CIA OMS doc

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To:Organization:

Wasbington, DC 2050515 J - ....... , ~ . 2005

'DOJ Command Center'For Dan Levin .Office of Legal C o u n s ~ l T ~ n A n ~ Y h h ~ n t o f J n s t l c e ------____, _____ ____________-___

,____ ~ P . . ; . . : ; h ~ o n ; . ; . . . ; e ; . . ; ; , . . ! _ ~ - , - - - . . . -:JFax: DOJCC Stu-illFrom:

Organization:. Phone:Fax:

Number o f p a g ~ (including cover sheet): 35. Comments: Dan., Latest DIVIS Guidelines ( ~ a m e

outwhile I was .out of the office. I haven't stUdied to see whatchanged f r ~ m the last version I sent you...; Nonp'tTO RECfPrEN'f .II Thl"in!ormotlon is p l ' ~ p e r t , ) J pJtit, {fnUtdSWa intcnddSDlelY/Of the ure ()/tha Imtily DrpmD1J namul a[JDVlf tuJdakf blay be trltpmey.diDll

prlvilqrcd 111 otllerwut t x ~ I I P ( frDm quclosutt unda appllenhle Imv. !flOu at't 1Iot flit i h f ~ n " d recipler,f Qjthis/l1.rffflfle, or he ~ M p l t ) } ' f f III'i agent rt.tpo1l$/bk fo r cJfdivering 1M mauaqt. 10 tht (nlelukd recipienf, you ore lIer:eby notified rhal m:dpt ofWI / l l C . J J a g ~ is no! Q wpfverOf rdcauI 0/anvapplicoblt privUt:gc or !UmptlDn from disclOsure, GIld that 1 ' C " A ~ tilsstmdnarJOlJ, cilstribution. orcopyittg ofIhu communtcation it strictly !.. lfyou haV! n ' ~ l w i this l'1faf!n'a( in error. plea.rt MlfJY ibIs o . f f l ~ tV die abDVd reJtphont IfflmCu (colfta)lor IttstrocdtJl1f t ~ g ( m : l l n g Its!iII,!i

' ~ ? t r U c t t O I 1 . Thank you.,-

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OMS GUIDELINES ON l'viEDICAL AND PSYCHOLOGICAL SUPPORT TODETAINEE REl'


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.Guidelines : C ~ : tne . ,: J S ~ ~ ' : l S ~ ( ~ 2 : ' : ' \ = S .

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NO. 378 P.10

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NO. 370 P.Il

DETENIION At-TD r N T E R J ~ O G A T I O N General intake evalua.tion

New detainees are to have a thorough initial liledical assessment Upon arrival atthe first Agency detention facility, witl! a complete, documented illstory and physicaladdreSSing in depth any chronic or previous medical problems. Tnis assessment shouldespeci attend to cardia-vascular ulmon3J lleurolodcal ffillSCU!oskelfindings.

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tiO.370 P.12

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the treatn1ent he believes he will receive .. un The more physical techniques are .delivered in a manner carefully limited to avoi.d serious physical hann. The slaps, forexample, are designed Uta induce shock, surprise. and/or humiliatlonu and "not to inflictphysical pain that is severe or lasting." ..To this end they must be delivered in aspecifically prescl1bed manner) e.g. wjili finger-s spread. Walling is performed onlyagainst a springboard designed to be loud and bouncy (and cushion the blow). Allwalling and most attention grasps are delivered only 'with the subject's head solidlysupported t1th a towel ,to avoid extension-flexion injury. .

OMS is responsible for assessing and mopJtoring the health ofaU Agencyd ~ t a . i n e e s subject to "enhanced>l interrogation techniques, and for detennining that theauthorized administration of these techniques would not be expected to cause serious orpermanent harm.' unCI Guidelines" have been issued formalizing these responsibilities)and these should be read directly. .

Advance Headquarters approval is required. to use any physical pressures;tecrulique"specific advanced a.pproval is required for all "enhancedtt . measures and isconditional on on-site medical and psychological personne12.confitming from directdetainee examination thit the enhanced teohnique(s) is not expected to prodUCe "severephysical or mental pain or suffering.it As a practical matter, the detainee's physicalcondition Inust be such that these interventions will not'have lasting effect, and hispsychological state strong enough that no severe psychological harm will resultV'

. The standard used by the Justice Department for Umentar' hann is ''prolonged mentalhann/' i.e.) Hmental harm of some lasting duration, e.g. t mental harm lasting months or yeatS:'"In the absence ofprolonged mental harm, no severe menrol pain or suffering would have beeninflicted." Memorandum of August I) 2002, p. 15.Unless is being used] the m ~ l l c a l waterboard requires the presence of a physician. can be aphysicim or aPA; use of the

