IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT …...Petitioner Mohammad Ahmad Ghulam Rabbani (known as Ahmad Rabbani), by and through undersigned counsel, and pursuant to Fed

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA

MOHAMMAD AHMAD GHULAM RABBANI, Petitioner/Plaintiff, v. BARACK H. OBAMA, et al., Respondents/Defendants.

Civ. No. 05-1607 (RCL)

NOTICE OF APPEARANCE TO THE CLERK OF COURT AND ALL PARTIES OF RECORD:

PLEASE TAKE NOTICE that Eric L. Lewis, a member of the firm Lewis Baach

PLLC, who is admitted to practice before this Court, hereby enters his appearance in the above-

captioned matter as counsel for Petitioner Mohammad Ahmad Ghulam Rabbani.

Respectfully submitted, By: /s/ Eric L. Lewis

Eric L. Lewis (#394643) LEWIS BAACH PLLC 1899 Pennsylvania Avenue, NW, Suite 600 Washington, DC 20006 Telephone: (202) 833-8900 Facsimile: (202) 466-5738 [email protected]

Counsel for Mohammed Ahmad Ghulam Rabbani

Dated: March 27, 2014

Case 1:05-cv-01607-RCL Document 302 Filed 03/27/14 Page 1 of 1

mailto:[email protected]



Civ. No. 05-1607 (RCL)

NOTICE OF APPEARANCE TO THE CLERK OF COURT AND ALL PARTIES OF RECORD:

PLEASE TAKE NOTICE that Elizabeth L. Marvin of the firm Lewis Baach PLLC,

who is admitted to practice before this Court, hereby enters her appearance in the above-

captioned matter as counsel for Petitioner Mohammad Ahmad Ghulam Rabbani.

Respectfully submitted, By: /s/ Elizabeth L. Marvin

Elizabeth L. Marvin (#496571) LEWIS BAACH PLLC 1899 Pennsylvania Avenue, NW, Suite 600 Washington, DC 20006 Telephone: (202) 833-8900 Facsimile: (202) 466-5738 [email protected]

Counsel for Mohammed Ahmad Ghulam Rabbani



mailto:[email protected]



Civ. No. 05-1607 (RCL)

MOTION TO PRACTICE AND NOTICE OF ENTRY OF APPEARANCE

Undersigned counsel respectfully files this Motion to Practice and Notice of Entry of

Appearance on behalf of Mohammad Ahmad Ghulam Rabbani (known as Ahmad Rabbani) pursuant

to Local Civil Rule 83.2(g) and Local Civil Rule 83.6(a). Counsel is a member in good standing of

the State Bar of California. Counsel hereby certifies that Petitioner in this case is indigent and

counsel is providing representation without compensation.

Dated: March 27, 2014 /s/

JON B. EISENBERG 1970 Broadway, Suite 1200 Oakland, California 94612 (510) 452-2581 [email protected]





Civ. No. 05-1607 (RCL)

PETITIONER’S APPLICATION FOR PRELIMINARY INJUNCTION

Petitioner Mohammad Ahmad Ghulam Rabbani (known as Ahmad Rabbani), by and through

undersigned counsel, and pursuant to Fed. R. Civ. P. 65 and the All Writs Act, 28 U.S.C. § 1651

(2012), applies to this Court for a preliminary injunction addressing (1) the unconstitutional and

inhumane force-feeding of hunger-striking detainees at Guantánamo Bay, and (2) a denial of their

right to religious free exercise. Petitioner requests an expeditious hearing on this motion because of

the extreme nature of the constitutional, ethical, and human rights violations that are presently

occurring at Guantánamo Bay.

In support of this Application, Petitioner submits the accompanying (i) Statement of Points

and Authorities; (ii) Declaration of Jon B. Eisenberg; (iii) Declaration of Clive A. Stafford Smith;

(iv) Declaration of Clive A. Stafford Smith for Imad Abdullah Hassan; (v) Declaration of Steven

H. Miles for Imad Abdullah Hassan; (vi) Declaration of Stephen N. Xenakis M.D. for Imad

Abdullah Hassan; (vii) Declaration of Cori Crider for Imad Abdullah Hassan; and (viii) Proposed

Order.


2

Petitioner is filing separately under seal pursuant to the September 11, 2008 Protective Order

and Procedures for Counsel Access to Detainees at the United States Naval Base in Guantánamo

Bay, Cuba (Case No. 1:08-cv001440-UNA) a Supplemental Memorandum in Support of Application

for Preliminary Injunction attaching the November 2013 and December 2013 protocols issued by the

Joint Medical Group, Joint Task Force Guantánamo Bay, Cuba detailing Medical Management of

Detainees with Weight Loss. The Government has designated these protocols as “Protected

Information” pursuant to the September 11, 2008 Protective Order.

Respectfully submitted, /s/ Jon B. Eisenberg

JON B. EISENBERG (CA State Bar #88278) 1970 Broadway, Suite 1200 Oakland, CA 94612 (510) 452-2581 [email protected]

/s/ Alka Pradhan REPRIEVE Clive Stafford Smith (LA Bar #14444) Cori Crider (NY Bar #4525721) Alka Pradhan (D.C. Bar #1004387) P.O. Box 72054 London EC3P 3BZ United Kingdom 011 44 207 553 8140 [email protected] [email protected] [email protected]


3


/s/ Eric L. Lewis LEWIS BAACH PLLC Eric L. Lewis (D.C. Bar #394643) Elizabeth L. Marvin (D.C. Bar #496571) 1899 Pennsylvania Avenue, NW, Suite 600 Washington, DC 20006 (202) 833-8900 [email protected] [email protected] Counsel for Petitioner/Plaintiff




Civ. No. 05-1607 (RCL)

CORRECTED STATEMENT OF POINTS AND AUTHORITIES IN SUPPORT OF

PETITIONER’S APPLICATION FOR PRELIMINARY INJUNCTION JON B. EISENBERG (CA State Bar #88278)

1970 Broadway, Suite 1200 Oakland, CA 94612 (510) 452-2581

REPRIEVE Clive Stafford Smith (LA Bar #14444) Cori Crider (NY Bar #4525721) Alka Pradhan (D.C. Bar #1004387) P.O. Box 72054 London EC3P 3BZ United Kingdom 011 44 207 553 8140

LEWIS BAACH PLLC Eric L. Lewis (D.C. Bar #394643) Elizabeth L. Marvin (D.C. Bar #496571) 1899 Pennsylvania Avenue, NW, Suite 600 Washington, DC 20006 (202) 833-8900

Dated: March 27, 2014 Counsel for Petitioner/Plaintiff

Case 1:05-cv-01607-RCL Document 308-1 Filed 03/27/14 Page 1 of 51

i

TABLE OF CONTENTS

Page TABLE OF AUTHORITIES ......................................................................................................... iii INTRODUCTION ...........................................................................................................................1 STATEMENT OF FACTS ..............................................................................................................3 A. The Reality of Force-Feeding at Guantánamo Bay .............................................................3

B. The Written Protocols on Force-Feeding at Guantánamo Bay ..........................................15

C. Deprivation of Communal Prayer During Ramadan .........................................................18 STATEMENT OF JURISDICTION..............................................................................................19

ARGUMENT .................................................................................................................................20 I. THIS COURT SHOULD ENJOIN PETITIONER’S FORCE-FEEDING

BECAUSE, GIVEN THE AVAILABILITY OF READY ALTERNATIVES, IT IS NOT REASONABLY RELATED TO LEGITIMATE PENOLOGICAL INTERESTS AND IS THEREFORE UNCONSTITUTIONAL .......................................20

A. The standard for determining the legality of the Guantánamo Bay force-

feeding practices and protocols—whether they are “reasonably related to legitimate penological interests”—asks whether there are any “ready alternatives.” ..........................................................................................................21

B. Force-feeding is an invasive and painful procedure which is inhumane,

degrading, and a violation of international law and medical ethics .......................22 C. The Guantánamo Bay force-feeding practices and protocols are

unreasonable because they inflict unnecessary pain and suffering ........................28 D. The Guantánamo Bay force-feeding practices and protocols are

unreasonable because they subject detainees to force-feeding before the detainees are at risk of death or great bodily injury ...............................................28

E. The Guantánamo Bay force-feeding practices and protocols are

unreasonable because “ready alternatives,” as exemplified by U.S. Bureau of Prisons regulations, can achieve the government’s legitimate interests ............32


ii

F. The Government has such complete control over the Guantánamo Bay detainees that hunger-strikers present no threat to institutional security ...............34

G. Even if the force-feeding protocols were to be upheld, this Court should

grant habeas relief because, in practice, the Government is deviating from those protocols .......................................................................................................35

II. DEPRIVATION OF COMMUNAL PRAYER VIOLATES THE RELIGIOUS

FREEDOM RESTORATION ACT (RFRA) ....................................................................35

III. PETITIONER MUST BE AFFORDED THE PROTECTIONS OF INTERNATIONAL LAW PURSUANT TO THE TREATY OF FRIENDSHIP AND COMMERCE BETWEEN THE UNITED STATES AND PAKISTAN ................38

IV. PETITIONER MEETS THE CRITERIA FOR GRANTING A PRELIMINARY INJUNCTION ....................................................................................................................40

CONCLUSION ..............................................................................................................................41


iii

TABLE OF AUTHORITIES

Page(s) CASES

Aamer v. Obama,

742 F.3d 1023 (D.C. Cir. 2014) ....................................................................................... passim

Al-Adahi v. Obama, 596 F. Supp. 2d 111 (D.D.C. 2009) .........................................................................................21

Association des Eleveurs de Canards et d'Oies du Quebec v. Harris, 729 F.3d 937 (9th Cir. 2013) ...................................................................................................25

Bell v. Wolfish, 441 U.S. 520 (1979) .................................................................................................................22

Bezio v. Dorsey,

989 N.E.2d 942 (N.Y. 2013) ..............................................................................................21, 31

Bluman v. FEC, 800 F. Supp. 2d 281 (D.D.C. 2011) .........................................................................................36

Citizens United v. FEC, 558 U.S. 310 (2010) .....................................................................................................36, 37, 38

Creek v. Stone, 379 F.2d 106 (D.C. Cir. 1967) .................................................................................................19

