civil force; consistent use of war language by drug-policy officials; imposition of compulsory treatment on drug users who have not been convicted of crimes; promulgation of wildly exaggerated anti-drug propaganda; imposition of harsh criminal penalties, including death, that are normally reserved for murder and treason; abrogation of normal protection of civil rights (as under martial law); public and official support for people who inform on their own families; support for violence, including torture, in the third world; use of economic levers against the third world that will cause the starvation of large numbers of people; widespread use of spies and agents provocateurs by enforcement agencies; imposition of suffering not only on drug traffickers and users, but also on police and medical patients".
These are not the wild claims of an anti-war propagandist but the careful researches of an academic psychologist. Much of the book is a review of scientific research into drug use and addiction, with chapters devoted to heroin and cocaine and, by contrast, to aspirin-like drugs. Alexander claims, with many references, that there is no drug epidemic in Canada (or anywhere else), that most drug use is non-addictive, and that many familiar terms, including addiction, drug abuse, and physical dependence, are "fanciful spectres created to justify the drug war". The most striking contrast with "medicinal" drugs is not that salicylates (for example) cannot be abused and create dependence, but that they have escaped the label of a drug of abuse. Thus the social and medical problems associated with overuse of salicylates are handled in a greatly different, far less socially disruptive, manner. Contrast this with the introduction of triplicate prescription for benzodiazepines in New York State-a striking recent example of legislation by which countless suffering people may be deprived of medication of proven efficacy because of an arbitrary decision that the drugs which could help them may cause addiction, whatever the overall risk-benefit ratio. As the intensity of the drug war has increased, so in turn has promulgation of what Alexander calls the "disease criminal model" of addiction. This concept has striking weaknesses that are readily acknowledged by academics and professionals; but for propaganda, they would have led to rebuttal of this model long ago. For example, there is little evidence that exposure alone causes addiction, many ADDRESS.
Regional Treatment Centre (Ontario), Kingston Penitentiary, Kingston, Ontario K7L4V7, Canada (G N Conacher, MRCPsych).
19. Schluchter MD, ed. BMDP Statistical Software. Technical report no 86. BMDP 5V: Unbalanced repeated measures. Models with structured covariance matrices. Los Angeles: BMDP Statistical Software, 1988. 20. Krolewski AS, Warram JH, Rand LI, Kahn CR. Epidemiologic approach to the etiology of Type I diabetes and its complications. N Engl J Med 1987; 317: 1390-98. 21. Karjalainen J, Salmela P, Ilonen J, Surgel H-M, Knip M. A comparison of childhood and adult type I diabetes mellitus. N Engl J Med 1989; 320: 881-86.
22. Tuomilehto J, Reunanen A, Lounamaa R, Rewers M, Åkerblom HK, and the DIME Study Group. Differences in epidemiology of diabetes between Finnish males and females, 0-14 years. Diabetologia 1990; 33 (suppl): A197. 23. Shah SC, Malone JI, Simpson NE. A randomized trial of intensive insulin therapy in newly diagnosed insulin-dependent diabetes mellitus. N Engl J Med 1989; 320: 550-54. 24. Diabetic honeymoon: prolonged at a price? Editorial. Lancet 1989; i: 1235-36.
VIEWPOINT
Hospital management of voluntary total fasting among political prisoners
In 1989 20
political detainees, held without trial for to were admitted, on hunger strike, to 32 months, up the Johannesburg Hospital, South Africa. Most were held under the regulations of the State of Emergency (since revoked) and 5 were held incommunicado under section 29 of the Internal Security Act (still in force). Guidelines for ethical management were based on the Declaration of Tokyo, which included the understanding that such detentions constituted mental torture. Conditions of detention in hospital were complicated by police interference in medical and nursing care, and by the chaining of some prisoners to their beds. Doctors are in a unique position to protest against inhuman treatment of prisoners, and should use this authority. Lancet 1991; 337: 660-62.
