Continuing Lack of Adequate Medical Care in Bahrain’s Prisons

Amnesty International today expressed its concern over persistent reports of failure to provide adequate medical care in Bahrain’s prisons, which in some cases may result in permanent health damage to individuals suffering from injuries or grave chronic illnesses. Amnesty has confirmed details regarding lack of medical care and other ill-treatment with relatives or family members of 11 prisoners, and has received credible allegations of failure to provide adequate medical care in multiple additional cases from local human rights organizations and exiled Bahraini activists. Their accounts, and supporting documentary evidence, paint a picture of frequent, ongoing, and in some cases willful medical negligence in Bahrain’s penitentiary system. In addition, prisoners and families report a range of lesser abuses which range from petty harassment to needless cruelty. Due to the strong possibility of reprisals against family members who share information on these abuses with international organizations, Amnesty cannot identify individual sources in this statement.

Nature of Medical Care Available in Bahraini Prisons

The cases reviewed by Amnesty International indicate that health care in Bahrain’s prison system is marred by regular instances of negligence, delay, and arbitrary exercise of authority, which in specific cases rise to the level of intentional ill-treatment, and which result in an overall lack of adequate care for detainees and prisoners. Medical treatment is provided within the prison system, but is far below the level of need and is frequently subject to bad-faith disruptions, delays, and denial.

Bahrain’s primary prison, the Jaw Rehabilitation and Reform Center (Jaw prison), had an officially recorded prisoner population of around 2,500 as of November 2015. Yet there are only two physicians on staff (one per shift), and no more than two to three medical staff on duty at any given time. The doctors at the prison are general practitioners; there are no specialist staff, and diagnostic equipment such as X-ray machines is lacking. Yet prisoners in need of specialist care for ailments requiring close medical management – such as dental surgery, sickle-cell anemia, multiple sclerosis, or cancer, to take examples documented in this statement –  are often denied transfer to appropriate medical facilities. The clinic typically dispenses Panadol or Restamol, common over-the-counter pain relievers, for all complaints, including ailments to which these have no application such as rashes or indigestion.

Clear Cases of Ill-Treatment and Willful Medical Negligence

Bahrain has the professional and financial resources to provide adequate health care to all prisoners. In multiple instances, though, it has failed to do so not for lack of capacity but as a matter of deliberate denial of treatment.

In one of the more egregious instances, Jaw prison authorities have coerced Ahmed Merza Ismaeel (who is the half-brother of Sheikh Ali Salman, the imprisoned leader of the now-dissolved Al-Wefaq National Islamic Society) into surrendering his right to be transferred for a scheduled hospital appointment for treatment of complications arising from sickle-cell anemia. In summer 2017, prison guards threatened to beat him and put him in solitary confinement if he did not sign papers cancelling his appointment. This appears to have been in response to a visit in summer 2017 by the International Committee of the Red Cross (ICRC) to the prison, during which ICRC staff spoke with Ismaeel. Prior to this resort to coercion there had been multiple instances in which his scheduled hospital appointments were canceled on various pretexts. Ismaeel has been in need of an operation to remove the gallbladder (cholecystectomy) since July 2016 due to chronic gallstones (a common complication of sickle-cell anemia). Lack of treatment led to a severe health crisis in December 2016, when the concentration of hemoglobin in Ismaeel’s blood dropped to a dangerous level, while his blood concentration of bilirubin was dangerously high (diagnosable as jaundice). This led to his hospitalization through January 2017, marking the last time he has been given a course of treatment in hospital. Since his discharge he has received no specialist care and no medication, not even painkillers, though sickle-cell anemia is an extremely painful disease requiring close management.

Another stark illustration is the case of Elyas Faisal al-Mulla, a 27-year-old from Sitra. Medical staff at the Jaw prison clinic allegedly beat al-Mulla during a prison riot that took place in March 2015. Al-Mulla has subsequently been diagnosed with cancer. For a period of roughly two months after he was hospitalized due to bloody vomiting on 1 August 2015, the prison administration refused to authorize release of al-Mulla’s medical reports to his family, and at one point told them that he had slipped in the prison bathroom and broken his leg. When his family was finally given a medical report, over eight weeks after he was initially hospitalized, it disclosed that al-Mulla had stage-three colon cancer with partial diffusion into the lymph system. Despite the fact that he was obviously very ill, he was transferred back to Jaw the same August, within less than a week of undergoing a colon biopsy. He continued to be held at Jaw throughout the course of chemotherapy in 2015 and 2016, while his hospital appointments were subject to arbitrary postponement and interruption. Most recently, since 7 August 2018, al-Mulla has been waiting to receive medication prescribed on that date. His medication was delivered to another prisoner due to an error in the prison clinic. Though the family informed the clinic immediately of the oversight, as of early September al-Mulla had yet to receive his medication.