Cruzan v. Director, Mo. Dep’t of Health, 497 U.S. 261 (1990) .................................................................................................................21

Fed. Election Comm’n v. Wis. Right to Life, Inc., 551 U.S. 449 (2007) .................................................................................................................37

Hicks v. Bush, 452 F. Supp. 2d 88 (D.D.C. 2006) ...........................................................................................21

Hudson v. Hardy, 424 F.2d 854 (D.C. Cir. 1970) .................................................................................................19

Makin v. Colorado Department of Corrections, 183 F.3d 1205 (10th Cir. 1999) ...............................................................................................36

Miller v. Overholser, 206 F.2d 415 (D.C. Cir. 1953) .................................................................................................19


iv

Rasul v. Myers, 563 F.3d 527 (D.C. Cir. 2009) ...........................................................................................36, 37

Salahuddin v. Coughlin, 993 F.2d 306 (2d Cir. 1993).....................................................................................................36

Sebelius v. Hobby Lobby Stores, Inc.,

No. 13-354, cert. granted, 134 S. Ct. 678 (Nov. 26, 2013) .....................................................36

Turkmen v. Ashcroft, 915 F. Supp. 2d 314 (E.D.N.Y. 2013) ...............................................................................37, 38

Turner v. Safley, 482 U.S. 78 (1987) ........................................................................................................... passim

United States v. Wilson, 471 F.2d 1072 (D.C. Cir. 1972) ...............................................................................................19

Washington v. Harper, 494 U.S. 210 (1990) .....................................................................................................20, 21, 22

Winter v. Natural Res. Def. Council, Inc., 555 U.S. 7 (2008) .....................................................................................................................40

FEDERAL STATUTES

42 U.S.C. § 2000bb-1 ....................................................................................................................35

FEDERAL REGULATIONS

28 C.F.R. § 549.65(a).....................................................................................................................32

28 C.F.R. § 549.65(c).....................................................................................................................33

28 C.F.R. § 552.20 .........................................................................................................................32

28 C.F.R. § 552.22(c)...............................................................................................................32, 33 28 C.F.R. § 552.22(c)(h)(2) ...........................................................................................................32

28 C.F.R. § 552.24 .........................................................................................................................33

PUBLIC LAWS Pub. L. 109-366, § 5(a), 120 Stat. 2600 (2006) .............................................................................39


v

INTERNATIONAL CASES Nevmerzhitsky v. Ukraine, App. No. 548255/00, Final Judgment, ¶ 98, Oct. 12, 2005

(Eur. Ct. H.R.) available at http://www.rwi.uzh.ch/lehreforschung/alphabetisch/ kiener/Vorlesungen/hs11-1/menschenrechte/unterlagen/ CASE_OF_NEVMERZHITSKY_v_UKRAINE.pdf ........................................................23, 24

Prosecutor v. Ŝeŝelj, Case No. IT-03-67-T, Urgent Order to the Dutch Authorities

Regarding Health and Welfare of the Accused 6 (Int’l Crim. Trib. for the Former Yugoslavia Dec. 6, 2006).........................................................................................................24

TREATIES

Treaty of Friendship and Commerce Between the United States of America and Pakistan,

art. III, 12 U.S.T. 110, 404 U.N.T.S. 259 (Feb. 12, 1961), available at http://tcc.export.gov/trade_agreements/all_trade_agreements/ exp_005355.asp .......................................................................................................................39

Geneva Convention Relative to the Treatment of Prisoners of War Art. 3, Aug. 12, 1949,

75 U.N.T.S. 135, available at http://www1.umn.edu/humanrts/instree/y3gctpw.htm ............24

UNITED NATIONS DOCUMENTS

U.N.H.R. Press Release, OHCHR, IACHR, UN Working Group on Arbitrary Detention, UN Rapporteur on Torture, UN Rapporteur on Human Rights and Counter-Terrorism, and UN Rapporteur on Health reiterate need to end the indefinite detention of individuals at Guantánamo Naval Base in light of current human rights crisis (May 1, 2013), available at www.ohchr.org/en/newsevents/ pages/isplaynews.aspx?newsid=13278&langl .........................................................................22

United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading

Treatment, Dec. 10, 1984, 1465 U.N.T.S. 85, 113 U.N. Doc. A/39/51, available at http://www1.umn.edu/humanrts/instree/h2catoc.htm ..............................................................23

EXECUTIVE ORDERS

Executive Order, Ensuring Lawful Interrogations, 13491, §3(a) (Jan. 22, 2009),

available at http://www.whitehouse.gov/the-press-office/ ensuring-lawful-interrogations ...........................................................................................................................27

TRANSCRIPTS

The Tokyo War Crimes Trial, vol. 6, Transcript of the Proceedings in Open Session (1981) ..........................................................................................................10, 11


http://www.rwi.uzh.ch/lehreforschung/alphabetisch/kiener/Vorlesungen/hs11-1/menschenrechte/unterlagen/CASE_OF_NEVMERZHITSKY_v_UKRAINE.pdf



http://tcc.export.gov/trade_agreements/all_trade_agreements/exp_005355.asp


http://www1.umn.edu/humanrts/instree/y3gctpw.htm

http://www1.umn.edu/humanrts/instree/h2catoc.htm

http://www.whitehouse.gov/the-press-office/ensuring-lawful-interrogations

http://www.whitehouse.gov/the-press-office/ensuring-lawful-interrogations

vi

OTHER AUTHORITIES

American Gastroenterological Association, American Gastroenterological Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition (1994) ...................9

George J. Annas, Sondra S. Crosby & Leonard H. Glanz, Guantánamo Bay: A Medical Ethics-free Zone? 369 New Eng. J. Med. 101 (July 11, 2013) .......................24, 25 Michael L. Gross, Force-Feeding, Autonomy, and the Public Interest,

New Eng. J. Med., 103 (July 11, 2013) .............................................................................24, 26 Institute on Medicine as a Profession and Open Society Forum, Task Force Report,

Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror (2013) ...........................................................................................................................27

Mohamed Haq Magid, Reflections on the Qur’an: A Ramadan Reader (2011) ..........................18 Darius Rejali, Torture and Democracy (2007) ..............................................................................10 George Ryley Scott, The History of Torture (1940) ......................................................................10 M. Stroud, H. Duncan & J. Nightingale, Guidelines for enteral feeding in adult hospital

patients, 52 Gut vii1, § 3.0 (2003) available at http://gut.bmj.com/content/52/suppl_7/vii1.full#sec-3 ..............................................................6

Marc Thiessen, Courting Disaster (2009) .....................................................................................11

MISCELLANEOUS Moath al-Alwi, A letter from Guantanamo: “Nobody can truly understand how we

suffer” (Mar. 13, 2014) available at http://www.aljazeera.com/indepth/opinion/ 2014/03/letter-from-guantanamo-nobody-c-201431385642747154.html .................................9

American Ass’n of Critical-Care Nurses, AACN Practice Alert: Verification of Feeding

Tube Placement 2 (2009), available at http://www.aacn.org/WD/Practice/Docs/ PracticeAlerts/Verification_of_Feeding_Tube_Placement_05-2005.pdf ..................................8

Joanna Briggs Institute, Methods for determining the correct nasogastric tube placement

after insertion in adults, 14(1) Best Practice 2 (2010), available at http://connect.jbiconnectplus.org/ViewSourceFile.aspx?0=5384 .........................................7, 8

Cal. Corr. Health Care Servs., Inmate Medical Services Policies & Procedures, Vol. 4, Ch. 22.2, Policy 4.22.2: Mass Organized Hunger Strike (Sept. 29, 2011, rev. July 2013) § VII.C, at 5 available at

http://www.cphcs.ca.gov/docs/imspp/IMSPP-v04-ch22.2.pdf ..........................................29, 30


http://gut.bmj.com/content/52/suppl_7/vii1.full#sec-3

http://www.cphcs.ca.gov/docs/imspp/IMSPP-v04-ch22.2.pdf

vii

Congressional Research Service, U.N. Convention Against Torture (CAT): Overview and Application to Interrogation Techniques (Jan. 26, 2009) available at http://www.fas.org/sgp/crs/intel/RL32438.pdf ........................................................................27

The Constitution Project, Report of the Task Force on Detainee Treatment (2013)

available at http://detaineetaskforce.org/read/files/assets/ basic-html/index.html#page1 ............................................................................................................26

Guantánamo: hunger strikes and a doctor’s duty, The Lancet (May 4, 2013), available

at http://www.thelancet.com/journals/lancet/article/ PIIS0140-6736(13)60962-9/fulltext ...................................................................................................................................23

Guidelines for enteral feeding in adult hospital patients at § 10.4, available at

www.http://gut.bmj.com/content/52/suppl_7/vii1.full ............................................................11 Int’l Comm. of the Red Cross, Hunger strikes in prisons: the ICRC’s position (Jan. 31,

2013) available at http://www.icrc.org/eng/resources/documents/faq/ hunger-strike-icrc-position.htm ......................................................................................................................23

International Covenant on Civil & Political Rights, Art. 18, para. 1 (1976) available at

http://www.refworld.org/pdfid/3ae6b3aa0.pdf ........................................................................39 Letter from Dianne Feinstein, Senator, to Honorable Chuck Hagel, Sec’y of Def. (June

19, 2013), available at http://www.feinstein.senate.gov/public/index.cfm/press-releases?ID=8af43b52-0301-42b9-8f72-27f88997bd39 .........................................................26

Letter from Jeremy A. Lazarus, M.D., President of Am. Med. Ass’n, to Honorable Chuck

Hagel, Sec’y of Def. (Apr. 25, 2013) available at http://www.jhsph.edu/research/ centers-and-institutes/center-for-public-health-and-human-rights/_pdf/AMA%20Hunger%20Strikes%20Letter.pdf.........................................................23

Ian Lovett, Inmates End Hunger Strike in California, N.Y. Times (Sept. 5, 2013)

available at http://www.nytimes.com/2013/09/06/us/ inmates-end-hunger-strike-in-california.html?_r=0 ..........................................................................................................28, 32

David McFadden, U.S. Military says number of Guantánamo prisoners on hunger strike

has dropped to 75 from 106, StarTribune, (July 18, 2013), available at http://www.startribune.com/politics/national/216036341.html ...............................................19

