Preventing Torture in Nepal: A Public Health and Human Rights Intervention
In this article we address torture in military and police organizations as a public health and human rights challenge that needs to be addressed through multiple levels of intervention. While most mental health approaches focus on treating the harmful effects of such violence on individuals and communities, the goal of the project described here was to develop a primary prevention strategy at the institutional level to prevent torture from occurring in the first place. Such an approach requires understanding and altering the conditions that cause and sustain “atrocity producing situations” (Lifton 2000, 2004). Given the persistence of torture across the world and its profound health consequences, this is an increasingly important issue in global health and human rights.
KeywordsTorture Public health Primary prevention Systemic approaches Nepal
Torture has been a significant concern for both health and human rights, with the former, focusing principally on the health impacts on victims and the latter on the political, legal, and social dimensions of torture and the need to put in place legal and political sanctions or constraints that will prevent torture.1 A structural public health approach, which locates the identified problem within a broader context of systemic causal factors and seeks both to identify those factors at multiple levels and then design interventions that can alter them, provides a potentially useful bridge between these fields and suggests a number of ways in which health professionals can work collaboratively with human rights organizations in the treatment and prevention of torture. The potential advantage of this approach is that it provides a framework where the different causal dimensions (political, legal, social, organizational, individual) and the impacts of torture can be integrated and responses to these different dimensions coordinated.
As an entry point, we might consider three levels of intervention recognized in public health approaches: primary prevention strategies, which emphasize health promotion, reduced risks, and other health protective measures; secondary prevention strategies, which focus on detecting early signs of difficulty, swift treatment, and reducing impact; and tertiary strategies, which include both therapeutic and rehabilitative measures implemented once a serious mental health problem is established. Like any systemic health intervention, treatment is not just for the identified patient or victim but the system as a whole. Before discussing the types of strategies that have been employed at each level, we briefly survey the principle impacts of torture, moving out from the direct victim to its broader effects.
The physical effects of torture on its direct victims include hearing loss from beating on the ears, scarring from electrical torture, occult and bone fractures, spine injuries, paraplegia as a result of beating or being hung by one extremity, and sexual dysfunction from genital torture (Goldfeld et al. 1988). Because the physical effects of torture make it easier to prove, there has been a shift, particularly in democracies, to utilizing forms of torture that leave no visible scars such as sensory and sleep deprivation, extended periods of isolation, and exploitation of phobias (Rejali 2007). The most common forms of torture reported in Nepal have been severe beating, verbal sexual humiliation, falanga (beating of the soles of the feet), being tied down, suspension, nutritional and hygienic deprivation, and forced acts in violation of one’s cultural and religious norms (Sharma and Van Ommeren 1998).
The psychological problems most commonly reported by torture survivors in uncontrolled studies reviewed by Goldfeld et al. (1988) and cited by Basoglu et al. (2001) include (a) psychological symptoms (anxiety, depression, irritability or aggressiveness, emotional lability, self-isolation or social withdrawal), (b) cognitive symptoms (confusion or disorientation, impaired memory and concentration, impaired reading ability), and (c) neurovegetative symptoms (lack of energy, insomnia, nightmares, sexual dysfunction). Controlled studies find that torture survivors had significantly more lifetime post-traumatic stress disorder (PTSD) than control groups (Basoglu et al. 1994). Similar findings on the impact of torture on mental health have been reported in Nepal, including elevated rates of PTSD, anxiety, depression, and somatic complaints among tortured Nepali-speaking Bhutanese refugees (Shrestha et al. 1998). Research with Nepali torture survivors has also shown a relation to disability in daily functioning (Tol et al. 2007).
Trauma and loss also impact the victim’s family and immediate community. Victims may experience a reduced capacity to function as parents, spouses, providers, and as active members of a broader economic and social community (Ritterman 1987, 1990). The parents feel paralyzed when they are unable to protect their children (Ortiz 2001). When a family member is tortured, the whole family often suffers from the emotional impact (Woodcock 1995). Insofar as torture is practiced as a form of political repression, it leaves whole communities in a heightened state of fear and anxiety.