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HO.378 P.1S

Medical treatmentAdequate medical care shall be provided to detainees, even those undergoingenhanced interrogation. Those requiring chronic. medications should receive acutemedical should be and aaelQua:te

The basic diet dUring the period ofenhanced interrogation need not be palatable,but should include adequate fluids and nutrition. Actual consumption should bemonitored and t e c o ~ d e d . 'Liquid Ensure (or e q \ l i v a l e ~ t ) is a good way to assure that thereis adequate n u t r i t i o ~ Individuals refusing a d ~ q u a t e thisfluids administered at the est of r { o . h , , , , J i t ' ~ - h I ' " If here is any question about adequacy ofshould be monitored and recorded.

must remain cognizant at ali timesere physical or mental pain or suffering.uUncomfortably cool environments .

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NO. 370 P.16

Core body temperature falls after more than 2 hours at an ambient temperature of1QOC/50F At this temperature 'increased 'metabolic rate cannot compensate 'for heat .loss. The WHO recommended minimum indoor temperature is 18C/64P." The"thermonelltral"ZOne" where minimal compens(ttory aotivity is required to maintain coretemperature is 2 0 ~ C / 6 8 F to 30C/86P t Within t h ~ thermoneutral zone, 26C/78F isconsidered Ie for clothed individuals and30C/86F for naked

I f here is any possibilitY that ambient temperatures are belo,,, the t h e ; 1 ' l n o n ~ ~ u ~ r u range, they sh:ould be monitored and the actual documented.

At ambient temperatw"es below 18C/64F detainees should be monitored for the" " r . . ~ " Q - n " " of .

pietary m a n i p ~ a t i o n during' interro2:ationDuring the interrogation phase, detainee diets may be modified to enhancecompliance with interrogators and facilitate movement to the debriefing phase, Detaineeshealth should not be jeopardized by such res1rictions, however) so medical officers shouldattend to adequate fluid and nutrition intake. In general, daily fluid and nutritionalrequh'ements may be estimated using the follo-wing formulae: .Fluid requirement; 35 m1 / kg I day. Will alter with ambient temperarure;body

temperature) level of activity, intercurrent illness. Monitoring offluid intake and of urineoutput and specific gravity may be necessary when the medical officer suspects thedetainee is becoming dehydrated.11


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NO.370 P.l7

Energy requirement (male); 900 + lOx weight in ldlograms for basal Kcalrequirement; multiply by 1.2 for sedentary activity level) 1A for moderate acti'Vity level.. Widely available commercial weight loss programs in the US employ diets of1000 KcaI I day for sustainedperiods ofweeks or longer w;i.thout required m e d i c a ~

supervision in persons voluntarily seeking to lose \veight; these diets have proven safeand effective in inducing short tenn weight 1088. Franchised medically supervised .programs may employ diets \vith even lower daily calorie provision (as low as 500 Kcal /day), but do entail some risk because of alterations in serum electrolytes.Should the intel1'ogation team choose to limit the detainee's food intake, OMSreconullends a minimum intake of 1500 Kcalories I day, recognizing that intakes of 1,000Keal are safe and sustainable for weeks at a time. The nutrients may be presented aseither a balanced liquid supplelnentJ such as Ensure Plus (360 Kcall can), or a reductionjn the detainee)s normal solid food intake. Ifenhanced interrogation methods are.contemplated, a liquid diet is appropriate to Inin;mjze risk to the detainee of aspiration; aliquid diet is mandatory if use of the walorboard is being contemplated. ..

Water dousjng

l\1edical officers should refer to eTCgut ofwater dousing techniques, which allow for water to beapplied using either a hose connected to tap water, or abottle or similar container as the- water source Care must be taken to keep water away from the face to avoid risk ofaccidental ingestion or aspiration.OMS guidelines for exposure to water are:

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HO.370 P.19

Shackling and p r o l o n ~ e d standingShackling in non-stressful positions requires only monitoring for the developmentfp e ~ t h t tr . tIn t d d'ustm t fth h kl d

If the detainee is to be shackled standing with hands at or above the head (as partofasleep deprivation protocol), the medical a s ~ e s s m e n t should include a pre-checkanatomic factors that influence how the arms

Assuming no medical contraindications are found, extended periods (up to 48hours) in a standing position can be approved if the hands are no than head leveland weight is borne the lower extremities.

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Sleep deprivction

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The maximum ti180 hours.