Samir Naji al Hasan Moqbel, Gitmo Is Killing Me, N.Y. Times (Apr. 14, 2013) available at http://www.nytimes.com/2013/04/15/opinion/ hunger-striking-at-

guantanamo-bay.html?_r=0 .....................................................................................................25


http://www.fas.org/sgp/crs/intel/RL32438.pdf

http://detaineetaskforce.org/read/files/assets/basic-html/index.html#page1

http://detaineetaskforce.org/read/files/assets/basic-html/index.html#page1

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60962-9/fulltext

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60962-9/fulltext

http://www.http/gut.bmj.com/content/52/suppl_7/vii1.full

http://www.icrc.org/eng/resources/documents/faq/hunger-strike-icrc-position.htm

http://www.icrc.org/eng/resources/documents/faq/hunger-strike-icrc-position.htm

http://www.refworld.org/pdfid/3ae6b3aa0.pdf

http://www.feinstein.senate.gov/public/index.cfm/press-releases?ID=8af43b52-0301-42b9-8f72-27f88997bd39

http://www.feinstein.senate.gov/public/index.cfm/press-releases?ID=8af43b52-0301-42b9-8f72-27f88997bd39

http://www.jhsph.edu/research/centers-and-institutes/center-for-public-health-and-human-rights/_pdf/AMA%20Hunger%20Strikes%20Letter.pdf



http://www.nytimes.com/2013/09/06/us/inmates-end-hunger-strike-in-california.html?_r=0

http://www.nytimes.com/2013/09/06/us/inmates-end-hunger-strike-in-california.html?_r=0

http://www.startribune.com/politics/national/216036341.html

viii

Pennsylvania Patient Safety Reporting Systems, Patient Safety Advisory, Confirming Feeding Tube Placement: Old Habits Die Hard 1 (2006), available at http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Dec3(4)/Pages/23.aspx. .....................................................................................................................................7

Carol Rosenberg, Guantánamo: 25 Captives Quit Hunger Strike Since Ramadan, Miami

Herald (July 14, 2013) available at http://www.miamiherald.com/ 2013/07/14/3499662/guantanamo-25-captives-quit-hunger.html ...........................................18

Charlie Savage, 15 Held at Guantánamo Are Said to Quit Hunger Strike, N.Y. Times

(July 14, 2013) available at http://www.nytimes.com/2013/07/15/us/ more-guantanamo-detainees-quit-hunger-strike.html .......................................................................19

Eric Schmitt & Tim Golden, Force-Feeding at Guantánamo Is Now Acknowledged, New

York Times (Feb. 22, 2006), available at http://www.nytimes.com/ 2006/02/22/international/middleeast/22gitmo.html?_r=0. ........................................................4

Dr. Sayyid M. Syeed, The Meaning of Tarawih, available at

http://www.nrcat.org/interfaith-campaign-to-address-anti-muslim-sentiment/background/the-meaning-of-tarawih .......................................................................18

U.S. Dep’t of Justice, Program Statement No. P5562.05 (July 29, 2005)

available at http://www.cbsnews.com/htdocs/pdf/BOP_FBI_hungerstrikepolicy.pdf ...........33 World Medical Association, WMA Declaration of Malta on Hunger Strikers (1991)

available at http://www.wma.net/en/30publications/10policies/h31/ ...............................22, 24

World Medical Association, WMA Declaration of Tokyo—Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment (1975) available at http://www.wma.net/en/30publications/10policies/c18/ ..........................................................22


http://www.miamiherald.com/2013/07/14/3499662/guantanamo-25-captives-quit-hunger.html

http://www.miamiherald.com/2013/07/14/3499662/guantanamo-25-captives-quit-hunger.html

http://www.nytimes.com/2013/07/15/us/more-guantanamo-detainees-quit-hunger-strike.html

http://www.nytimes.com/2013/07/15/us/more-guantanamo-detainees-quit-hunger-strike.html

http://www.cbsnews.com/htdocs/pdf/BOP_FBI_hungerstrikepolicy.pdf

http://www.wma.net/en/30publications/10policies/h31/

http://www.wma.net/en/30publications/10policies/c18/

INTRODUCTION

Petitioner Mohammad Ahmad Ghulam Rabbani (known as Ahmad Rabbani), by and

through undersigned counsel, moves this Court for a preliminary injunction addressing (1) the

unconstitutional and inhumane force-feeding of hunger-striking detainees at Guantánamo Bay,

and (2) a denial of their right to religious free exercise. Petitioner requests an expeditious

hearing on this motion because of the extreme nature of the constitutional, ethical, and human

rights violations that are presently occurring at Guantánamo Bay.

Force-feeding at Guantánamo Bay is a violent, painful, and degrading process that

violates international law and medical ethics. Perhaps most notably, as reflected in public

statements by United States military personnel, the force-feeding process includes techniques

that inflict gratuitous pain and suffering on the detainees, in an effort to coerce them to give up

their peaceful protest. These techniques include the following:

1. Using so-called Forcible Cell Extraction (FCE) teams of soldiers to take detainees

to feeding sessions by force and violence, despite their lack of resistance;

2. Genital searches;

3. Use of an immobilizing restraint chair;

4. Force-feeding twice each day when medically unnecessary;

5. Pulling the 110-centimeter-long feeding tubes out after each feeding and then

forcibly re-inserting them for the next feeding, instead of leaving tubes in place

from feeding to feeding;

6. Using feeding tubes that are too thick for detainees’ nasal passages;

7. Using an outdated and unreliable method to determine proper placement of the

feeding tube;

8. Forcing fluids into detainees at excessive speed, which causes severe enteral pain;


2

9. If a detainee vomits during the process, repeating the process immediately, with

vomit still on the prisoner; and if a detainee defecates during the process, leaving

him sitting under physical restraint in his own feces.

Fluids are sometimes forced through detainees’ feeding tubes at such an extreme rate—

nearly two-thirds of a gallon in as little as 20 minutes—as to constitute a form of the “Water

Cure” torture, which dates back to the Middle Ages.

Medical professionals are complicit in the infliction of this unnecessary pain and

suffering in the effort to coerce the detainees to stop hunger-striking. Medical judgments have

been made subservient to military orders.

The Guantánamo Bay force-feeding practices and governing written protocols are

unconstitutional, given the availability of ready alternatives, which are exemplified by standards

followed by the U.S. Bureau of Prisons and California state prisons. The Guantánamo detainees

are being unnecessarily force-fed well before they are actually at risk of death or great bodily

injury, and during the force-feeding they are being unnecessarily subjected to unnecessary and

illegal physical abuse.

Petitioner wishes to make clear that he is not seeking an injunction to permit him to

continue his hunger strike until death. Rather, he is seeking a constitutional protocol that ensures

he is not force-fed prematurely and is not subjected to methods of force-feeding that cause

unnecessary pain and suffering.

Hunger-striking detainees have also been deprived of the ability to participate in

communal prayer during the Islamic holy month of Ramadan. This happened in 2013, and

absent this Court’s intervention it will surely happen again this year, when Ramadan begins on

approximately June 28.


3

The United States Court of Appeals for the District of Columbia Circuit recently held that

challenges by Guantánamo Bay detainees to the conditions of their confinement properly sound

in habeas corpus and thus are not barred by the Military Commissions Act of 2006. Aamer v.

Obama, 742 F.3d 1023 (D.C. Cir. 2014). This motion invokes this Court’s habeas jurisdiction

to take action to remedy the festering wound of human rights violations that the detention facility

at Guantánamo Bay has become.

STATEMENT OF FACTS

A. The Reality of Force-Feeding at Guantánamo Bay.

Petitioner is a Pakistani national whose family, including three children, still lives in

Pakistan. After capture by U.S. forces and detention at the infamous Dark Prison in Afghanistan,

he was transferred to Guantánamo Bay in September 2004. See Declaration of Clive Stafford

Smith ¶¶ 6,7 (“Stafford Smith Decl.”).

Petitioner joined the widespread hunger strike in February 2013, and has been on a

continuous strike since that time. Stafford Smith Decl. ¶¶ 8, 12, 14-15, 71, 73. He joined the

peaceful protest because he believes that his continued detention at Guantánamo Bay, for nine

years without charge or trial, is wrong. He also finds the conditions at Guantánamo Bay

deplorable, from physical abuse, arbitrary punishments, and disrespect of his religion to JTF-

GTMO’s withholding of his legal materials. Id. ¶¶ 9-11.

Hunger striking has taken place at Guantánamo since 2005, when detainees first sought to

bring the prison into compliance with the Geneva Conventions and peacefully protest their

detention without charge or trial. In late 2005 and early 2006, JTF-GTMO decided to use

punitive force-feeding measures on hunger strikers to coerce the end of the peaceful protest. This

tactic was confirmed in a New York Times interview with General Bantz J. Craddock, who was


4

then in overall command of the armed forces at Guantánamo Bay. General Craddock told the

New York Times precisely what the detainees had been warned: that new procedures had been

adopted in an effort to end their hunger strike. He candidly admitted that he and senior officials

at the Department of Defense had decided to take measures intended to make hunger-striking at

Guantánamo Bay “less convenient”—a not-very-subtle euphemism for more painful—saying he

had reviewed the use of restraint chairs and other new techniques and had decided that these new

techniques would convince the detainees that hunger-striking was not worth their while: “

‘Pretty soon it wasn’t convenient, and they decided it wasn’t worth it,’ he said of the hunger

strikers. ‘A lot of the detainees said: “I don’t want to put up with this. This is too much of a

hassle.” ’ ” Eric Schmitt & Tim Golden, Force-Feeding at Guantánamo Is Now Acknowledged,

New York Times (Feb. 22, 2006), available at http://www.nytimes.com/

2006/02/22/international/middleeast/22gitmo.html?_r=0.

Thus, the commanding officer for Guantánamo Bay publicly conceded that he had

changed existing practices solely for the purpose of inflicting gratuitous pain and suffering in

order to coerce detainees to call off their hunger strike, and the detainees were made to

understand this.

Petitioner feels, ironically, that only the most physically violent protests from detainees,

such as throwing urine or feces, elicit positive change from the JTF-GTMO authorities. Rather

than engage in such acts, Petitioner instead chose to join the general hunger strike of 2013.