Torture also has consequences for perpetrators, security organizations, and the families and communities of members of the security sector. The limited research on the impact of torture on perpetrators indicates that they experience increased levels of PTSD, depression, anxiety, and substance abuse (Kohrt et al. 2008; MacNair 2001; Moscardino et al. 2012). Mental health consequences include domestic and sexual violence and child abuse (Evans et al. 2007; MacNair 2001). As a result of “bearing witness to perceived immoral acts, failure to stop such actions, or perpetration of immoral acts” in particular those that are inhumane and that bring about pain and suffering, perpetrators also experience “moral injury,” defined as the “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner” (Drescher et al. 2011, 2).
Beyond individuals and immediate others, torture injures the entire population’s social, cultural, and physical ecologies, causing “collective trauma” (Saul 2013). Torture has a pervasive impact on the family, friends, and the victim’s entire social network. It often leads to severe ruptures between the police/security organizations and the communities they are supposed to be serving. The terrors of political violence, including torture, may leave populations suffering from a chronic sense of fear, hopelessness, and despair as documented by Somasundaram (Somasundaram 2010, 2014) in reference to the effects of collective trauma due the civil wars in Sri Lanka.
Traditionally, the principal approach to torture adopted within the field of mental health has been to focus on tertiary or more recently on secondary prevention, that is, on alleviating the impact on the victim. Since torture is an instrument of political violence intended to radically disempower its victims, break their spirit, and leave them as warnings of the consequences of opposition to an oppressed population, treatment cannot focus merely on the removal of symptoms. In Nepal, where this study took place, torture reached its height during the armed conflict between the Maoists and Nepali security forces between 1996 and 2006 and was used not only to seek information but as a form of political control and intimidation (Office of the High Commissioner for Human Rights 2012; Sharma 2014). Even well after the cessation of the conflict the use of torture continues to be highly politicized and to target vulnerable groups (Terai Human Rights Defenders’ Alliance [THRD] 2015). In fact, to merely pathologize the effects of torture threatens to minimize the political and moral context in which such abuse takes place. Treatment must begin with an acknowledgement of the torturer’s cruelty and the impact of torture. Such effects as social withdrawal, psychic numbing, and intense grief need to be seen as normal coping responses to an abnormal situation. Torture, like other traumas, robs a person of their sense of power and control, thus the central principle of recovery is the restoration of a sense of agency, control, and security (Herman 1992). According to Herman the process of recovery comprises three stages—safety, remembrance and mourning, and reconnection. While these stages may not follow a straightforward, linear progression, they are helpful in organizing the major themes in treatment. From this perspective, one may view recovery from trauma as a gradual progression from unpredictable danger to reliable safety—from dissociated trauma to acknowledged memory and from stigmatized isolation to restored social connection and sense of future. From this perspective, the therapeutic relationship supports the shoring up of internal strengths that enable the survivor to eventually cope with and integrate the painful and destabilizing memories of the abuse (Saul et al. 2003).
directed towards strengthening and uniting families; rebuilding and regenerating community structures and institutions; encouraging leaders; facilitating self-support groups; village and traditional resources; using creative arts; cultural, ritualistic practices; as well as linking up with other service sectors like education, social service, local and regional government (Somasundaram 2010, 26).
There is an emerging literature on interventions that address collective trauma at multiple systemic levels by strengthening the collective capacities of populations to promote constructive action—from projects promoting transitional justice and truth and reconciliation (Hamber 2009; Hayner 2002), to conflict management and peace building (Hamber and Gallagher 2014), to disaster preparedness and response (Norris et al. 2008), and psychosocial work with refugee and immigrant communities (Miller and Rasco 2004; Weine et al. 2004).