Mohamed Ali Jaafar, who has had multiple sclerosis (MS) since before his detention, was also not receiving his medication (Gilenya) as of early September. He has not received the annual MRI scans that are prescribed for MS patients since the day he was imprisoned in 2014.

Willful Medical Negligence Following Alleged Beatings

In several cases documented by Amnesty, prisoners are in need of treatment due to past injuries allegedly sustained from abuse by security forces or prison guards. Ahmed Abdulla al-Arab, who was tried while still a minor, was allegedly beaten at the time of detention in 2015 and now suffers waves of back pains that prevent him from standing or sitting comfortably. A doctor at the prison clinic has advised that he should be transferred for X-rays, but this has not been done. Mohamed Merza Moosa was in good health prior to his detention, being a member of Bahrain’s national jujutsu team. He now suffers chronic back pains due to alleged beating after his detention in 2011. A doctor has told him that he is in need of an orthopedic mattress, but this has not been supplied by the Jaw prison administration.

 Redha Merza Mushaim have told Amnesty International that two of his teeth were broken due to beating in detention, and that in 2012, prior to his imprisonment, his arm was seriously injured by a tear-gas canister fired near their home in Sanabis, which required surgery. He had a rod inserted in his arm, which was to be removed once the arm had healed. Since his detention in 2014, however, Bahraini authorities have not permitted this operation to be performed, which has resulted in chronic pain. Another young man from Sanabis is in need of dental surgery, allegedly due to beatings by security forces at upon his initial detention in 2013. One tooth was broken at that time, and subsequently about seven more of his teeth have fallen out due to the failure to provide dental care He is in need of comprehensive surgery including root canals, removal of some teeth, and resetting of others.

The Women’s Prison in Isa Town

At the women’s jail and prison facility in Isa Town, Amnesty International has been informed of several failures to provide proper diagnosis and/or follow-up treatment. Hajer Mansoor Hassan, who is imprisoned in reprisal for the human rights activism of her exiled son-in-law Sayed Ahmed al-Wadaei, has not been allowed to obtain her medical records or given a diagnosis for worrisome breast cysts despite repeated requests. Fawzeya Mashaalla Haji, a 56-year-old who has been detained pending trial since December 2017, had surgery on both knees shortly before she was taken into custody on charges of sheltering fugitives and has had two fainting spells in detention. On 11 March 2018, she fainted while in custody and was transferred to the clinic at the Ministry of Interior facility known as al-Qalaa. She was treated for only a few hours before being transferred back to jail. On 22 May she had a second fainting spell due to a drop in her blood sugar level. Some of the medications she had been taking have not been provided to her in detention. The requests of prisoner Medina Ali to be examined by a forensic doctor for what she claims are marks left from torture have not been granted since she was detained in May 2017.

On 16 September 2018, according to family members, guards at Isa Town prison, led by the Major in charge of the facility, physically assaulted Hajer Mansoor Hassan, Najah Ahmed Yusuf, and Medina Ali, who share the same cell. Hajer suffered a drop in her blood glucose level to approximately 2.0 millimoles/liter (36 milligrams/deciliter) – a dangerous level, and an alarming development in that Hajer had never been diagnosed with diabetes – and had to be transferred to hospital. She was left with bruises from the blows received, and all three were held in solitary confinement for several hours on the same day. Hajer in particular has been active in protesting poor treatment in the prison, and the previous week the three’s grievances with the prison administration had been noted in a UK parliamentary debate.