Unfortunately, the widespread strike only inspired the JTF-GTMO authorities to add further

violent measures to the force-feeding techniques, which continue to be used on the Petitioner and

other hunger-striking detainees to this day. Stafford Smith Decl. ¶¶ 8, 16, 36, 46, 51, 65. They

include:


5

1. Forcible and violent removal of detainees to the force-feeding location. A FCE

team uses force and violence to take detainees to the feeding location, causing them substantial

pain. The soldiers rush the detainee’s cell, force him onto the concrete floor, shackle his hands

painfully behind his back, shackle his legs, and then carry his body to where he will be force-fed.

Petitioner reports that after each FCE event, he has had pain in his back for days. He now

attempts to walk to the force-feedings, although this act is involuntary because he simply cannot

withstand the intense pain cause by the FCE process. Regardless, he and other detainees continue

to be FCE’d periodically for various transgressions, including the genital searches detailed

below. Stafford Smith Decl. ¶¶ 16, 18-30, 33. Petitioner also describes the FCE process as

“second degree torture,” as he witnesses other detainees being subjected to FCE violence each

day with the knowledge that he will be have to endure the same pain if he does not comply by

walking to his feeding. Id. ¶ 17. See also Declaration of Clive Stafford Smith for Imad Abdullah

Hassan ¶¶ 42, 43, 45, attached to this motion as Exhibit A (“Exh. A”).1

2. Unnecessary and degrading genital searches. If detainees refuse to walk to the

force-feeding chairs, the FCE team performs manual searches of their genitals, an arbitrary

punishment that is particularly degrading to Muslim men due to their religious beliefs. Stafford

Smith Decl. ¶¶ 30-35. These so-called “Scrotum Searches” were previously used only for

external detainee movements, not internal movements such as going to or returning from a force-

feeding. When Petitioner was first subjected to a Scrotum Search following a force-feeding in

January 2014, he protested and received an apology from the soldier performing the search. But

1 Mr. Hassan has also filed an application for preliminary injunction, similar to the present application. See Hassan v. Obama, Civ. No. 04-cv-1194 (UNA), Doc. #1001, filed March 11, 2014.


6

in February, Petitioner’s genitals were again searched on his way to a force-feeding. When he

protested, an FCE team was called to violently extract him from his cell. Id. ¶ 33.

3. Use of restraint chairs. Force-feeding now occurs in a specially-made restraint

chair, with the detainee forcibly strapped down tightly at his hands, legs, waist, shoulders, and

head. The detainees have dubbed this the “Torture Chair.” Stafford Smith Decl. ¶¶ 38, 39. See

also Exh. A ¶¶ 42, 43, 45.

4. Insistence on two force-feedings per day. Although only one force-feeding per

day is necessary to keep detainees alive—JTF-GTMO’s stated purpose in force-feeding the

detainees—they are unnecessarily subjected to the violent force-feeding procedures twice daily.

Stafford Smith Decl. ¶¶ 12, 53, 70. Petitioner has pointed out to medical staff that his weight

does not fluctuate when he is force-fed only once daily, and has requested once-daily feedings

due to the pain and severe gas that force-feeding causes his stomach. His requests have been

ignored. Id. at ¶ 53.

5. Insertion and withdrawal of feeding tubes twice each day. Instead of being left in

place for extended periods of time (to avoid undue pain, infection and medical complications),

feeding tubes are withdrawn after each feeding and are re-inserted for the next feeding, twice

daily. Exh. A ¶ 40. This is a departure from customary medical practice, whereby feeding tubes

are left in place from one feeding until the next. Declaration of Steven H. Miles for Imad

Abdullah Hassan ¶ 8(a), attached to this motion as Exhibit B (“Exh. B”); see M. Stroud, H.

Duncan & J. Nightingale, Guidelines for enteral feeding in adult hospital patients, 52 Gut vii1, §

3.0 (2003), available at http://gut.bmj.com/content/52/suppl_7/vii1.full#sec-3 (nasogastric tubes

“should usually be changed every 4-6 weeks swapping them to the other nostril”). Routine

removal and reinsertion of feeding tubes increases the risk that the tube will go into the lungs


7

where it, or inadvertently-administered feeding solution, could cause serious injury or death.

Exh. B ¶ 8(a).

6. Use of thicker feeding tubes. Unnecessarily thick feeding tubes are used. Instead

of the size 8 French feeding tube previously used in 2005, feeding tubes as thick as size 14

French are now used, which allows for much faster feeding. Stafford Smith Decl. ¶ 41; Exh. A ¶

41, 60, 92. Size 14 French feeding tubes are generally used only when there is a need to remove

contents from the stomach, which is not necessary except in persons with some neurologic

conditions that impair gastric emptying or when the rate of feeding is excessively rapid. Exh. B

¶ 8(b).

7. Use of unsound method to confirm placement of feeding tube. Guantánamo Bay

staff use a dangerous and unreliable method called “auscultation” to verify feeding tube

placement. See infra at 16. “Auscultation involves instilling air into the feeding tube with a

syringe while using a stethoscope placed over the stomach to listen for rushing air. However,

this method cannot differentiate between tube placement in the stomach or the lung/bronchial

tree.” Pennsylvania Patient Safety Reporting Systems, Patient Safety Advisory, Confirming

Feeding Tube Placement: O ld Habits Die Hard 1 (2006), available at

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Dec3(4)/Pages/23.aspx.

It is an antiquated procedure which in customary medical practice has been replaced by

radiographic confirmation with a chest x-ray or by determining the pH of fluid aspirated from the

feeding tube. Id. at 2-3, 5. With auscultation, misplacements of feeding tubes are frequent, and

each occurrence of misplacement increases the risk for future misplacement. Id. at 4; accord,

Joanna Briggs Institute, Methods for determining the correct nasogastric tube placement after

insertion in adults, 14(1) Best Practice 2 (2010), available at http://connect.jbiconnectplus.org/


8

ViewSourceFile.aspx?0=5384 (“auscultation is not a reliable method to differentiate gastric and

respiratory placement”); American Ass’n of Critical-Care Nurses, AACN Practice Alert:

Verification of Feeding Tube Placement 2 (Dec. 2009), available at

http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/Verification_of_Feeding_Tube_

Placement_05-2005.pdf (“[t]he auscultatory method is not reliable in distinguishing between

respiratory and gastric placement”).

8. Speed of force-feeding. JTF-GTMO force-feeds detainees an astonishing and

medically unnecessary amount of liquid in very short periods of time. Stafford Smith Decl. ¶ 49;

see also Exh. A ¶ 50. The March 2013 written protocols for force-feeding at Guantánamo Bay

prescribe 20 to 30 minutes per feeding. See infra at 16. Over time, the amount and speed of

force-feeding has varied from detainee to detainee. One detainee reports having been force-fed

with quantities of nutrient and water totaling as much as 3,400 milliliters (ml) in a single force-

feeding session. Exh. A ¶ 48. Another detainee recently reported that at each force-feeding

session he currently receives as much as 1,100 ml of nutrient mixed with water, which may be

followed by another 500 ml of water mixed with anti-constipation medication, which may then

be followed by another draught of water bringing the total to nearly 2,300 ml—taking roughly 20

minutes and rarely more than 30 minutes. Id. ¶ 49. This report is consistent with the governing

protocols at Guantánamo, which prescribe about 2,300 ml for average-sized detainees. See infra

at 16. Petitioner reports being force-fed around 1,000 ml of nutrient mixed with water, beyond

which he may be given more liquid to wash through the feed and yet more liquid with laxative

medication. See Stafford Smith Decl. ¶¶ 54-55.

Thus, twice each day, as much as 2,300 ml of liquid (or more)—nearly two-thirds of a

gallon (or more)—may be forced into a detainee in as little as 20 minutes. This is an


9

extraordinary departure from customary medical practice. Exh. B ¶ 8(d); Declaration of Stephen

N. Xenakis M.D. for Imad Abdullah Hassan ¶ 12, attached to this motion as Exhibit C (“Exh.

C”). Guidelines promulgated by the American Gastroenterological Association (AGA) for

nasogastric tube feeding describe typical “rapid bolus” feeding at a rate of 250 ml of nutrient

with 10 ml of water per 15 minutes. See AGA, American Gastroenterological Association

Medical Position Statement: Guidelines for the Use of Enteral Nutrition 17 (1994), available at

http://www3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html. The Guantánamo Bay

detainees may be force-fed at speeds nearly seven times this rate.

Petitioner has reported that during some of his force-feedings, the JTF-GTMO staff, and

sometimes the nurses themselves, squeeze the liquid feed bags to increase the speed at which the

liquid enters his stomach. This causes immense pain as his stomach expands much more rapidly

than is natural. Stafford Smith Decl. ¶ 46. If a detainee vomits at any time during or after a

feeding, the process, including re-insertion of the nasal tube, is repeated. No matter how much

liquid is expelled during vomiting, a full two cans of nutritional supplement is pumped back into

the detainee’s stomach. Id. at ¶¶ 48, 51.

Another hunger-striking detainee has further reported that frequently the guards “lie me

down on my stomach in my cell and press my back forcefully, squeezing out any remaining

feeding solution from the previous force-feeding session.” Moath al-Alwi, A letter from

Guantanamo: “Nobody can truly understand how we suffer” (Mar. 13, 2014),

available at www.aljazeera.com/indepth/opinion/2014/03/letter-from-guantanamo-nobody-c-

201431385642747154.html.

This rapid infusion of high volumes of liquid into the stomach inevitably produces

intense pain by distending the intestines. It also increases the risk that stomach contents will be


10

regurgitated into the lungs. Exh. B ¶ 8(d); Exh. C ¶ 12. The speed-up of the force-feeding

process amounts to “pumping,” a form of the “Water Cure” torture, which has been practiced

since the Middle Ages. Exh. B ¶ 8(d). “Pumping” featured prominently in the Spanish

Inquisition and has historically been considered “one of the most fearful tortures.” Darius Rejali,

Torture and Democracy 279-80 (2007). It is performed by forcing copious amounts of water

into the stomach and intestines. Id. at 279.2 “[O]nce water is forced into the intestines in this

manner, the organs stretch and convulse, causing ‘some of the most intense pain that visceral

tissues can experience.’ Victims feel their organs are being burned or cut on the inside.” Id.