A community resilience project with Liberian refugees in New York City exemplifies a community-based approach to the collective traumatic impacts of torture (Saul 2013). The project, African Refuge, was developed to address the mental health and psychosocial impact of war and torture on a population of six to eight thousand Liberian war refugees in Staten Island. Rather than focusing primarily on individuals who could be screened for mental health symptoms and referral, the project approached the entire community of Liberians as a torture-affected population. The project trained and supported local leaders as change agents to mobilize community members themselves to address their most pressing concerns around housing, jobs, education, parenting, and other displacement stressors.
Turning now to the human rights field and its approach to preventing torture, there has in recent years been a significant turn towards recognizing and analysing the “root causes” of violations. Illustrative examples include studies on the root causes of child, early, and forced marriage (United Nations 2014); homelessness (Kothari 2005); torture (McCarthy 2006); and contemporary forms of slavery (Shahinian 2011). When it comes to interventions however, critics have pointed to a persistent focus on symptoms rather than causes, as evidenced by the emphasis on alleviating the suffering of victims (Agamben 1998; Brown 2004; Rieff 2003; Žižek, S 1999) and on individual rather than structural causal factors, as evidenced by the prominence of strategies directed towards criminal sanctions against direct perpetrators (Kennedy 2002; Meckled-García and Cali 2006) and on providing human rights training for security personnel (Celermajer and Grewal 2013). As Susan Marks puts it, “the investigation of causes is halted too soon … effects are treated as though they were causes. … [A]nd … causes are identified, only to be set aside” (Marks 2011, 70).
Previous torture prevention approaches have identified the need to address more structural or systemic factors insofar as they attend to the practices in police and law enforcement agencies.2 As Nigel Rodley, former United Nations Special Rapporteur on Torture observed, since early in the torture prevention movement, the centrality of eliminating “the preconditions of torture” (Rodley 2009, 15) has been well recognized. The European Committee on the Prevention of Torture, for example (Evans and Morgan 1998), routinely checks places of detention and makes recommendations to authorities about how to improve conditions that render torture more likely, such as prolonged and isolated detention. UN Special Rapporteurs on Torture have consistently recommended prompt access to lawyers and doctors, thorough judicial review, independent investigation of allegations of torture, training in modern interrogation methods and the judicial inadmissibility of evidence produced through forced confessions (Nowak 2012). In Nepal specifically, civil society organizations that have been working on torture since its peak during the armed conflict have pointed to the range of legal, political, institutional, and attitudinal factors that cause and sustain torture and advocated broad-based reform (Advocacy Forum and Human Rights Watch 2008, 2009, 2010).
The problem comes at the point of operationalizing these insights, a process usually involving attempting to strengthen formal legal regulations, imposing external monitoring, and working horizontally with other stakeholders (government, non-government organizations, and civil society) to put pressure on security sector organizations to comply (Celermajer 2015a). Such strategies have been shown to bring about changes in some contexts and under certain scope conditions (Hafner-Burton 2008; Simmons 2009), but such approaches may be impeded insofar as security sector organizations are able to resist or adapt to such external pressures without making significant changes to their internal operations and cultures (Bullock and Johnson 2011). As policing criminologists have consistently argued, laws and formal guidelines are always mediated by police cultures and police have less regard for the black letter of the law than they do for the local normative environment in which they operate and negotiate their actions and decisions (Chan 2003; Chan and Dixon 2007). Ensuring that detainees are seen by medical professionals, for example, requires more than doctors showing up; it also requires that police officers responsible for detainees observe this requirement and that the doctors who are called understand themselves as independent and bound by certain principles and that they have the institutional capacity to exercise such independence.
The current project was thus oriented to address the need to effect systemic and cultural change in the perpetrator institutions so as to reduce the risk of torture occurring. This theoretical approach can be located against two broad bodies of literature. The first is the principally social psychological literature that emphasizes that violence needs to be understood against the situational or systemic factors within which individuals’ actions are shaped (Bandura 1973; Lifton 2004; Milgram 1974; Zimbardo 2005) or within the context of what Lifton (2000, 2004) calls “the atrocity producing situation.” Second is the sociological and criminological literature concerning organizational dynamics and security sector organizations in particular (Bayley 2001; Chan 1997).