Introduction Since the first state of emergency in South Africa was declared after the Sharpville shootings in 1960, between 70 000 and 80 000 people have been detained without triaJ.1 Most have been held since 1986 in the recent states of emergency. Early in 1989 nearly 800 of these emergency detainees, imprisoned throughout the country, started a hunger strike (voluntary total fast, VTF). This event was an unprecedented, desperate protest by individuals who had been indefinitely detained without charge or due process of law. At about that time a smaller number of individuals who were held under section 29 of the Internal Security Act (ISA), 1982, also began hunger strikes. Section 29 allows for the indefinite detention of individuals for interrogation. The health care of political prisoners on hunger strike is complicated by medical, ethical, and individual factors?-5 This report summaries the management of emergency and section 29 detainees admitted to Johannesburg Hospital, South Africa, in 1989.
The detainees 15 men (aged 17-37 years, mean 25) who had been held in detention for an average of 16 months (range 4-32) were admitted to Johannesburg Hospital. The fasts were usually begun by detainees sharing cells, who thus had a high level of motivation and mutual support. Reported daily intake
typically consisted of a jug of tap
water, sometimes with a teaspoon of sugar and salt. The fasts lasted for a total of 6-27 days. 5 other detainees who had been held under section 29 of the I SA for up to 7 months were admitted in the next few weeks. Under this law prisoners are held without access to
family, friends, or lawyers, reading or writing materials (except the Bible), or the media; they are, however, visited at least once in 2 weeks by a district surgeon and a magistrate, and by an inspector of detainees. Such prisoners are subjected to sensory deprivation and have made allegations of threats and physical and verbal abuse before the courts, where, nevertheless, confessions and statements by them have often been accepted as evidence. All section 29 detainees had been on hunger strike once or twice before for a few days to about 2 weeks. On every occasion, it was claimed, the authorities had made promises that had led these prisoners to break their fasts, but their material conditions had not changed. On admission they had been fasting for 10-12 days, and fasting continued for up to 23 days in hospital.
Management Ethical considerations and care in
hospital
The medical and nursing staff decided to regard the hunger strikers as ordinary patients, as far as possible. On the basis of the Declaration of Tokyo (1975)6 on the treatment of prisoners, three guidelines were followed. First, the principle of full patient participation and consent in all clinical decisions was applied. Secondly, the ethical provisions with respect to hunger strike (article 5 of the Declaration) and the consequences of VTF were explained objectively. The patients were not pressurised to end their fast, and the confidentiality of all discussions was emphasised. Thirdly, it was decided to try to prevent police interference in patient care. The hospital staff agreed that the conditions of detention, ADDRESS: Department of Medicine, University of the Witwatersrand Medical School, and National and Medical Dental Association Detainees Service, Parktown 2193 Johannesburg, South Africa (Prof W. J. Kalk, FRCP), and Department of Medicine, Coronation Hospital and University of Witwatersrand Medical School, Johannesburg (Dr Yosuf Veriava, FCPSA) Correspondence to Prof W. J Kalk.
661
especially those of the I SA, constituted torture as defined in the Declaration of
Tokyo "...
torture
is defined
as
the
deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, make a confession, or for any other reason". Staff attitudes were also governed by article 1: "The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including conflict and civil strife". Therefore doctors caring for these patients refused to discharge them to prison on recovery, on the grounds that indefinite remand in custody without trial is torture. The board of the Faculty of Medicine of the University of the Witwatersrand later endorsed this policy.’7
Conditions of detention in hospital
prisoners were guarded continuously by two armed policemen; senior officers made frequent inspections. The police also had written instructions that allowed them to impede hospital practices and to enforce prison conditions of detention. Hospital staff continually negotiated these conditions with senior police officers, and several regulations were initially tacitly ignored. Thus radios, newspapers, books, and frequent family visits, all judged therapeutic, were allowed. Once the patients had recovered from the effects of VTF, occupational therapy was arranged. Most police officers behaved correctly and professionally, but those who did not (generally non-commissioned officers, but also an officer in the security police) generated considerable friction, usually by the seemingly capricious enforcement of regulations. Relations between the police and hospital staff deteriorated after a few prisoners had escaped from another hospital, once it became known that the emergency prisoners were to be released from custody, and with the arrival of the section 29 detainees, who were regarded as serious security risks. Relations reached a nadir with three developments. The police decreed that the doctor-patient relationship was no longer privileged and that a policeman All
had
to
be present
at
all doctor attendances
on
detainee-
patients (under the I SA medical visits to detainees are privileged). A week later, after vehement protest, this regulation was rescinded. The police attempted to restrict nursing contact with the detainee-patients. Protest to senior officers ended this interference. Patients were denied personal privacy-the prisoner had always to be in direct sight of a policeman. The rationale offered for this was the possibility of suicide among these patients. The culmination of these events was the chaining of 2 prisoners to their beds "to prevent escape". The regional Divisional Commissioner of Police disclaimed authority to remove the chains. A week later the shackles were removed without comment. During the ensuing weeks in hospital these prisoners, who were now awaiting trial, were arbitrarily chained or handcuffed to their beds for short periods, or were threatened with chaining. Objections to this practice, lodged with the Ministers of Law and Order and of Health and Population Development proved fruitless. The Minister of Law and Order justified chaining by citing such practice in the USA,8 and by alleging that our patients were "murderers or potential murderers", although their cases were subjudice.