(quoting Edward Peters, Torture 167 (2d ed. 1996)).3

More recently, water torture by “pumping” was used by the Imperial Japanese Army

against U.S. and allied prisoners of war during World War II, in ways very similar to what is

now happening at Guantánamo Bay. See e.g., The Tokyo War Crimes Trial, vol. 6, Transcript of

the Proceedings in Open Session (1981) at 13,342 (“When the stomach was filled with water, the

Kempei Tai put a wooden board on the stomach and then pressed or jumped on this”); 13,684

(Japanese soldier “stepped on my belly and tried to stamp so long that the water came out of my

mouth”); 14,170 (prisoners “were given the water cure by having water forced into their

stomachs and then were jumped on by the Japanese”); 15,339 (“a soldier held my head with one

hand and with the other stopped my mouth—during this time a second soldier poured cold water

2 Water torture by “pumping” is to be distinguished from water torture by “choking”—sometimes called “waterboarding”—which prevents breathing. Torture and Democracy at 279. 3 A graphic personal account of the Spanish Inquisition’s torture of William Lithgow in 1620 describes how he was bound to a rack and pumped seven times—spaced a half-hour apart—with a half-gallon of water by means of a pot with an incised hole in its bottom that was held over his mouth, “ ‘whereupon my hunger-clunged belly waxing great, grew drum-like imbolstred, for it being a suffocating pain, in regard of my head hanging downward, and the water reingorging itself, in my tiiroat [sic], with a struggling force, it strangled and swallowed up my breath from yowling and groaning.’ ” George Ryley Scott, The History of Torture 174-75 (1940).


11

from a teapot into my nostrils . . . . This operation was repeated about fifteen times . . . . I

estimate that I must have had about 3 or 4 litres of water forced down me.”); 15,372 (“A Kempei

pressed against my belly to fill out my chest”).

These sorts of practices are indisputably torture. See, e.g., Marc Thiessen, Courting

Disaster 147 (2009) (arguing that CIA practices against detainees during Bush administration

were not torture because “[n]o funnel was placed in their mouths, so that the water could fill their

stomachs and distend their internal organs. . . . No CIA interrogators jumped on the detainees’

stomachs to revive them and make them vomit . . . . [¶] . . . these techniques practiced by the

Japanese are clearly torture”).

9. Forcing detainees to defecate on themselves. Due to the speed at which the liquids

are pumped into detainees’ stomachs, they often must defecate while still in the feeding chair.

Stafford Smith Decl. ¶¶ 49-50, 51, 56, 57. Petitioner has asked repeatedly for a chair with an

attached toilet to avoid this degradation, but this concession has never been made despite his

doctors agreeing that it was a medical necessity. Id. at 56. Neither is he allowed to use the toilet

in the force-feeding room, instead being forced to wait until he returns to his cell. He is therefore

sometimes forced to defecate on himself. Id. at 57. Force-feedings may also include doses of

anti-constipation medications. This may cause detainees to defecate on themselves while still in

the restraint chair, after which they are not given clean clothes. Exh. A ¶¶ 46, 48. Some

detainees feel that that this is perhaps the most humiliating part of the process. Id. ¶ 46. It also

defeats the purpose of nasogastric feeding, which is to place nutrients in the intestines to be

absorbed. Exh. B ¶ 8(c); see Guidelines for enteral feeding in adult hospital patients at § 10.4,

available at http://gut.bmj.com/content/52/suppl_7/vii1.full (“Whenever diarrhoea occurs with

[enteral tube feeding], all laxatives must be stopped”).


12

Petitioner has endured these abusive force-feeding procedures since February 2013. He

is taken from his cell twice daily to a room where he and other hunger strikers are strapped down

to feeding chairs in eight places—around their hands and legs, two across their shoulders, one

across their waists, and one across their heads. Stafford Smith Decl. ¶ 39. The room contains

five or six feeding chairs, and at the side of the room there is a foul-smelling toilet that causes

Petitioner to become nauseated and feel the urge to vomit. Id. at ¶ 37. If detainees make any

attempt to resist the feeding, the FCE team will hold their heads still and squeeze their necks to

completely immobilize them. Id. at ¶ 40.

A tube is then inserted through the detainees’ noses into their stomachs. Stafford Smith

Decl. ¶ 40. Petitioner and other detainees have endured this process undertaken by nurses and

medical staff who lack the skill or knowledge to direct the tubes properly. On various occasions

the metal-tipped tubes have been pressed into his organs and scraped the sides of his esophagus

and stomach, and on at least one occasion soldiers rushed into the room at the sound of

Petitioner’s screams. He eventually fainted from the pain. Regardless, requests to change the

medical staff have been refused and Petitioner now suffers from throat and stomach infections

resulting from the multiple and incorrectly-performed feedings. Id. at ¶¶ 40-46.

Petitioner continues to suffer terrible pain as a result of his abusive force-feeding,

including severe stomach pain. He has said that he often feels like smashing his head against the

wall out of desperation from the pain. Stafford Smith Decl. ¶¶ 63, 65-66, 77. At various times as

a result of his force-feeding, he has experienced double vision, coordination problems, and

memory loss. He also vomits and coughs blood regularly. Id. ¶¶ 13, 74.

Petitioner has also suffered at the hands of the FCE teams, being hit violently in the chest,

having teeth knocked loose during extractions for force-feedings, and enduring degrading genital


13

searches, all as a result of his peaceful protest. Stafford Smith Decl. ¶¶ 30, 62, 64, 67. Before his

hunger strike, Petitioner’s weight was 167 pounds. In early March, he was weighed at between

109 and 110 pounds. Id. ¶ 13.

Most recently, after the mass hunger strike of 2013, new abuses have been heaped upon

the hunger strikers. Exh. A ¶ 99. Some detainees who are willing to submit to force-feeding

without physical resistance (including one who is wheelchair-bound) are nevertheless subjected

to Forcible Cell Extractions. Id. ¶ 96, 97. If the detainee does not allow the FCE team to take

him to the restraint chair “walking,” he is denied recreation privileges. Id. ¶ 98. Detainees in

Camp VI who go on hunger strike are punished by transfer to Camp V—the punishment camp

for non-compliant detainees. There, they spend their first few days in Camp V Echo, where cells

are constructed almost entirely of steel (including bed, floor, walls, ceiling and door) and are

very cold, and what passes for a toilet is a hole in the ground, which is particularly difficult for

the detainees to use in their weakened condition. Id. ¶¶ 100, 101, 102. Petitioner has been in

Camp V Echo for months. He is forced to sleep on a steel slab despite doctors prescribing that

he sleep with an isomat (a waterproof sheet), and endures severe back pain from the metal slab

that prevents him from defecating normally. Even in this regard, Petitioner is degraded, as the

hole in the floor does not have sufficient room for him to place his feet and squat, so he is forced

to defecate in his own food container, the only other repository in the steel cell. Stafford Smith

Decl. ¶¶ 65, 66.

The punitive nature of force-feeding at Guantanamo is underscored by the fact that even

if Petitioner wanted to end his strike and the pain of force-feeding, he is not physically capable of

doing so. During the summer of 2013, Petitioner was told that he must consume 3,000 calories

per day in order to avoid force-feeding, with foods being assigned point values of 100 points =


14

1,000 calories: fruit was 5 points, milk was 20 points, pastry was 40 points, and one can of

Ensure was 25 points. Stafford Smith Decl. ¶ 58. It is physically impossible for Petitioner,

particularly in a weakened state from his hunger strike, suddenly to consume the amount of food

that would constitute 3,000 calories in one day. Petitioner is still told that this is the only way for

him to end force-feeding. Id.

Information is withheld from Petitioner regarding the contents of his feed bag. In addition

to a nutritional supplement, Petitioner strongly suspects that medications or drugs are mixed into

his feedings. Immediately after feedings, in addition to the pain caused by feeding, Petitioner

experiences memory loss and confusion, numbness, and hallucinations. Stafford Smith Decl. ¶

71. Other detainees have also stated that unidentified drugs are mixed into their feedings. Exh.

A ¶ 93.

Even some of the JTF-GTMO staff have expressed dismay at the detainees’ abusive

treatment. In 2005, a doctor apologized to detainee Imad Abdullah Hassan for his pain and

suffering. This doctor said he was being ordered to participate in what he referred to as “the

crime” of force-feeding, and that he would not participate if he had the choice. Exh. A ¶ 22.

More recently, a sympathetic soldier told Hassan: “I don’t make the rules. I am only a

sergeant.” Id. ¶ 23. When Petitioner has sought help for the painful side effects of the force-

feeding (severe stomach pain and gas among others), doctors at Guantánamo have ridiculed him

for being on hunger strike and one stated that he had no authority to do anything to help. As a

result, Petitioner does not trust the doctors at Guantánamo and avoids seeing them even for his

chronic pain and illnesses. Stafford Smith Decl. ¶ 28.

Such is the current state of affairs for hunger-striking detainees at Guantánamo Bay.

Their treatment is not humane; it is horribly abusive.


15

B. The Written Protocols on Force-Feeding at Guantánamo Bay.

As of March 5, 2013, force-feeding at Guantánamo Bay was governed by a 30-page set

of publicly available protocols—also called “SOP,” for “standard operating procedure.” See

Joint Task Force Guantánamo Bay, Cuba, Joint Medical Group, Medical Management of

Detainees on Hunger Strike (Mar. 5, 2013) (“Medical Management of Detainees”), attached to

this motion as Exhibit D (“Exh. D”). The March 2013 protocols pronounce a policy that when a

hunger striker refuses sustenance, “medical procedures that are indicated to preserve health and

life shall be implemented without consent from the detainee.” Id. Exh. D, at 2. Those so-called

“medical procedures” include the detainees’ forcible nasogastric tube feeding under physical

restraint.

According to the March 2013 protocols, force-feeding will be considered for a hunger-

striker (a detainee who has missed nine consecutive meals or has had weight loss to a level less

than 85% of Ideal Body Weight) under any of the following circumstances: (1) “[t]here is

evidence of deleterious health effects reflective of end organ involvement or damage . . . ,” (2)

“[t]here is a pre-existing co-morbidity that might readily predispose to end organ damage . . . ,”

(3) “[t]here is a prolonged period of hunger strike (more than 21 days),” (4) “[t]he detainee is at a

weight less than 85% of the calculated Ideal Body Weight (IBW),” or (5) “[t]he detainee has

experienced significant weight loss (greater than 15%) from previously recorded or in-processing

weight.” Medical Management of Detainees, Exh. D, at 2, 5.