Preventing Torture in Nepal
Based in his 2005 fact-finding mission the United Nations Special Rapporteur on Torture concluded that torture in the police and armed police in Nepal was systematic, a finding confirmed by the UN Committee Against Torture as of 2011 (Committee Against Torture 2011, ¶108). Such findings both drew on and have been confirmed by the close empirical research conducted by civil society organizations in Nepal, principally Advocacy Forum and the Informal Sector Service Center (INSEC) (Sharma 2014; INSEC 2000, 2001). Such studies do reveal a decline in the use of torture since the end of the armed conflict in 2006. A baseline survey of the criminal justice system in 1999 showed that 69 per cent of detainees reported experiencing inhumane treatment and being tortured during police detention (Center for Legal Research and Resource Development 1999), while a 2014 study found that 16.7 per cent of detainees complained of incidents of torture or other cruel, inhuman, or degrading treatment during detention—a reduction from 22.3 per cent in 2012 (Advocacy Forum—Nepal 2014). Nevertheless, with Nepal’s own Attorney General’s Office monitoring report finding in a study conducted on detainee treatment in prisons in 2012 that 15 per cent of detainees experience torture, (reported in United States Department of State 2013, 4), it is evident that the drivers of torture are persisting well beyond the context of armed conflict. Recent studies by non-government organizations conclude that legal safeguards against torture remain inadequate or ineffective and impunity is the rule (Advocacy Forum and Human Rights Watch 2010). The Special Rapporteur noted, for example that “he was repeatedly told by senior police and military officials that torture was acceptable in some instances, and was indeed systematically practiced” (Nowak 2006, 2).
(i) Research Methodology and Findings on the Organizational Root Causes
The principle research problem was to identify the root causes of torture, focusing on the organizational level and with an emphasis on the context of the intervention (Celermajer 2015e). Research methods comprised reviewing a range of relevant literatures (criminology, social psychology, public health, law, organizational studies) on the root causes of torture, and, in order to ensure attention to the particular context (Jensen and Jefferson 2009), primary empirical research was conducted at the intervention sites (Celermajer 2015b).3 Given the closed and hierarchical nature of policing organizations, in order to gain access to subjects from the police and to police stations as observational sites for the research and in order to implement the intervention, co-operative relationships needed to be developed with the leadership of the Nepal Police and Armed Police Force. This was facilitated by the local partner (KSL), which had a long-term existing working relationship with the organizations and Home Ministry and was in a position to manage the relationship and negotiate issues as they arose through the life of the project. Obtaining and retaining buy-in from the Associates in a project that potentially exposed their inner workings and past or present violations and that, from the outset, required acknowledgement of the persistent use of torture required careful processes of negotiation. Working in this manner also required a complex balancing of pragmatic and ethical considerations: having an eye both to ensuring that the Associates could see the benefits of being involved in the project so as to motivate their cooperation, while also being alive to the inevitable differences that would arise, to the constraints that come along with working “from the inside,” and to the difficult balance between the project’s independence and intellectual freedom on the one hand and continued access on the other.
Using key informants, a local team conducted interviews (principally in Nepali), focus group discussions, and observation over the course of one year (Grewal and Celermajer 2015). The police interview subjects (sixty Police, forty-three Armed Police) were from a range of ranks and in various locations4 and interviews were also conducted with representatives from the justice and human rights sector within governmental and non-governmental organizations. Such qualitative methodologies afford a fine-grained picture of the day-to-day conditions of law enforcement organizations and of the broader social, cultural, and political contexts within which they operate. They also take us beyond a positivist analysis of causal factors to provide a phenomenological analysis of how personnel experience those factors and insight into their subjective relationship with dynamics of compliance or possible resistance.
Focusing on the level of the security sector organizations, where our intervention was taking place, our research identified a range of organization-level factors that can be categorized within eight themes: work environment; incentives; politicization; corruption; defective criminal justice system; attitudes to human rights; societal expectations; and training. As one would anticipate and insofar as our ecological model implies the inter-penetration of the different levels, in many instances the factors bled across into the community, cultural, political, and legal dimensions but were experienced within the security sectors themselves.
