January 20, 2016KR OnlineNonfiction

What Do You Do to the Enfermos?

The Senate Intelligence Committee’s report on the CIA’s use of torture, titled the Committee Study of the Central Intelligence Agency’s Detention and Interrogation Program, contained 208 uses of the word “medical.”

[The CIA’s Office of Medical Services, OMS] completed draft guidelines on the use of the CIA’s enhanced interrogation techniques, specifically addressing the waterboard interrogation technique. These guidelines were sent to the medical personnel at the detention site. The guidelines included a warning that the risk of the waterboard was “directly related to number of exposures and may well accelerate as exposures increase,” that concerns about cumulative effects would emerge after three to five days, and that there should be an upper limit on the total number of waterboard exposures, “perhaps 20 in a week.”

I took a week off after my son was born, and we kept my three-year-old daughter home from day care that week, too. On the morning of my first day back at work, my daughter watched me making lunch and asked me why I had to go back to work. “Porque yo soy un doctor,” I said. “Y tengo que ayudar los enfermos.” I spoke to her in Spanish, because my wife is Mexican-American and we’re raising our children to be bilingual. Perhaps my answer might have been more nuanced and therefore more accurate if I’d used English.

During these sessions, KSM (Khalid Shaykh Muhammad) ingested a significant amount of water. CIA records state that KSM’s “abdomen was somewhat distended and he expressed water when the abdomen was pressed.” KSM’s gastric contents were so diluted by water that the medical officer present was “not concerned about regurgitated gastric acid damaging KSM’s esophagus.” The officer was, however, concerned about water intoxication and dilution of electrolytes and requested that the interrogators use saline in future waterboarding sessions. The medical officer later wrote to OMS that KSM was “ingesting and aspiration [sic] a LOT of water,” and that “[i]n the new technique we are basically doing a series of near drownings.”

The only version of Anton Chekhov’s death that I know is the one that Raymond Carver relayed in his story “Errand.” Chekhov was receiving hospice care in a luxury hotel in southern Germany, and his physician was summoned late in the night by Chekhov’s wife, who reported that her husband was becoming more short of breath and coughing up blood. When the physician arrived, he saw that Chekhov was nearing his end; oxygen might help, but that would have taken nearly five hours to retrieve, and by then Chekhov would be gone. The physician picked up the phone and dialed the hotel’s kitchen, ordering up a bottle of champagne with three glasses. Chekhov drained his glass, complimented the champagne, and then passed away. When discussing the physician’s decision to order champagne instead of oxygen for the dying Chekhov, Carver wrote, “It was one of those rare moments of inspiration that can easily enough be overlooked later on, because the action is so entirely appropriate it seems inevitable.”

In response to [Acting Assistant Attorney General Steven] Bradbury’s query as to when edema or shackling would become painful as a result of standing sleep deprivation, the CIA responded, “[w]e have not observed this phenomenon in the interrogations performed to date, and have no reason to believe on theoretical grounds that edema or shackling would be more painful,” provided the shackles are maintained with “appropriate slack” and “interrogators follow medical officers’ recommendation to end standing sleep deprivation and use an alternate technique when the medical officer judges that edema is significant in any way.” The CIA response added that the medical officers’ recommendations “are always followed,” and that “[d]etainees have not complained about pain from edema.”

Harold Roberts, whose research helped decode the clotting cascade (the series of proteins in our bodies that prevent us from bleeding out), was an emeritus professor at the University of North Carolina when I was a resident in internal medicine. He gave grand rounds about his discovery, years ago, of a crucial clotting factor; his lecture relayed the story of the patient, a young boy, whose genetic predisposition to bleeding keyed Roberts in to his breakthrough finding. When the boy died, Roberts told us, his mother asked if Roberts and his colleagues could attend the funeral wearing their white coats. Roberts, nearing age ninety, confessed that he’d viewed the boy and his mother as more than just a patient and his family, so her request unsettled him. The boy and his mother viewed Roberts solely as a doctor, and now he was the doctor of a boy whose life he was unable to save.

A different CIA physician assistant, who had not been involved in the previous examinations determining the need for the detainees to avoid weight bearing, stated that it was his “opinion” that Abu Hazim’s and Abd al-Karim’s injuries were “sufficiently healed to allow being placed in the standing sleep deprivation position.” He further reported that he had “consulted with [CIA’s Office of Medical Services] via secure phone and OMS medical officer concurred in this assessment.” CIA Headquarters approved the use of standing sleep deprivation against both detainees shortly thereafter.