The March 2013 protocols state that when force-feeding initially commences, it is

continuous, starting at 20 milliliters-per-hour (ml/hr) and gradually increasing to 100 ml/hr after

96 hours. Medical Management of Detainees, Exh. D, at 15-16. Force-feeding is then

transitioned to intermittent. Id. at 16. “Intermittent enteral feedings are usually done two times a

day.” Id. at 18. The detainee is shackled, a mask is placed over his mouth, and he “is escorted to


16

the chair restraint system and is appropriately restrained by the guard force.” Id. “The feeding

tube is passed via the nasal passage into the stomach,” tube placement is confirmed by

auscultation, “[t]he tube is secured to the nose with tape,” and the feeding is typically completed

“over 20 to 30 minutes,” after which the feeding tube is removed. Id. The detainee may be kept

in the restraint chair for two hours after the force-feeding is completed. Id.

The portions of the March 2013 protocols on intermittent force-feeding are somewhat

opaque with regard to the quantity of liquid that is force-fed over 20 to 30 minutes, to the extent

they merely state that “an appropriate quantity of the daily calories” is administered. Medical

Management of Detainees, Exh. D, at 16. Nevertheless, a section of the protocols prescribing

equations and calculations for determining quantities of nutrient and water indicates that a man

of average weight (80 kilograms) may be force-fed 948 ml of nutrient (calculated on a basis of

35 Kcal per kilogram of weight) and 1,400 ml of water (calculated on a basis of 35 ml per

kilogram of weight) twice daily. Id. at 20-21. Thus, the protocols indicate essentially the same

as what the detainees report: some 2,300 ml of liquid may be forced into a detainee in as little as

20 minutes.

Force-feeding ceases only “[w]hen a hunger striking detainee voluntarily resumes eating

or when the detainee has attained 100% of calculated IBW for at least fourteen (14) consecutive

days . . . . ” Medical Management of Detainees, Exh. D, at 16. Detainees may be regularly force-

fed “for a prolonged period of time,” which is defined as generally exceeding 30 days. Id. at 3.

Sixteen numbered paragraphs govern the use of the restraint chair in the force-feeding process,

under the title “Chair Restraint System Clinical Protocol for the Intermittent Enteral Feeding of

Detainees on Hunger Strike.” Id. at 18-19.


17

The March 2013 protocols were revised on November 14, 2013, and again on December

16, 2013. Near the end of 2013, Government counsel provided Petitioner’s counsel with copies

of the November 2013 and December 2013 revised protocols under designation as “protected

information” that could not be publicly disclosed. See Declaration of Jon B. Eisenberg ¶ 2

(“Eisenberg Decl.”). On March 10, 2014, after numerous denials, Government counsel finally

provided Petitioner’s counsel with a redacted version of the December 2013 revised protocols for

public disclosure (a copy of which is attached to this motion as Exhibit E). Id. ¶ 5. The public

version of the December 2013 revised protocols has been extensively redacted, and none of the

publicly-available portions addresses the quantity or speed of continuous or intermittent force-

feeding.

In many respects the December 2013 revised protocols are similar to the March 2013

protocols, but in some ways they differ substantially. For a discussion of these differences, see

the Supplemental Memorandum filed separately under seal in connection with this motion (to

which unredacted copies of the November 2013 and December 2013 protocols are attached as

Exhibits G and H).

Among other things, the December 2013 revised protocols, unlike the March 2013

protocols, do not address the use of restraint chairs in the force-feeding process. In mid-

December of 2013, Government counsel advised Petitioner’s counsel that there is now a separate

SOP that governs the use of restraint chairs, but that Government counsel “will not agree to

provide you with that SOP. . . . ” Eisenberg Decl. ¶ 3. On March 7, 2014, Government counsel

reiterated this refusal and also refused a request to disclose any other SOP that currently governs

force-feeding and the use of restraints. Id. ¶ 4. This motion requests an immediate emergency

order requiring such disclosure forthwith, so that it may be determined whether the revised


18

restraint chair SOP or any other as-yet-undisclosed SOP on force-feeding differs significantly

from the March 2013 protocols.

C. Deprivation of Communal Prayer During Ramadan.

During the Islamic holy month of Ramadan, Muslims traditionally perform extra

communal prayers—called tarawih—after each day’s final evening prayer, by reciting portions

of the Qur’an while standing, bowing, prostrating and sitting alongside each other. See e.g.,

Mohamed Haq Magid, Reflections on the Qur’an: A Ramadan Reader, 11-14 (2011).

Dr. Sayyid M. Syeed, National Director for Interfaith & Community Alliances and

former General Secretary of the Islamic Society of North America, explains tarawih as follows:

“Tarawih is a prayer during which the entire Qur’an is recited throughout the month of

Ramadan. One-thirtieth of the Qur’an is recited each night during the 30 nights of the month.

Muslims typically arrange for someone with beautiful recitation to lead the prayer and chant the

sacred scripture. This is a special part of Ramadan tradition and is a collectively performed act

of piety. If a person were prevented from performing this highly valued and deeply spiritual

practice, it would truly create a great sense of deprivation and distress.” Dr. Sayyid M. Syeed,

The Meaning of Tarawih, available at http://www.nrcat.org/interfaith-campaign-to-address-anti-

muslim-sentiment/background/the-meaning-of-tarawih (last visited Mar. 5, 2014).

In 2013, Ramadan began on July 8 and ended on August 7. On July 14, 2013, the

McClatchy news service reported that 25 detainees had “quit their hunger strike during

Ramadan” because the Government required them to do so in order to be permitted “to live in

communal detention—where they can pray and eat in groups—after months alone in maximum-

security lockdown.” Carol Rosenberg, Guantánamo: 25 C aptives Quit Hunger Strike Since

Ramadan, Miami Herald (July 14, 2013), available at http://www.miamiherald.com/


19

2013/07/14/3499662/guantanamo-25-captives-quit-hunger.html; see also Charlie Savage, 15

Held at Guantánamo Are Said to Quit Hunger Strike, N.Y. Times (July 14, 2013), available at

http://www.nytimes.com/2013/07/15/us/more-guantanamo-detainees-quit-hunger-strike.html (“at

the start of Ramadan . . . the military began moving compliant detainees who were not

participating in the hunger strike back into communal living conditions, where they could pray

together”). On July 18, 2013, the Associated Press reported that Army Lt. Col. Sam House “said

eating regular meals is ‘a condition of communal living.’” David McFadden, U.S. Military says

number of Guantánamo prisoners on hunger strike has dropped to 75 f rom 106, Star Tribune

(July 18, 2013), available at http://www.startribune.com/politics/national/ 216036341.html.

One detainee says that on July 11, 2013, he was told that if he did not stop hunger-

striking he would be moved into isolation, that “[c]ommunal prayers are our tradition in

Ramadan,” and that “[m]y feeling is that they blackmailed me into taking food.” Declaration of

Cori Crider Decl. for Hassan (attached to this motion as Exhibit F (“Exh. F”) ¶¶ 5, 6, 7. Mr.

Hassan was also denied communal prayer. Exh. A ¶ 77.

In 2014, Ramadan will begin on approximately June 28 and will end on approximately

July 28. Petitioner reasonably anticipates that this year the hunger-striking detainees will again

be deprived of the ability to perform the communal tarawih prayer during Ramadan unless they

stop hunger-striking.

STATEMENT OF JURISDICTION

Challenges by Guantánamo Bay detainees to the conditions of their confinement properly

sound in habeas corpus. Aamer, 742 F.3d 1023; see generally United States v. Wilson, 471 F.2d

1072, 1080-81 (D.C. Cir. 1972); Hudson v. Hardy, 424 F.2d 854, 855 & n.3 (D.C. Cir. 1970);

Creek v. Stone, 379 F.2d 106, 109 (D.C. Cir. 1967); Miller v. Overholser, 206 F.2d 415, 419


20

(D.C. Cir. 1953). With regard to the habeas relief that a court might grant, a detainee “may be

vindicated by an order enjoining the government from continuing to treat the petitioner in the

challenged manner,” or “a court may simply order the prisoner released unless the unlawful

conditions are rectified, leaving it up to the government whether to respond by transferring the

petitioner to a place where the unlawful conditions are absent or by eliminating the unlawful

conditions in the petitioner’s current place of confinement.” Aamer, 742 F.3d at 1035.

ARGUMENT

I. THIS COURT SHOULD ENJOIN PETITIONER’S FORCE-FEEDING BECAUSE, GIVEN THE AVAILABILITY OF READY ALTERNATIVES, IT IS NOT REASONABLY RELATED TO LEGITIMATE PENOLOGICAL INTERESTS AND IS THEREFORE UNCONSTITUTIONAL.

While prison administrators may take measures that impinge on inmates’ constitutional

rights—as force-feeding plainly does—such measures must be ‘ “reasonably related to legitimate

penological interests.” ’ Washington v. Harper, 494 U.S. 210, 223 (1990) (quoting Turner v.

Safley, 482 U.S. 78, 89 (1987)). Preserving the lives of inmates is a legitimate penological

interest, but force-feeding may be undertaken only if this interest cannot otherwise be achieved

without impinging on constitutional rights. Harper, 494 U.S. at 223.

In contrast, current Guantánamo Bay force-feeding practices cause—and plainly are

intended to cause—unnecessary suffering. Legitimate penological interests can be served

without causing such suffering. This Court should enjoin those practices and disapprove the

existing Guantánamo Bay protocols in favor of readily-available and widely-used protocols that

do not cause such suffering.


21

A. The standard for determining the legality of the Guantánamo Bay force-feeding practices and protocols—whether they are “reasonably related to legitimate penological interests”—asks whether there are any “ready alternatives.”

“Prison walls do not form a barrier separating prison inmates from the protections of the

Constitution.” Turner, 482 U.S. at 84. Such constitutional protection includes a right to refuse

unwanted medical treatment. See Cruzan v. Director, Mo. Dep’t of Health, 497 U.S. 261, 278-

79 (1990).