Work environment includes lack of basic infrastructure, poor working conditions, and abusive relationships between senior and junior personnel leading to high levels of frustration and the normalization of violent relationships and the abuse of power. As a civil society subject put it: “The reasons for physical torture also include their [Police] living conditions: their rations, working hours, their barracks, offices, and kitchen. There is no environment for generating new ideas and thoughts in there.”
The system of rewards and punishment, both explicit (for example disciplinary actions or promotions) and through other forms of capital, has a significant impact on the patterns of behaviour (Chan 2003; Clarke and Homel 1997; Ede 2000), shaping how individuals coordinate their actions with the expectations of superiors and peers (Janis 1971; Kelman 1989; Schachter 1959). Respondents indicated that positively standing up for human rights, by refusing to use torture and so not delivering a confession, or challenging others’ abusive behaviours, was not rewarded and may be damaging for career progression.
Politicization, within the forces and through political interference was consistently identified as a major obstacle to respecting human rights. High levels of corruption within the organization were reported as a strong source of dissatisfaction amongst respondents. Previous research has identified a link between corruption and torture through the use of extortion both in Nepal (Saferworld 2007) and internationally (Baker 2012).
Failures in the criminal justice system, including continued reliance on confessions and physical evidence were frequently cited as leading to torture. Consistent with findings made by Wahl (2013a, 2013b, 2013c) and Jauregui (2013) in India, our research indicated that in the face of a perception that criminals, particularly recidivists, are unlikely to receive official justice, police may decide upon a form of rough justice involving physical violence, even reframing this from torture to justice.
Our data indicated that police personnel in Nepal are somewhat ambivalent about human rights, stating that human rights too often privilege the rights and interests of perpetrators over those of victims, the community, or police themselves and that human rights are a Western imposition and not suitable in policing contexts in Nepal (Grewal and Celermajer 2015). The inapplicability of human rights was explained in terms of the need for harsh methods when it comes to “uncivilized” suspects and the lack of investigative infrastructure and failures of the criminal justice system. Attitudes about the need and appropriateness of violence when it comes to certain types of people go beyond police. As a civil society representative told us, “The Police have to deal with criminals who will not listen to them at all unless violence is used. … Similarly, the society we live in expects the Police to beat up criminals and bad people.” Such societal expectations, heightened by the demand for quick results exacerbate the use of torture.
Police respondents were sceptical about the impact of human rights training, which is often held to be a panacea for human rights violations (Celermajer and Grewal 2013). They indicated that it was overly theoretical and disconnected from their actual contexts: “We have had lots of training, we’ve been listening to theoretical knowledge many times: We need different types of training—training that is more practically oriented.” The broader study of human rights training for security sector personnel conducted as part of the overall project indicated similar problems with training as the principal approach to capacity building and the need for approaches that avoided the trap of seeing the transmission of knowledge as sufficient to bringing about change to entrenched patterns of behaviour (Celermajer 2015d).
Strong, demonstrable, and consistent leadership in favour of the changes (Davis and Mateu-Gelabert 1999; King 1992; Kotter 1996; Shin and McClomb 1998), but leadership at every level and not only at the top (Chan 1997).
Reform must be motivated from within and below. As Police expert David Bayley insists, “the grain of the organization must be made to work with, and not against, reform” (Bayley 2001, 20).
Reform must occur in a way that can be assimilated by the organization. This is facilitated when reforms are simple, continuous with existing practices, rolled out in small steps, and where those required to implement the changes can see their advantages for them (Austin and Claassen 2008).