Medical Problems Due to Poor Prison Sanitation

Sanitation is a significant problem at Jaw prison, as has been documented in part by Bahrain’s Prisoners and Detainees Rights Commission. The Commission noted in its 2016 report on Jaw that some of the buildings suffered from “bad hygiene,” with “insect infestation in some rooms, broken toilets and poor cleanliness.” Cases of skin disease and allergic reactions are frequent. Both Mohamed Ali Jaafar and Ahmed Merza Ismaeel have had skin outbreaks due to the unclean environment. In October 2017, Jaw inmate Sayed Ahmed Redha Hemaidan contracted an eye infection due to the prison’s poor sanitary conditions. The situation is particularly acute in building no. 4, cellblock 1, where a local human rights organization has told Amnesty International that it has recorded more than 30 cases of skin diseases.

Sectarian Discrimination and Other Forms of Harassment

Multiple prisoners’ families have told Amnesty International that sectarian discrimination is common in Jaw prison. Harassment and abuse of Shi’a inmates, who make up the majority of the prison population, tends to escalate around Shi’a religious holidays, especially during Muharram, the first month of the Islamic calendar, which includes a number of important religious dates commemorated by Shi’a in Bahrain, most importantly Ashura or the 10th of Muharram. One young man who had observed Shi’a rituals during Muharram in 2017 was put in solitary confinement months later and told by the guards that it was punishment for his religious observance. Ahmed Merza Ismaeel was physically assaulted by guards in 2017 in reprisal for Shi’a religious practice. Other prisoners have told their families of being threatened with solitary confinement or denial of family visits in order to deter them from practicing their faith. Prison guards only recognize and accept Shi’a worship on Ashura during Muharram, and prisoners are generally fearful of attempting religious observances on that day without explicit permission from the guards. At Isa Town prison, the cellmates Hajer Mansoor Hassan, Najah Ahmed Yusuf, and Medina Ali have been denied permission to join the gathering of other prisoners for Ashura, and their requests for religious texts to read from on the occasion have gone unanswered.

Amnesty International has received various reports of prisoners being denied basic items or services needed for personal health, hygiene, comfort, and dignity. At present the prisoners in building no. 2, cellblock no. 1 of Jaw prison, are not receiving adequate amounts of food. Running water in the prison bathrooms is frequently cut off. All prisoners at Jaw are currently held in their cells for 23 hours per day, and during summer 2018 the one hour outside the cells granted for yard time has been set at mid-day when the sun is hottest. Air conditioning is often shut off during the hottest summer months. Families have to pay for many necessities, including most recently bedding, through the prison commissary, at inflated prices well above market rates. This is an economic burden that can be significant for families who have already lost a breadwinner, as is the case with the family of Elyas Faisal al-Mulla, who have limited income and are in debt. Phone calls are charged to prisoners’ families, who must purchase the calling cards used from the commissary, and are closely monitored by prison guards, who either remain at the prisoner’s side during the phone call or listen in on another line. Around the beginning of 2018, guards at Isa Town prison told Fawzeya Mashaalla Haji that they would deny her access to phone calls if she told her family about her medical complaints in detention. Prisoners who do not wish to exit their cells during yard time due to the heat have also been told that their phone calls would be revoked.

In 2017, the length of time granted for family visitation was cut to half an hour per visit, a period so short that – especially given the lengthy waits and sometimes invasive searches of both prisoners and family that are conducted – many prisoners now feel it is not worth burdening their families with the trouble of visiting at all. Family visitation is limited to two appointments per month, and families are usually required to go to the prison twice in person to arrange a single visit.

Ineffective Accountability Mechanisms

Bahrain has established a number of mechanisms which are supposed to address human rights concerns, including in prisons. The most significant of these are the Ombudsman for the Ministry of Interior and the National Institute for Human Rights (NIHR). Amnesty International has previously reported how these oversight bodies have failed to provide effective protection or remedy in cases of human rights violations, a trend also in evidence in their handling of medical grievances within the prison system.

Some prisoners fear speaking openly with Ombudsman staff about prison abuses due to the danger of reprisals. In one case, a prisoner was threatened with beating and solitary confinement if he spoke openly with the Ombudsman’s office about his treatment. He was later held in solitary confinement for two periods of over a week each in reprisal for his family’s attempts to pursue the matter.