Ending of hunger strikes Once the continuing hunger strike among emergency detainees had spread to hundreds of people, the Minister of Law and Order agreed to see legal representatives and to review the need for detention. Thus nearly all prisoners were released from detention, many with greatly restricted freedom. Some prisoners broke their fast soon after admission; others did so only when they had been assured by their lawyers of their release. Management of the section 29 detainees was far more difficult than the remand prisoners. They refused to eat until they were either charged or released. District surgeons were informed of the prisoners’ condition and were requested to urge the police to complete their investigation rapidly, to prevent patients’ further deterioration. In most cases these appeals seemed to have no effect. In one instance, a direct appeal to the Attorney General was unsuccessful. What did succeed in hastening official responses was a medical report indicating that the detainee-patients’ condition had seriously deteriorated, and that the fast was entering the stage of potential complications, usually during the fourth week.3 Several patients continued their fasts for three additional weeks, before such action could be taken. These periods of waiting proved highly stressful for the patients and for the health care team, whose efforts to influence the authorities proved futile. Only when the detainee-patients had been formally charged in court, with an automatic change in their section 29 status, did any individual agree to eat. On one previous occasion after such a report the authorities formulated charges (later dropped) and convened a court in the hospital ward, within a few hours. 3 patients remained in hospital for several months after recovery, for treatment of depression. Bail had been refused and psychiatric assessment indicated a risk of relapse if they were returned to prison. At the time of formal trial, the courts ordered the imprisonment of 2 detainees, against medical and psychiatric advice. The remaining patient voluntarily agreed to return to prison to stand trial. two to
Discussion The scale of the hunger strikes and the large numbers of prisoners admitted to public hospitals confronted many health workers with situations that they had not experienced. Through their patients, they were directly exposed to the damaging effects of prolonged detention without trial, and of solitary confinement. Previously only the few doctors caring for detainee-prisoners had witnessed the destructive effects of such practices; their public silence on these issues raises the question of their complicity in -
torture.9 The ethical principles in the Declaration of Tokyo were introduced in the hospital regimen with the admission of emergency detainees, whose fasts soon ended. The guidelines proved invaluable in the management of hunger strikers held under section 29, who had suffered extreme privation and who had become very ill during their second or third VTF. The Faculty of Medicine’s acceptance of working guidelines for the management of these prisoners..’ and the condemnation ofdetentions by virtually all independent medical organisations provided additional moral support for hospital staff. The legal conditions of detention without trial in South Africa are in conflict with medical ethics. These have been subverted by the legalisation of unacceptable, unethical
662
practices, to which there must be open and resolute objections." The experience at Johannesburg Hospital has clear messages for all health workers who have to care for such prisoners. The carers’ prime responsibility is to the patient. They must insist on complete clinical independence, resist attempts to undermine it, and withstand the development of a "security mentality". To gain the detainee-patient’s trust, he must be convinced that the doctor is working in the patients’ best interests. Health personnel should not be, and not be perceived to be, subservient to the security forces. Doctors should be prepared to appeal to the courts if the health of their patients is threatened." There are still some 100 section 29 detainees in South Africa, and new hunger strikes have started. Doctors are in a unique position to help to alleviate some of the worst aspects of detention without trial. They, and all other health workers, should be in the forefront of public efforts to expose harmful practices and to create mechanisms to prevent torture and other forms of inhumane and degrading treatment of prisoners.s
OCCASIONAL