These principles strongly resonated with an observation that researchers made during the course of their fieldwork: that certain police in mid-level leadership positions had taken the initiative to make local level changes that created a more professional and less violent atmosphere in their police stations. These “implicit change agents” were able to shift the culture of the organization in which they were working by employing small but creative innovations. This observation, combined with findings from the organizational change literature and recent work on organizational resilience (Saul 2013), led to our hypothesizing that an intervention that sought to enhance these leadership capacities and link them specifically with the structures and processes within the organization that form the preconditions for torture might provide an effective strategy for torture prevention. This idea of identifying such leaders who could initiate change within police organizations and then working with them on the systemic factors underpinning torture became a central principle in the project’s theory of change. Not unlike the serendipitous observations that are important in doing effective clinical treatment and research, it is often through unique opportunities that points of change within a system can be found.
(ii) Theory of Change
Torture is the outcome of the operation of a system that comprises various levels and the components and dynamics of this system can be shifted through strategic intervention.
Certain identified actors within the system can intervene effectively and strategically to bring about those shifts.
They can do so most effectively if they have certain knowledge, attitudes, skills, resources, and leadership capacities that will enable them to identify and reduce risk factors and strengthen inhibiting factors for torture occurring.
The project team can best facilitate the development of these capacities by providing them with structure and resources.
The most important parts of this theory of change from the point of view of the intervention design are first the assertion that change needs to take place at the level of the systemic factors that underpin torture and second that these changes must be driven by personnel within the organization itself, with the strategic support of outsiders.
(iii) Structural Intervention
While the ToC furnishes the basic architecture and logic of an intervention, it still needed to be operationalized and fleshed out, specifically in relation to who those leaders would be, what types of capacities they would need, how to develop those capacities, and then how they would act to address systemic factors (Noonan and Celermajer 2015). At this point, the active cooperation of the Associates also became critical, as police personnel would now need to become active participants in the process. As noted earlier, leaders from the Nepal Police and Armed Police force had been involved in the project development from early on, and throughout the research phase, regular meetings had been held with them to discuss findings and the development of the project design.
Drawing on research on change agents (Gendreau et al. 2002), the project team developed a set of criteria for selecting the change agents and then requested that the leadership identify personnel meeting these criteria. Sixteen “Human Rights Protection Facilitators” (HRPFs) as they were called, were selected on the basis of their position (mid-ranking leaders in operational positions) and their prior record in leadership, positive influence of peers and subordinates, communication skills, initiative, and respect for human rights. Drawing on the ToC, the aim at this point was to work with them to build their capacity to identify and address structures and processes that create risks of torture within the part of the organization where they had influence and then to develop and lead projects to address those factors. The various tasks—identifying risk factors, designing a project that would strategically target risks, and delivering a project—involved a diverse range of skill sets and, as such, capacity building took place along several dimensions.
First, we presented our research on root causes to seek their views on how this related to their own experience. Next, with the support of the local research team and drawing on research skills that had been developed during the workshops, they conducted new primary research within their own workplaces to identify risk or inhibiting factors. It was important for them to identify the relevant local dynamics, structures, opportunities, and constraints and by being partners in the research and working with their own people, they had ownership over the process—a critical component of organizational change. Third, they were asked, again working closely with the research team, to design feasible projects that would address the identified risk factors. Here, it was important to encourage the HRPFs to adopt a results-oriented approach whereby the activities that they proposed were chosen because there was reason to believe that they would produce a particular result that they had identified as necessary to achieve their objective. Working back from objective to results to activities can be contrasted with the tendency to automatically opt for activities, an approach that tends to replicate what people have seen or done before without adequate attention to whether those activities actually produce the desired results. For example, several HRPFs automatically opted for interventions involving training in human rights law, even where they had themselves found that a lack of knowledge was not a key causal factor. Project plans also had to include tools to evaluate how well the results had been achieved.
Finally the HRPFs implemented their projects, examples of which are provided below. While each project was fairly modest, the objective was to pilot projects addressing a range of structural factors to demonstrate the feasibility of change using this model (Celermajer 2015c).