The constitutional rights of prisoners, however, must sometimes yield to the practical

needs of prison administration. Turner, 482 U.S. at 84. Accordingly, the Supreme Court has

prescribed a test that strikes a balance between these two interests: “[T]he proper standard for

determining the validity of a prison regulation claimed to infringe on an inmate’s constitutional

rights is to ask whether the regulation is ‘reasonably related to legitimate penological interests.’ ”

Harper, 494 U.S. at 223 (quoting Turner, 482 U.S. at 89).

A key consideration in determining the reasonableness of a prison regulation is whether

there are “ ‘ready alternatives’ ” to the regulation. Harper, 494 U.S. at 225 (quoting Turner, 482

U.S. at 90). “[T]he existence of obvious, easy alternatives may be evidence that the regulation is

not reasonable, but is an ‘exaggerated response’ to prison concerns. . . . [I]f an inmate claimant

can point to an alternative that fully accommodates the prisoner’s rights at de minimis cost to

valid penological interests, a court may consider that as evidence that the regulation does not

satisfy the reasonable relationship standard.” Turner, 482 U.S. at 90-91. The question is

“whether, viewed in a pragmatic light, it is feasible for prison authorities to address their

institutional concerns through other means.” Bezio v. Dorsey, 989 N.E.2d 942, 950 (N.Y. 2013).

This standard has been applied to claims by Guantánamo Bay detainees. See Al-Adahi v.

Obama, 596 F. Supp. 2d 111, 120 (D.D.C. 2009); Hicks v. Bush, 452 F. Supp. 2d 88, 101

(D.D.C. 2006). It makes no difference whether the purpose of the detention is intended to be


22

punitive, because the “legitimate penological interests” test refers to the “interest in security and

management” of prisons and jails. Harper, 494 U.S. at 247. Thus, even if a restriction

accompanying pretrial detention does not amount to punishment (although indefinite detention

without trial for twelve years under the notorious conditions at Guantánamo Bay is indisputably

punitive), the restriction is still unlawful if it is “not reasonably related to a legitimate

[governmental] goal.” Bell v. Wolfish, 441 U.S. 520, 539 (1979).

B. Force-feeding is an invasive and painful procedure which is inhumane, degrading, and a violation of international law and medical ethics.

The consensus of the United Nations Rapporteurs, the World Medical Association, the

American Medical Association, bioethicists, and human rights organizations is that force-feeding

of prisoners falls within the ambit of torture and constitutes cruel, inhuman, and degrading

treatment or punishment. E.g., U.N.H.R. Press Release, OHCHR, IACHR, UN Working Group

on Arbitrary Detention, UN Rapporteur on Torture, UN Rapporteur on Human Rights and

Counter-Terrorism, and UN Rapporteur on Health reiterate need to end the indefinite detention

of individuals at Guantánamo Naval Base in light of current human rights crisis (May 1, 2013),

available at http://www.ohchr.org/en/NewsEvents/Pages/ isplaynews.aspx?newsid=13278&langl

(“it is unjustifiable to engage in forced feeding of individuals contrary to their informed and

voluntary refusal of such a measure”); World Medical Association, WMA Declaration of

Tokyo—Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading

Treatment or Punishment in Relation to Detention and I mprisonment (1975), available at

http://www.wma.net/en/30publications/10policies/c18/ (“Where a prisoner refuses nourishment

and is considered by the physician as capable of forming an unimpaired and rational judgment

concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be

fed artificially.”); World Medical Association, WMA Declaration of Malta on H unger


23

Strikers (1991), available at http://www.wma.net/en/30publications/10policies/h31/ (“Forcible

feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by

threats, coercion, force or use of physical restraints is a form of inhuman and degrading

treatment.”); Letter from Jeremy A. Lazarus, M.D., President of Am. Med. Ass’n, to Honorable

Chuck Hagel, Sec’y of Def. (Apr. 25, 2013), available at

http://www.jhsph.edu/research/centers-and-institutes/ center-for-public-health-and-human-rights

/_pdf/AMA%20Hunger%20Strikes%20Letter.pdf (“[T]he forced feeding of detainees violates

core ethical values of the medical profession.”); Guantánamo: hunge r strikes and a doc tor’s

duty, The Lancet (May 4, 2013), available at http://www.thelancet.com/

journals/lancet/article/PIIS0140-6736(13)60962-9/fulltext (“[T]o force-feed infringes the

principle of patient autonomy.”); Int’l Comm. of the Red Cross, Hunger strikes in prisons: the

ICRC’s position (Jan. 31, 2013), available at http://www.icrc.org/eng/resources/documents/

faq/hunger-strike-icrc-position.htm (“The ICRC is opposed to forced feeding or forced

treatment; it is essential that the detainees’ choices be respected and their human dignity

preserved.”); Exh. B ¶¶ 3, 4, 5; Exh. C ¶¶ 2, 3.

According to international law, force-feeding of prisoners under restraint and without

proof of a life-threatening decrease in state of health constitutes “treatment of such a severe

character warranting the characterisation of torture.” Nevmerzhitsky v. Ukraine, App. No.

548255/00, Final Judgment, ¶ 98, Oct. 12, 2005 (Eur. Ct. H.R.), available at

http://www.rwi.uzh.ch/lehreforschung/alphabetisch/kiener/Vorlesungen/hs11-1/menschenrechte/

unterlagen/CASE_OF_NEVMERZHITSKY_v_UKRAINE.pdf; see United Nations Convention

Against Torture and Other Cruel, Inhuman or Degrading Treatment, Dec. 10, 1984, 1465

U.N.T.S. 85, 113 U.N. Doc. A/39/51, available at http://www1.umn.edu/humanrts/instree/


24

h2catoc.htm (“Convention Against Torture”) (defining torture as intentional infliction of “severe

pain or suffering” for specified purposes or reasons); Geneva Convention Relative to the

Treatment of Prisoners of War Art. 3, Aug. 12, 1949, 75 U.N.T.S. 135, available at

http://www1.umn.edu/humanrts/instree/y3gctpw.htm (requiring that armed-conflict detainees in

“all circumstances be treated humanely”); see generally Prosecutor v. Ŝeŝelj, Case No. IT-03-67-

T, Urgent Order to the Dutch Authorities Regarding Health and Welfare of the Accused 6 (Int’l

Crim. Trib. for the Former Yugoslavia Dec. 6, 2006) (approving force-feeding of prisoner only

“to the extent that [it is] not contrary to compelling internationally accepted standards of medical

ethics or binding rules of international law,” and referencing provision in WMA Declaration of

Malta on H unger Strikers, supra, that force-feeding “is never ethically acceptable” and “is a

form of inhuman and degrading treatment”); Exh. B ¶ 5.

Medical ethicists have universally condemned the force-feeding of hunger strikers. See

George J. Annas, Sondra S. Crosby & Leonard H. Glanz, Guantánamo Bay: A Medical Ethics-

free Zone?, 369 New Eng. J. Med. 101, 101 (July 11, 2013) (“Annas et al.”) (“That force-feeding

of mentally competent hunger strikers violates basic medical ethics principles is not in serious

dispute.”); Michael L. Gross, Force-Feeding, Autonomy, and the Public Interest, 369 New Eng.

J. Med., 103, 103 (July 11, 2013) at 1 (“Gross”) (“[M]ost bioethicists unequivocally oppose

force-feeding.”); Exh. B ¶¶ 3, 4; Exh. C ¶¶ 2, 3, 9 (a psychiatrist should assess the mental

capacity of a hunger-striking prisoner, and “[s]hould the conclusion of the assessment be that the

patient has mental capacity to refuse food, the physician is bound by medical ethics and

international and US law to refrain from enteral feeding”). “Physicians can no more ethically

force-feed mentally competent hunger strikers than they can ethically conduct research on

competent humans without informed consent.” Annas et al., supra at 102. “Force-feeding a


25

competent person is not the practice of medicine; it is aggravated assault.” Id. Indeed, a recent

article in the New England Journal of Medicine, describing Guantánamo Bay as having become

“a medical ethics-free zone,” urges the military physicians there to refuse to participate in force-

feeding. Id. at 103.

Forcible nasogastric tube feeding—even short of the “Water Cure”—can be extremely

painful, as Petitioner attests. Stafford Smith Decl. ¶¶ 15, 16, 39, 40, 41, 42-47, 63-67. Another

Guantánamo Bay detainee has written: “I will never forget the first time they passed the feeding

tube up my nose. I can’t describe how painful it is to be force-fed this way. As it was thrust in,

it made me feel like throwing up. I wanted to vomit, but I couldn’t. There was agony in my

chest, throat and stomach. I had never experienced such pain before. I would not wish this cruel

punishment on anyone.” Samir Naji al Hasan Moqbel, Gitmo Is Killing Me, N.Y. Times (Apr.

14, 2013), available at http://www.nytimes.com/2013/04/15/opinion/hunger-striking-at-

guantanamo-bay.html?_r=0.

The Ninth Circuit recently upheld California’s legislative ban on force-feeding of ducks

and geese to produce foie gras, deeming the ban to be a lawful pursuit of the state’s “interest in

preventing animal cruelty.” Association des Eleveurs de Canards et d’Oies du Quebec v. Harris,

729 F.3d 937, 952 (9th Cir. 2013). The irony of protecting ducks and geese from a practice that

is inflicted on human beings at Guantánamo Bay needs no further elaboration.

Petitioner does not wish to die. Stafford Smith Decl. ¶ 84. But he is faced with a

“Hobson’s choice” of either continuing to submit passively to his indefinite detention—lingering

in a twilight of half-death—or taking the only peaceful course available to him to protest his

situation, in the hope that he can restore himself and others to the freedom that even the

Government has determined he deserves. Hunger striking is his only recourse. See Annas et al.,


26

supra at 102 (“Hunger striking is a peaceful political activity to protest terms of detention . . . .

Hunger strikers are not attempting to commit suicide . . . [t]heir goal is not to die but to have

perceived injustices addressed.”); Gross, supra at 103 (“Hunger striking is a nonviolent act of

political protest. It is not the expression of a wish to die . . . .”); Exh. B ¶ 6 (“[A] hunger strike is

virtually the only means of meaningful expression of personal rights and public appeal open to

the petitioners.”); Exh. C ¶ 6.