REFERENCES 1. Human Rights Commission. Weekly Mail: March 3, 1989. 2. The handbook of medical ethics. London: British Medical Association 1981. 3. Frommel D, Grautier M, Questiaux E, Schworzenberg L. Voluntary total fasting: a challenge for the medical community. Lancet 1984, i: 1451-52. 4. Editorial. Shackled, shameful, and shoddy. Lancet 1988; ii: 1402-04. 5. Harding TW. Prevention of torture and inhuman or degrading treatment: medical implications of a new European convention. Lancet 1989, i: 1191-93. 6. Declaration of Tokyo. Guidelines for medical doctors concerning
torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. World Med J 1975; 22: 87. 7. Voluntary total fasting: ethical-medical considerations. Faculty of Medicine, University of the Witwatersrand, Johannesburg, 1989. Document S89/278. 8. Natal Mercury Oct 28, 1989. 9. Veriava Y. Torture and the medical profession in South Africa: complicity or concern. Critical Hlth 1989; 26: 39-52. 10. Levin J. Intervention in detention: psychological, ethical and professional aspects. S Afr Med J 1988; 74: 460-63. 11. Y Mohamed vs the Minister of Law and Order and the Commissioner of Police (case no 90/24318). Johannesburg, September-October, 1990.
BOOK
Drugs and demagogues
"Along with much of the world, Canada has been swept a ’War on Drugs’ that clouds its values, brutalizes its actions, and, in the end, exacerbates the problems it was
into
intended to solve." So opens the introduction to Alexander’s Peaceful Measures-a disturbing and thought-provoking analysis of modern approaches to the social problems of psychoactive drug use. It is no news that a state of war exists against illicit drugs, declared by Canada’s southern neighbour and waged throughout the world with a commitment that fully justifies the most bellicose metaphor. But how much has the associated propaganda penetrated our thinking and subverted rational approaches to the very real problems and suffering associated with drug use? This war has been waged for the past two centuries; the drug disapproved of may have changed several times but the war-like measures, and especially the propaganda, have been remarkably constant. Alexander argues that, in stark contrast to normal peacetime practice, these measures include: "massive application of military and civil force; consistent use of war language by drug-policy officials; imposition of compulsory treatment on drug users who have not been convicted of crimes; promulgation of wildly exaggerated anti-drug propaganda; imposition of harsh criminal penalties, including death, that are normally reserved for murder and treason; abrogation of normal protection of civil rights (as under martial law); public and official support for people who inform on their own families; support for violence, including torture, in the third world; use of economic levers against the third world that will cause the starvation of large numbers of people; widespread use of spies and agents provocateurs by enforcement agencies; imposition of suffering not only on drug traffickers and users, but also on police and medical patients".
These are not the wild claims of an anti-war propagandist but the careful researches of an academic psychologist. Much of the book is a review of scientific research into drug use and addiction, with chapters devoted to heroin and cocaine and, by contrast, to aspirin-like drugs. Alexander claims, with many references, that there is no drug epidemic in Canada (or anywhere else), that most drug use is non-addictive, and that many familiar terms, including addiction, drug abuse, and physical dependence, are "fanciful spectres created to justify the drug war". The most striking contrast with "medicinal" drugs is not that salicylates (for example) cannot be abused and create dependence, but that they have escaped the label of a drug of abuse. Thus the social and medical problems associated with overuse of salicylates are handled in a greatly different, far less socially disruptive, manner. Contrast this with the introduction of triplicate prescription for benzodiazepines in New York State-a striking recent example of legislation by which countless suffering people may be deprived of medication of proven efficacy because of an arbitrary decision that the drugs which could help them may cause addiction, whatever the overall risk-benefit ratio. As the intensity of the drug war has increased, so in turn has promulgation of what Alexander calls the "disease criminal model" of addiction. This concept has striking weaknesses that are readily acknowledged by academics and professionals; but for propaganda, they would have led to rebuttal of this model long ago. For example, there is little evidence that exposure alone causes addiction, many ADDRESS.
Regional Treatment Centre (Ontario), Kingston Penitentiary, Kingston, Ontario K7L4V7, Canada (G N Conacher, MRCPsych).