Case Study 1
Deputy Superintendent of Police (DSP) BR leads a large police station in the far east of Nepal. The police station is poorly resourced, with two cramped, stiflingly hot cells holding people for up to sixty days. The police barracks are extremely basic, with personnel sharing beds on a daily rotational basis. DSP BR is aware that police personnel use torture as well as violence against people crossing the nearby Indian border crossings where smuggling occurs. Research that DSP BR conducted with police personnel and community members indicated that while there were general level codes of conduct and laws concerning the treatment of detainees, at the local level these were very abstract and the actual incentive system that shaped police behaviour did not reward respect for human rights. To address this, DSP BR worked closely with representatives of different ranks to create a simple local reward and punishment system where performance would be evaluated in terms of observance of human rights and not only arrest or confession rates. One hundred and fifty police were trained in this new system and supervisors were given specific training in evaluating and officially recording performance. In addition, personnel’s performance was made public with the best performers highlighted on a daily and monthly basis as a way of reinforcing the importance of human rights at the local level and thereby shifting attitudes towards valuing human rights compliant policing.
Case Study 2
Superintendent of Police (SP) US runs a large police station on the Southern border. The problem he identified was the weakness of systems within the police station to effectively deal with women who come in as victims of crime or as suspects. He linked these systemic weaknesses with the use of torture in several ways. First, women were reluctant to give statements about violence, particularly from intimates, with the effect that police were more likely to torture suspects to get confessions. The inadequate processes for supporting female victims of violence to make complaints and provide evidence also reduced the effectiveness of the criminal justice system in addressing domestic violence, which is increasingly recognized as a form of torture (Bunch 1995; Copelon 1993), an interpretation SP US endorsed. Third, women were likely to experience inhuman and degrading treatment in the police station. The objective of SP US’s project was to create an environment in the station that was friendly and accommodating to women. To achieve this he established a set of procedures for handling all women who come into the station, clearly defining the role of all staff and training them in the new procedures, creating mechanisms for oversight and supervision at a senior level, and strengthening cooperation with women’s groups in the community to support and provide feedback on the procedures.
Case Study 3
Deputy Superintendent of Police RR leads a large police station in the Kathmandu valley with significant problems associated with urban youth unemployment and marginalization. The problem he identified was systematic violent treatment of drug users, underpinned by an attitude that their drug use is a sign of moral failure and that physical punishment is an appropriate form of law enforcement and moral correction. Such perceptions form part of a more general failure within the community to understand drug abuse as a public health issue and similar views that drug users deserve physical violence. To address the problem he worked at two levels—with the police officers and community members of the general public. For the police, he prepared targeted educational material on drug abusers, ran workshops, and provided demonstrations on how to behave with drug users, with weekly sessions to reinforce the importance of attitudinal and behavioural change. He developed a community education process with more than three hundred participants emphasizing the need to understand drug use as a health and social problem. An unanticipated but beneficial development was that the program received significant attention in the local media, which opened a larger conversation about institutional and social discrimination against drug users and the need for a broader shift in treatment approaches.
Expert evaluation of the research and theory of change, using a modified DELPHI technique (Witkin and Altschuld 1995);
Evaluation of the effectiveness of the capacity-building activities by assessing changes in subjects’ knowledge, skills, and attitudes using a combination of questionnaires and interviews with subjects, peers, superiors, and community members and adopting a contribution analysis approach (Mayne 2012);
Tailored evaluation for each of the HRPF projects assessing the implementation of planned activities, the achievement of the specific results set out in the project plans, and the link between the specific objectives and the broader problem of torture in the organization.
The multi-disciplinary research had produced a unique body of work increasing our understanding of the root causes of torture and providing a basis for the development of future prevention work;
The projects conducted in Nepal involved 709 junior police officers as direct beneficiaries. All the HRPFs and the junior officers involved reported strengthened commitment and capacity to protect human rights and in some cases prevention of torture, a greater understanding of human rights and the norms against torture and how to use this knowledge in their practical work;
Many but not all of the HRPFs projects were likely to have contributed to building the capacity of security sector personnel to address and prevent torture at a localized level. Qualifications on this finding included a recognition that HRPFs were able to demonstrate outputs but not necessarily outcomes and that many of the projects addressed human rights in general without a specific focus on torture.
