Getting justice for victims of torture and other abuses used to be just about impossible. It's still extremely difficult, but decades of work by activists, lawyers — and increasingly by doctors — have brought new tools to the struggle, whether they're working in a war zone or a hostile political environment.
These days, Syria tends to dominate the discussion, in part because modern technology provides glimpses of atrocities almost in real time. Activists, sometimes taking great risks, can record the aftermath of attacks on hospitals, schools and homes and post their videos to the internet.
Ziad Mhirsi with Physicians for Human Rights, or PHR, says these videos make for powerful, attention-grabbing advocacy, but they don't actually do much to hold people accountable.
"Yes, it creates visibility, you can do it for advocacy purpose," he says. "But if you want justice, you have to think judiciary system, you have to think collection of evidence, chain of custody. There is a whole process."
And that's the good news: there is a process and it's been gaining ground. For more than a decade, doctors caring for patients who have been tortured have had a manual of guidelines approved by the U.N. to turn to. It's called the Istanbul Protocol, and physicians use it to document wounds in such fine, forensic detail that the results can serve in court as corroborating evidence of torture.
Gathering Evidence In War Zones
Even in a scene of daily carnage like the northern Syrian city of Aleppo, neurosurgeon Rami Kazali says when he treats people who say they were tortured by Syrian prison guards or by the Islamic State, his team carefully follows the protocol. Kazali risked his life to come to Istanbul for a PHR workshop this month on how to teach other doctors these same techniques.
He emphasizes that it's worth explaining to patients that the painstaking documentation process is worthwhile. His own approach is not to talk about international courts like the one in the Hague, but about a future Syrian government more willing to hold torturers to account.
"Some of them, because they don't have trust anymore in the international community, they say, 'No, we don't need this,'" he says. "But when we explain that it could be for our country and for our courts in the future, they said yes – because the idea is excellent, actually."
Here's how the protocol can help: Let's say someone confesses to a crime under torture and later tries to get a judge to throw that confession out because it was coerced.
In the past, it would just be the victim's word against that of the police. But now, doctors guided by the Istanbul Protocol can support many details of the victim's story with forensic evidence – what type of knife made this cut, serrated or single-edged? Was it made by a left- or right-handed person, from above or below? Kazali says all those details matter.
"So, we document everything, we make medical evaluation and psychological evaluation," he says. "So we are now, I think, we are experts in documenting cases [of those] who were under torture."
But what if you're working not in the chaos of a war zone, but in a country where prisoners are routinely tortured?
Gaining Trust Of Patients
Forensic physician Rusudan Beriashvilli has experience with that in a number of post-Soviet states, including her native Georgia. She says the attitudes she and her colleagues confront among governments and bureaucrats in their region are comparable with those found in the Middle East, Africa or Latin America.
Governments don't like it when doctors push for human rights, but a patient, relentless approach can slowly win adherents even in stubborn bureaucracies.
Beriashvilli has been doing a lot of work in Kazakhstan, where she says it was virtually forbidden to even speak of torture in detention. Now, after a four-year effort, she says the government has incorporated the Istanbul Protocols into a manual for physicians, and the Ministry of Health now requires doctors to document cases to international standards.
"So it's up to the professionals to build capacity, to know how to do best their work," she says. Finding the line between convincing and confronting authoritarian governments is important. "This is really the process that brings very much important changes."
Torture That Leaves No Outward Trace
Another Georgian, psychiatrist Mariam Jishkariani, is a veteran of another aspect of this struggle. She evaluates the psychological scars that torture can leave, invisible but capable of causing lasting damage. The International Committee of the Red Cross says torture during interrogation, for example, can avoid physical assault and yet inflict "severe psychological pain and suffering."
Physicians at the Istanbul gathering described examples of psychological torture suffered by Syrians — victims forced to watch their relatives being tortured, raped or killed, or even forced to commit torture themselves.
Jishkariani says science began to make advances in understanding psychological torture back during the Second World War, and it's commonly accepted in the medical community that virtually all torture inflicts some level of psychological trauma.
Jishkariani says cases of post-traumatic stress are noticeably higher among torture victims than those who suffer "ordinary trauma," such as a car accident.
But even today, she says in some countries it's hard to get investigators and judges to give psychological torture the same weight as the more obvious physical torture.
"It is, unfortunately, very common that forensic experts evaluate only physical scars, nothing more," she says. "We have to train doctors to do this. It is also something lawyers have to know, prosecutors have to know, judges have to know."
PHR Program Director Widney Brown says compared with the progress made in proving crimes involving physical torture, psychological torture has some catching up to do.
"I would say in the acceptance of psychological evidence, we're a couple of decades behind," says Brown. She believes that will change. "Within the community of psychiatry and psychology," she says," if you talk to people who are highly trained in this, there's a lot of confidence that they can consistently get this right."
Conflict, Chaos Threaten Gains
But in the current climate of raging conflicts, with millions of people facing atrocities at home and hostility when they try to flee, Brown worries that human rights improvements may be in jeopardy. She cites hospitals being shelled in Yemen, doctors kidnapped in Libya, patients killed in their hospital beds in South Sudan, and worries that years of work raising legal standards could be undermined by the rampant abuses taking place in Syria.
"More than anyplace else, you just have absolute shredding of those norms," she says. "And what it's going to take to recover, and how damaged those norms are, is a huge question for us."