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small box is allowable up to 2 hours. Confinement in the large box is limited to 8consecutive hours, up to a total of 18 hours a day.Waterboard

This is by far the most traunlatic ofthe enhanced interrogation techniques. Thehistorical context here was limited knowledge of the use of the waterboalli in SEREtraining (several hundred trainees experience. it.every year or nvo).. In the SERE modelthe subject is immobilized on his back, and his forehead and eyes c.overed \vith a cloth.A stream ofwater is.directed at the upper lip. Resistant subjects then have the clothlowered to cover the nose and m o u t h ~ as the water continues to be applied,' fullysaturating the cloth, and p ~ e c l u d i n g the passage ofair. Relatively little water enters themouth. The occlusion (wbJch may be partial) lasts no more than 20 seconds. On removalof the cloth, the subject is immediately able to breathe, but continues to have waterdirected at the upper lip to prolong the effect. This process can ~ n t i n u e for severalminutes, and involve up to 15 canteen cups ofwater. Ostensibly the primary desired

. effect derives from the sense of suffocation roswting from the wet cloth temporarilyoccluding the nose and mouth, and psychological impact of the continued a p p l l c a t i ~ n ofwater after the cloth jg removed. SERE trainees usUally have only a single exposure tothis technique, and never more than two; SERE trainers consider it their most effective.tecMi and deem it irresistible in .

Vlhile SERE trainers believe that trainees are unable to maintain psychologicalresistance to the waterboard J our experience was otherwise. Some subjects .unquestionably can withstand a large number of applications, -with DO ifllljl1eC11ate,lvdiscernable oumulative . their aversion tothe exp:enelClce.

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1'10.370 P. 23

The SERE training progt'am has applied the waterboard technique (singleexposure) to trainees for years) and reportedly there have been thousands of applications\'tJithout significant or lasting medical complications. The procedure nonetheless carriessome potential risks, particularly when repeated a arge number of times or \vhen appliedto an individual less fit than a typical SERE trainee. Several medical dimensions need tobe monitored to. ensure the safety of the subject.

In our limited experience, extensive sustained use of the waterboard can introducene\v risks. Most seriously, for reasons ofphysical fatigue Or psychological resignation,the subjectmay shnply give up, allowing excessive filling oftbe airways and loss 9consciousness. An unresponsive subject should be righted innnediately, and theinterrogator should deliver a s u b - x y p ~ o i d thrust to expel the water. If this fails to restorenormal breathing) aggressive medical intervention is requited. Any subject who hasreached this degree of compromise is not considered an appropriate candidate f o ~ thewaterboard, and the physician on the scene can not concur in further use of hewaterboard without specific C/OMS cOl1sultation and approval.A rigid guide to mediCally approved use ofthe waterboard in essentially healthyindividuals is not possible, as safety will depend on how the \vater is applied and the

. specific response each time it is used. The following general medical guidelines arebased on very limited knowledge. drawn from very few subjects whose experience andresponse was quite varied. These represent only the medical guidelines; legal guidelinesalso are operative and may be more restrictive.19


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NO.370 P.24

A series (within a "sessionll) of several relatively rapid v/aterboard applications islnedically acceptable all ofsomeL J I . . . . . , L . T ' " I " T " I ~ ......... vulnerabi

Several such sessions per 24 hours beenapparent complicatiolt The exact"number of sessions cannot be medicallyprescnoed, and will depend on thy r e ~ p o n s e to each; however, all medical officers mustbe a'ware of the Agency policy on waterboard exposure. ofDecemher 2004, eTCguidelines limit such sessions as follows:"a. Approvals for useof he waterboard last for only 30 days. During that 30-day period,the waterboard may not be used on more than 5 days during that 30-day perio!l

b. The number ofwaterboard sessions during any given 24-hour period may nQt exoeedtwo.e. A waterboard llsession ll is the period of time in which a subject is strapped to thowaterboard before beingl'emoved. It may involve multiple applications of water. A waterboardsession may not last longer than tWo hours.d.- An flapplicationll during a waterboard session is the time peri()d in which water is

p o ~ e d on the cloth being held on the subjecttg face. Under the DCI interrogation guidelines, thetime of totat contaot ofwater with the face will not exceed 40 seconds. The- vast majority ofapplications are less than 40 seconds, many for fewer than 10 -seconds. Indivi4ual applicationslasting 10 seconds or longer will be lhnited to no more than six applications during anyonewaterboard session. The Agency willllmit the aggregate ofapplications to no more than 12mL'1tites in anyone 24-hour period . . -

By-days 3-5 afan aggressive p r o g ~ cumulative effects become-a potentialconcern. \Vithout any hard data to quantifY either this risk or the .advantages of histechni que, we believe that beyond this point continued intense '\vaterboard applicationsmay not be medically appropriate. Continue-d aggressive use of the waterboard beyondthis point should be revie\ved . . . toany further aggressive u

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MO. 378 P.25

}{OTE; In order to best infonn future medical judgments and rec01nmendations, it isimportant that every appliclitiolf of he waterboard be thoroughly documented: how longeach application (and the entire procedure) lastedt haw much }Vaterlvas used in theprocess (realizing that m-uch splashes ofJ), how exactly the waier was applied, b"a sealwas achieved, if he nas() or oropharynx was filled} what sort ofvolume was e:cpelletLho'tv long r ~ Q ' S the break bern1een applications, and how the subject looked betrveen eachtreatment.