Clinicians may play a variety of roles in addressing the health impact of torture on direct victims, their families, and communities as well as on security organizations and personnel where torture is practiced. They also may play an important role in helping shift from treatment that focuses primarily on victims to treating the system itself that produces the problem. More specifically, clinicians can participate in the development of torture preventive strategies in security organizations as staff clinicians, stress management practitioners, or outside consultants. They may contribute as well as researchers of the mental health impact of torture on perpetrators, bystanders, and functionaries in organizations where torture is practiced as well as providing mental health interventions for those affected as part of a prevention strategy. They may also provide appropriate oversight and supports to staff that are implementing systems interventions among people who have complex and violent histories.
Thus clinicians may exert leadership and be crucial partners in developing primary prevention strategies by helping address “upstream” risk and inhibiting factors that may lead to torture and other forms of institution violence downstream. The EHRP suggests a number of important lessons for the operationalization of strategies seeking to take a systemic approach to prevention of torture-related trauma.
First, operationalizing a systemic approach requires being realistic about the unavoidable gap between the systemic analysis of the problem and change that an intervention can bring about. As systems-oriented health professionals know, the structural causal factors of serious problems span a number of dimensions including the political, ideological, legal, institutional, cultural, and societal. One of the reasons so few interventions take a systemic approach is that a structural diagnosis may convey that change is impossible in the face of entrenched and varied structures. The process of working out a systemic approach will involve attending both to which drivers are most critical in causing or sustaining the problem and where it is feasible to intervene given the access and resources that one has. Nevertheless, a limitation of this approach is that addressing systemic factors at one level only (organization) will not be sufficient, particularly where there are strong factors at other levels, and in particular the political level.
Second, systemic change by its nature is not something that can be brought about by external agents acting on a system. Clinicians should get inside systems and partner with personnel to ensure that changes are embedded in organizational practices and cultures and that they are facilitators and allies rather than experts directing the process. This requires accepting that the interventions developed may not conform with those that experts would design and may bring about fairly modest changes.
Third, evaluating the effectiveness of a systemic intervention presents significant challenges. Clinical researchers need to develop methodologies that can address the links between variables at different systemic levels in order to understand the effect that interventions implemented at one location in the system may have on organizational change and the reduction of institutional violence and torture. They also need to develop indicators of the sustainability of organizational change and decreased violence.
Health and human rights has, in recent years, become and expanding field, pointing to both the centrality of health as a human right but also to the critical role that health professionals can play in a range of human rights issues. Embedding clinicians in broader human rights teams can significantly enhance these teams’ capacity to draw on the systemic insights of public health and clinical expertise as well as providing a context in which clinicians can expand their engagement with the structural dimensions of illness and injury.
Throughout this article the term torture will be used to cover a range of practices involving the use of violence against people in detention, including lesser forms of force that may not constitute torture. The United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) (1987) defines torture as severe physical or mental pain or suffering inflicted intentionally at the instigation or with the consent or acquiescence of a public official to obtain information or a confession, inflict punishment, intimidate or coerce or for any reason based on discrimination. Of the acts condemned by the convention, torture is the most severe.
The terms structural and systemic both point to causal factors that lie within institutional practices, discourses, and cultures. Given the historical use of the term, systemic approaches in public health in general and analyses of institutional violence in particular, this term is used throughout the article but with an understanding that it is pointing to causal structures.
Ethics approval for all aspects of the empirical research, including interviews, surveys, focus groups, and participant observation, and attending to issues concerning subject and researcher safety and confidentiality was obtained from the University of Sydney Human Research Ethics Committee.
While police participation was voluntary and confidential, it is noted that access to subjects was facilitated by the Associates and as such, the material communicated needed to be interpreted within this context of direct or indirect oversight of superiors. Access to the unmediated views of police personnel, as with access to other empirical material in the security sector, is always constrained in this manner.
We would like to acknowledge Aastha Dahal, Kiran Grewal, Rohit Karki, Anna Noonan, and Pradeep Pathak for the research and project work in Nepal that is discussed in this article.
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