Prison doctors have conflicted loyalties everywhere, says Red Cross health in detention chief
Israel's handling of Palestinian hunger strike was 'nearly' by the book, Raed Abu Rabi tells Haaretz.
After many long weeks, the hunger strike by administrative detainees in Israeli prisons ended last Monday. Two days earlier, because of the increasing concern for the lives of the detainees, the International Committee of the Red Cross sent one of its senior physicians, Dr. Raed Abu Rabi, its health in detention coordinator. "I came at a crucial moment," he told Haaretz last week, "when we thought that we had to put things clear to everybody because (the situation) was deteriorating." Dr. Abu Rabi, a Swiss citizen, came to Israel five days after his organization published an exceptional statement asking the Israel Prison Service to hospitalize six of the hunger strikers in a civilian hospital "without delay," and also to allow the strikers to meet with their relatives. The two requests were not fulfilled before the strike ended. As is customary at the Red Cross, the statement itself was published only after the two requests had been raised in closed meetings.
When he arrived, Abu Rabi met with representatives of the Prison Service and of the Israel Medical Association as well as with the strikers, members of their families and Palestinian Authority representatives who are responsible for the prisoners.
Abu Rabi, a native of Nablus who has been with the Red Cross for 18 years, refused to respond to the observation by Haaretz that among the lawyers accompanying the hunger strikers, there was a sense that this time the Israeli authorities were prepared to take the risk that one of the strikers might die.
"One should remember," he said, "that we did not know what they were discussing among themselves - Palestinians and Israeli authorities. There is a committee, daily meetings. It's a kind of negotiation and this is politics and we don't want to be part of it. What we were concerned about and are always concerned about is that we are talking about patients who are detainees, patients in a place of detention. We were pushing the two parties to respect the humanitarian aspect and not to lose lives."
Hunger strikes by prisoners is nothing new but they have become more common in recent years. Abu Rabi said with satisfaction that not only did the hunger strike in Israel end without any deaths, but so have all the hunger strikes that have been held since the beginning of the year. In addition to an approximately two-week hunger strike by 6,000 prisoners in Kyrgyzstan, 399 prisoners have gone on hunger strikes this year in various countries.
According to him, prison authorities have learned to acknowledge the existence of a problem within a prison's walls and how to manage the crises. Abu Rabi credits this in part to the training courses given by the Red Cross and to the guidelines the organization has formulated with various prison authorities.
Doctors' dual loyalty
Abu Rabi, who in his official capacity is well acquainted with the situation in prisons in 82 countries, instructs workshops and enrichment courses and is familiar with the background of every hunger strike, said the problems in prisons are universal. One of the main ones, in his view, is the dual loyalties of doctors in prison facilities: They are ethically obligated on the one hand to the patient and on the other hand to their employer, the prison.
In Israel, it is not the Health Ministry that appoints the medical personnel in the prisons but rather the Public Security Ministry. There is a similar practice in other countries, where it is the justice ministry or interior ministry that appoints the medical personnel. However, in Europe, says Abu Rabi, there is a move toward a change: In France the medical teams are already subordinate to the Health Ministry, which ensures commitment to medical ethics and prisoners' rights more than to a security and policing duty. In other countries such as Spain and England, change is underway. Abu Rabi said the Red Cross is also accompanying a number of Arab countries in a similar process.
The tension between the two loyalties is liable to be exacerbated during a hunger strike in a prison. "We know that a hunger strike is political," said Abu Rabi, "but its consequences are felt in health. We are neither with nor against the people who are doing the hunger strike - but we are with the patient."
The Malta Declaration formulated in 1991 and amended in 2006 sets clear guidelines for doctors' conduct during a hunger strike. The declaration was an initiative by the British Medical Association after the hunger strike by Irish prisoners in 1980, which ended in the deaths of 10 of the strikers. The declaration, which recognizes the prisoners' right to go on hunger strike, establishes that the prisoner must not be force-fed and that the giving of medical care (requested by the prisoner ) must not be made contingent on ending the hunger strike.
"Physicians with dual loyalties," states the declaration, "are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient."
According to Abu Rabi, "The Israel Medical Association confirmed on two occasions that they are fully in support of the Malta Declaration and are advising their doctors to respect it. Honestly, until now what we have seen is that nearly everything is implemented according to the declaration."
Abu Rabi did not specify what he meant by "nearly," and stressed that he is committed to confidentiality in accordance with the Red Cross principle of neutrality.
He identifies with the distress of the doctors who see the hunger striker every day as he grows weaker. "It's huge, heavy pressure for the health staff everywhere in the world to deal with a hunger strike, to see someone who is not eating, getting worse. You are the doctor, you advise him, but you cannot change him. I doubt there is any doctor who is not looking at any detainee as a patient, especially during a hunger strike, but it's difficult and he doesn't know what to do. He has no power to decide to make it stop - and he has to deal with all the consequences.
"I have talked with many doctors around the world," says Abu Rabi, "who say they are unable to sleep. I don't know what to do, they say. If I tell him to eat, he is upset, if I agree with him, it means I agree with the political demand. We don't come to talk only about the detainees but we would like to share this with the doctors who are under huge pressure. We are also for the doctors who are working with the hunger strikers."
In meetings with hunger strikers, the Red Cross doctors try to ascertain whether there is any element forcing them to strike and that this is their own decision, freely made. "In any case," stressed Abu Rabi, "a person who is on hunger strike for 77 days can't be under duress." When strikers are released, Red Cross representatives revisit them to confirm that the strike had been of their own free will. Thus, said Abu Rabi, from every hunger strike he and his organization expand their knowledge and understanding so they can act more effectively in the next hunger strike by prisoners anywhere in the world.