In medical school, during my surgery rotation, I was expected to report for service rounds at five a.m. All of the patients on the floors needed to be rounded on prior to the OR cases, which began at seven a.m. Therefore, to pre-round on my patients, I arrived at the hospital at four a.m. I figured this was a good time to experiment with growing out my hair and not shaving. Midway through the rotation, a cardiothoracic surgeon suggested I get a haircut and shave. He did this in private; it was not a rebuke, rather a suggestion. He advised, “Your patients want you to look and act like the doctors on television.” Indeed, he looked and acted like a doctor on television.

Prior to the third waterboard session of that calendar day, the onsite medical officer raised concerns that the waterboard session—which would be the fourth in 14 hours—would exceed the limits included in draft OMS guidelines that had been distributed the previous afternoon. Those draft guidelines stated that up to three waterboard sessions in a 24 hour period was acceptable. At the time, KSM had been subjected to more than 65 applications of water during the four waterboarding sessions between the afternoon of March 12, 2003, and the morning of March 13, 2003. In response to a request for approval from the chief of Base, Counterterrorism Center (CTC) attorney ____ assured detention site personnel that the medical officer “is incorrect that these guidelines have been approved and/or fully coordinated.” ____ sent an email to the detention site authorizing the additional waterboarding session. Despite indications from ____ that the detention site personnel would receive a formal authorizing cable, no such authorization from CIA Headquarters was provided. At the end of the day, the medical officer wrote ____ OMS that “[t]hings are slowly evolving form [sic] OMS being viewed as the institutional conscience and the limiting factor to the ones who are dedicated to maximizing the benefit in a safe manner and keeping everyone’s butt out of trouble.”

One of the diseases I specialize in, granulomatosis with polyangiitis, used to be called Wegener’s granulomatosis. The name was changed a few years ago upon the discovery that Wegener was a military doctor for the Nazi party and may have participated in human experiments.

Later, after one of Abu Zubaydah’s eyes began to deteriorate, CIA officers requested a test of Abu Zubaydah’s other eye, stating that the request was “driven by our intelligence needs . . . [w]e have a lot riding upon his ability to see, read and write.”

On the way to her day care, my daughter asked me why there were so many cars on the road. “Todos van a la estación de tren,” I answered in Spanish to her English question. She is old enough, and speaks Spanish well enough, to tire easily of my attempts at speaking a foreign language—so she typically saves her Spanish for her native-speaking mother and talks to me in English or, more often, Spanglish. “They’re going to the ciudad?” she asked. “Si,” I answered, “y tu daddy también, después I drop you off.” “You work in the ciudad?” she asked rhetorically. Not expecting an answer to that question, she followed up with a more difficult one: “What do you do to the enfermos?”

In an email to OMS leadership entitled “So it begins,” a medical officer wrote: “The sessions accelerated rapidly progressing quickly to the water board after large box, walling, and small box periods. [Abu Zubaydah] seems very resistant to the water board. Longest time with the cloth over his face so far has been 17 seconds. This is sure to increase shortly. NO useful information so far . . . He did vomit a couple of times during the water board with some beans and rice. It’s been 10 hours since he ate so this is surprising and disturbing. We plan to only feed Ensure for a while now. I’m head[ing] back for another water board session.”

When I lived in Greece, I made extra money giving private English lessons to an elderly couple. We sat in their living room, an hour at a time, making small talk over Johnny Walker Red Label and salted peanuts. They were planning a trip to Canada for their nephew’s wedding, and then some sightseeing after the wedding, and so they wanted to work on their English in anticipation of the trip. They had no children but they adored their cat, Iatros. I asked about the origin of his name. “It means doctor,” the husband said. “I know,” I said, “but why did you name your cat Doctor?” The wife, whose English was stronger than the husband’s, said, “Cats are supposed to improve your health.” “To make you feel better,” the husband chimed in through a mouthful of peanuts.

Andrew Bomback is a physician and writer. He is the author of You’re Too Wonderful To Die, a novel (Flame Books, 2007), and Chronic Kidney Disease and Hypertension Essentials, a textbook (Jones & Bartlett Learning, 2010). His essays have recently appeared or are forthcoming in Hobart, Essay Daily, Harlequin, BULL, For Every Year, Pharos, New England Journal of Medicine, and Journal of the American Medical Association.