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NO. 370

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NO. 370

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NO.37B P.31

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- . -_ . . . . . ~ , , ; "' t . c.r r r l NO. 370 P.33

General re.ferences: In addition to standard medical works, medical officers should referto the"Department ofJustice Buteau of Prisons ,vebsite at W\vw.boD.eov, accessing"Central Office"l then ''Health" Services" to view their clinical practice guidelines. Theseguidelines and policies are useful references for'procedures in nove) . ituations,Other standard references which medical officers may find useful include,"Standards for Health Services in Prisons!t,.a regular publication of the NationalCo:tn.mission on Con"ectional Health Care, last revised in 2003. Clinical Practice in

Correctional A { e d i c i 1 J e ~ Michael Puisis, edt 1vlosbyPublisbing, 1998, is ausefulc o ~ p e n d i u m of care for cbi'onic and infectious health issues in the prison s e ~ g .

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- .- . . . . . L . ~ Ii ' C.or1'l l'kl.370 P.34

Appendix A. Medical rationales for ~ t a t i o n s on p h ' Y ~ i c a l pressures!\treasureShaving

Stripping

Diapering

R:ooding

Isolation

'White noiseContinuouslight ordarknessUncomfortablycoolenvironment

Restricted diet

lVledicalLimitationNone'

Ambient airtemperature atminimum. 64 FI 18CEvidence of loss ofskin integrity due tocontact with humanw-aste materials

79 dB maxRelated to sleepdeprIvation


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. - .. ---- ""-c....,..,.. . , NQ.37B P.35

body weight; or significant malnutritionevidence of and requ1res correctivedehydration actionShaekingin 48 hours stfUidard; Prolonged standing likely ere guidelines;npright sittillg longer periods to induce dependent experience with. r horizontal require medical edema, increase risk for 20+ detaineesposition monitoring DVT, c e l l u l i t i s ~ 'Vater donsing Cessation upon Increased h ~ a t loss nWildernessevidence of promoted by Ctlntact with Medicine" 4th Ed.,hypothermia; water below 35 C; death Ch 6. - Accidentalambient can result from prolonged Hypothermia; Ch 9temperature (Le. 6hour) exposure to Immersion intominimum of64 F j 15 C water, 2 hr5 at 10 C, "cold water;18 C; potable ,vater 1hr at 5 C; hypothemria Transport Canada,

SO\ll'ce be induced in 30 IfSunrival in Coldminutes with' 5 C141 F \ V a t e r s ~ ' , PRBAL\vater, 45 Illinutes with 10 OperatingC I 54 F water} and 60 InsttllCtioDsminutes \yith 15 C / 59 F\vater immersion.Immersion at

) temperatures below 25 C /77 F will eventually befatal over lime.Sleep 48 hours for Periods ofsleep eTC Guidelines"; .deprivation deprivation of90+ hours Home, J. Why \\]ehave been shown to be Sleepsafe and without long NfNDSINIH webterm sequellae in large sitegroups, anq 200+ hours inindividuals; requiredrecuperative periodundefined. Note 0.5 C" drop in body temperature:which may impact use ofwater. Sleep deprivationdoes degrade cognitiveperformance, may inducevisual disturbances may .reduce immunecompetence acutely.

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Attentiongrasp

Facial hold

Abdomiitalsla.p

Stress positions

\Valling

Crampedconfinement

\Vaterboard

Correct technique;no pruxistinginjury likely to beaggravatedCorrect teclurique;no preexistinginjury likely to beaggravatedCorrect technique; .no preexistinginjury likely to beaggra"l1tedCorrect technique;no preexistinginjury likely to be~ g g r a v a t e d Correct tcqbnique;no preexistinginjury likely to beaggra-vatedCorrect technique;no preexistinginjury likely to beaggravatedCorrect technique;no preexistinginjury likely to beaggravated

A t ~ n t 1 ( ) n to risks ofimmobilization, inoludingDVT, and claustrophobia;ensure adequate air flOVl)ambient temperatureCorrect tecllnique; Risks include drO\vrung orno preexisting . near drowning; .injmy like! hypothermia from \varer

capabilityimmediately athand; potable watersource

exposure; aspirationpneUmonia,laryngospasm,

NO. 370 P.36

PREAL OperatingInstructions

PREAL OperatingInstructions

O ~ 1 S Guidelines;

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00.373 P.37

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