The problem is not just lack of capacity to protect, however, but lack of will to take prisoners’ and families’ complaints seriously. In most of the cases Amnesty documented for this statement, prisoners or their families had filed complaints with the Ombudsman with no result. In most instances where the Ombudsman has acted – by interviewing prison authorities and/or prisoners – its follow-up has been ineffective. The family of Mohamed Ali Jaafar, for instance, had as of this writing received no news of any prison visit or other action by the Ombudsman to ensure delivery of the medication he needs to treat his multiple sclerosis. The Ombudsman’s procedures generally lack transparency. The office typically does not provide any form of paper trail to members of the Bahraini public, and when families of detainees approach the agency they are not given any formal record of filing a grievance other than, sometimes, a file number.

Earlier this month, the Ombudsman issued a statement relaying its findings on the case of prisoner of conscience Hassan Mshaima. The Ombudsman’s office indicated that it was satisfied with Jaw prison administration’s assurances that its insistence that Mshaima be shackled whenever he is taken to a medical appointment “would not prevent the provision of required healthcare services where there was an urgent need or medical emergency.” This statement disregards the fact that Mshaima’s principal medical concern is to have all of his medications dispensed to him regularly and without delay. This could be done by simple delivery to his cell, without the need for the unnecessarily demeaning and cumbersome procedure of shackling him and bringing him to the prison clinic. The failure to deliver full tranches of all medications prescribed to Mshaima persisted for months before international coverage and a hunger strike by Mshaima’s son Ali in front of Bahrain’s London Embassy most probably induced the prison authorities and the Ombudsman to respond.

The National Institute for Human Rights (NIHR) has an equally spotty record. The NIHR appears to have taken no action on behalf of Elyas Faisal al-Mulla, despite multiple reports from his family about the course of his cancer; Mohamed Ali Jaafar, the prisoner suffering from multiple sclerosis, although the NIHR has been apprised of his condition; or Mohamed Merza Moosa, despite receiving reports that he is in need of surgery to remove hemorrhoids, in addition to the orthopedic mattress for his chronic back pain. In the case of Ahmed Merza Ismaeel, it appears that the only purpose of a hospital transfer earlier this year, which included no tests or treatment, was to allow the NIHR to log the event.

A third institution with a monitoring mandate is the Special Investigations Unit, established by administrative order within the Office of Public Prosecution in order to investigate allegations of abuse by state agents. Amnesty has reviewed an attorney’s document from 2015 requesting an investigation into a case of physical assault by guards at Jaw prison. No action appears to have been taken in response. The Office of Public Prosecution also refused to meet with the family of Fawzeya Mashaalla Haji, who is under pretrial detention, in April of this year to discuss the possibility of release on bail for medical treatment.

Another failure of accountability lies in the partial or total withholding of medical records. Ahmed Merza Ismaeel’s family have been told that his hospital file will not be released to them because it is part of a “police case.” The difficulties encountered by Elyas Faisal al-Mulla’s family in obtaining his diagnosis with metastasized cancer have already been noted, as has the failure to provide a diagnosis to Hajer Mansoor Hassan. Families have also told Amnesty that the names of the medical staff at Jaw, like the guards, are not disclosed, undermining transparency and accountability when medical negligence or ill-treatment is alleged.

Obligations of Prison Authorities

Amnesty International calls on the authorities at Jaw prison, the women’s jail and prison at Isa Town, and all other places of detention in Bahrain to abide by international human rights law and standards in their treatment of detainees and prisoners.

As a state party to the International Covenant on Economic, Social and Cultural Rights, Bahrain is legally obliged to respect, protect and fulfil “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” Rule 24 of the UN Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules) clarifies that “The provision of health care for prisoners is a State responsibility” and that “Prisoners should enjoy the same standards of health care that are available in the community” without discrimination. The Nelson Mandela Rules also provide that prisoners who require specialist treatment must be transferred to specialized institutions or outside hospitals when such treatment is not available in prison (Rule 27).

Under the UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, as well as the Nelson Mandela Rules, health care provided to individuals in custody must be free of charge (Principle 24).

The failure to provide adequate health care to prisoners may violate the absolute prohibition of torture and other cruel, inhuman or degrading treatment or punishment, including under Article 7 of the International Covenant on Civil and Political Rights, to which Bahrain is a state party. This is particularly true when such failure is the result of a deliberate act by officials.

Amnesty International urges Bahrain to take immediate measures to fulfill its human rights obligations to all those held in the custody of the state, and to establish practices that will ensure against failure to provide medical care to prisoners.