Senator Dianne Feinstein, writing as Chair of the United States Senate Select Committee

on Intelligence, has voiced her objection to force-feeding at Guantánamo Bay as being “out of

step with international norms, medical ethics and practices of the U.S. Bureau of Prisons.”

Letter from Dianne Feinstein, Senator, to Honorable Chuck Hagel, Sec’y of Def. (June 19,

2013), available at http://www.feinstein.senate.gov/public/index.cfm/press-releases

?ID=8af43b52-0301-42b9-8f72-27f88997bd39. She states: “Hunger strikes are a long known

form of non-violent protest aimed at bringing attention to a cause, rather than an attempt of

suicide. I believe that the current approach raises very important ethical questions and

complicates the difficult situation regarding the continued indefinite detention at Guantánamo.”

Id.

A bipartisan report by The Constitution Project’s Task Force on Detainee Treatment

found that “Forced feeding of detainees is a form of abuse and must end.” The Task Force, a

group of 11 Republican and Democrat former U.S. government officials and prominent figures,

came to this conclusion after examining detainee statements as well as evidence from doctors

and military staff at Guantanamo Bay dating back to 2005. The Constitution Project, Report of

the Task Force on Detainee Treatment (2013) at 19, available at

http://detaineetaskforce.org/read/files/assets/basic-html/index.html#page1.


27

In Aamer v. Obama, the D.C. Circuit observed “we have no doubt that force-feeding is a

painful and invasive process that raises serious ethical concerns.” Aamer, 742 F.3d at 1039. The

D.C. Circuit quoted what it called “a scathing report detailing the abuses of medical ethics in the

government’s treatment of detainees at Guantanamo, Afghanistan, and Iraq, concluding

specifically that doctors who assist in the treatment of hunger-striking Guantanamo detainees

‘have become agents of a coercive and counter-therapeutic procedure that for some detainees

continued for months and years, resulting in untold pain, suffering, and tragedy for the detainees

for whom they were medically responsible.’ ” Id. (quoting Institute on Medicine as a Profession

and Open Society Forum, Task Force Report, Ethics Abandoned: Medical Professionalism and

Detainee Abuse in the War on Terror 84 (2013)).

We also note that current force-feeding practices at Guantánamo Bay violate President

Obama’s own Executive Order 13491, which states that, consistent with Common Article 3 of

the Convention Against Torture, detainees at U.S. detention facilities “shall in all circumstances

be treated humanely and shall not be subjected to violence to life and person (including . . . cruel

treatment, and torture), nor to outrages upon personal dignity (including humiliating and

degrading treatment).” Executive Order Ensuring Lawful Interrogations, 13491, § 3(a) (Jan. 22,

2009), available at http://www.whitehouse.gov/the-press-office/ensuring-lawful-interrogations,

“The Convention’s definition of torture includes not only acts committed by public officials, but

also those acts to which they acquiesced.” Congressional Research Service, U.N. Convention

Against Torture (CAT): Overview and A pplication to Interrogation Techniques 5 (Jan. 26,

2009), available at http://www.fas.org/sgp/crs/intel/RL32438.pdf (citation omitted). Thus,

persons presently in violation of Executive Order 13491 would include respondents Chuck

Hagel, Secretary of Defense, and Rear Admiral Richard Butler, Commander of JTF-GTMO.


28

C. The Guantánamo Bay force-feeding practices and protocols are unreasonable because they inflict unnecessary pain and suffering.

There can be no doubt that the current Guantánamo Bay force-feeding practices and

protocols do not meet the Turner standard of reasonableness. There cannot be any “legitimate

penological interests,” Turner, 482 U.S. at 89, in inflicting “inconvenient” pain and suffering

upon force-fed detainees by subjecting them to unnecessary physical violence and restraint, or

inserting and withdrawing feeding tubes twice daily, or using excessively-thick feeding tubes, or

force-feeding detainees at excessive speeds that echo a notorious form of torture, or using anti-

constipation medication to cause them to defecate during the force-feeding process and sit in

their own feces.. For this reason alone, this Court should enjoin these egregious abuses.

D. The Guantánamo Bay force-feeding practices and protocols are unreasonable because they subject detainees to force-feeding before the detainees are at risk of death or great bodily injury.

In Aamer v. Obama, the D.C. Circuit observed that “the overwhelming majority of courts

have concluded, as . . . we do now, that absent exceptional circumstances prison officials may

force-feed a starving inmate actually facing the risk of death.” Aamer, 742 F.3d at 1041

(emphasis added). This cautious approach, requiring a life-threatening health crisis before a

prisoner is force-fed, is exemplified by California’s recent response to a two-month hunger strike

by 100 state prison inmates. See Joint Request for Order Authorizing Refeeding Under Specified

Conditions of Hunger Striking Inmate-Patients and Order Thereon at 1, Plata v. Brown, No.

3:01-cv-01351-TEH (N.D. Cal. Aug. 19, 2013), ECF No. 2699 (“Plata Order”); Ian Lovett,

Inmates End Hunger Strike in California, N.Y. Times (Sept. 5, 2013), available at

http://www.nytimes.com/ 2013/09/06/us/inmates-end-hunger-strike-in-california.html?_r=0.


29

According to a preexisting California policy on prisoner hunger-strikes, the state “shall

grant participants autonomy in health care decisions related to nutrition and shall not force feed

the participant” if the inmate clearly and consistently indicates such intent and is able to give

informed consent. See Cal. Corr. Health Care Servs., Inmate Medical Services Policies &

Procedures, Vol. 4, Ch. 22.2, Policy 4.22.2: Mass Organized Hunger Strike (Sept. 29, 2011, rev.

July 2013) § VII.C, at 5, available at http://www.cphcs.ca.gov/docs/imspp/IMSPP-v04-

ch22.2.pdf (“Policy 4.22.2”).

On August 19, 2013, a local federal district judge signed an order in Plata—jointly

requested by attorneys for the State of California, a prison receiver, and the hunger-striking

inmates—which supplements Policy 4.22.2. The order states, by way of preamble:

A widespread, orchestrated hunger strike poses significant challenges in the prison setting and presents difficult, sometimes conflicting, policy questions concerning institutional safety and security, inmate-patient autonomy over their person and the receipt of medical treatment, the ability of medical staff to monitor and provide adequate care to striking inmates and medical ethical requirements pertaining to the protection of patients from harm while respecting patient autonomy.

Plata Order at 2.

In addressing these concerns, the Plata order includes two key provisions: First, if a

prison’s chief medical officer “determines, to a reasonable degree of medical certainty, that a

hunger-striker is at risk of near-term death or great bodily injury in the absence of intervention

or has become incompetent to give consent or make medical decisions, refeeding or other

lifesaving measures may commence immediately” unless the inmate “previously executed a

valid ‘do not resuscitate’ directive.” Plata Order at 4 (emphasis added). Second, “a previously

executed ‘do not resuscitate’ directive will not be considered valid” if the chief medical officer,


30

“reasonably and in good faith, determines it was the result of coercion or otherwise not the

product of the hunger striker’s free will when executed . . . .” Id. (emphasis added).4

Thus, Policy 4.22.2 and the Plata Order strike a reasonable balance between various

competing concerns by affording hunger-striking prisoners the right of personal autonomy until

they are at near-term risk of death or great bodily injury, and by disregarding a “do not

resuscitate” directive if it is determined to have been coerced. With this measured approach,

intrusions upon personal autonomy and principles of medical ethics are minimized or avoided

entirely, while prison security is preserved by ensuring against coercion from other inmates,

thereby keeping institutional control in the hands of the warders.

The California approach differs starkly from the March 2013 Guantánamo force-feeding

protocols. Those protocols, like the Plata Order, authorize force-feeding if a hunger striker is at

risk of near-term death or great bodily injury, by authorizing “[i]nvoluntary medical treatment” if

“[t]here is evidence of deleterious health effects reflective of end organ involvement or damage.”

Medical Management of Detainees, Exh. D, supra at 5 (emphasis added). But the Guantánamo

protocols go much, much further. Unlike the Plata order, the March 2013 Guantánamo

protocols authorize force-feeding in situations well short of near-term death or great bodily

injury, including: (1) “[t]here is a pre-existing co-morbidity that might readily predispose to end

organ damage (e.g., hypertension, coronary artery disease or any significant heart condition,

renal insufficiency or failure, or endocrinopathy,” (2) “[t]here is a prolonged period of hunger

strike (more than 21 days),” (3) “[t]he detainee is at a weight less than 85% of the calculated

4 Petitioner here is not seeking the right to execute a medical directive allowing him to continue his hunger strike until death. Rather, he seeks to ensure that he is not force-fed prematurely and is not subjected to methods of force-feeding that cause unnecessary pain and suffering.


31

Ideal Body Weight (IBW),” or (4) “[t]he detainee has experienced significant weight loss

(greater than 15%) from previously recorded or in-processing weight.” Id.

Thus, for example, a Guantánamo hunger striker may be force-fed simply because he is

taking medication for high blood pressure (which is true for many Americans), or has lost a

significant amount of weight (to which many Americans aspire), or weighs less than 85% of his

Ideal Body Weight (as did Abraham Lincoln during the latter part of his presidency, and as did

many Guantánamo detainees when they were first detained), or for no reason other than that he

has been on hunger-strike for more than 21 days—without any showing that life-sustaining

measures are currently necessary to prevent near-term death or great bodily injury. These

scenarios demonstrate that, in contrast with the California approach, the Guantánamo protocols

are “an ‘exaggerated response’ to prison concerns,” Turner, 482 U.S. at 90, and that “it is

feasible for [the Guantánamo] authorities to address their institutional concerns through other

means,” Bezio, 989 N.E.2d at 950. None of these four Guantánamo standards constitutes an

essential metric for preventing death or serious organ failure. Yet, to note just another

remarkable irony, persons who previously interrogated these detainees were allowed to take all

measures short of causing death or serious organ failure in conducting so-called “enhanced

interrogations,” but now the detainees may be force-fed under painful and humiliating conditions

that fall well short of that standard.

The Government will likely contend it has a legitimate interest in preserving the lives and

preventing suicidal acts of persons in its custody. While Petitioner would submit that hunger-

striking as a form of protest, without Government restriction, is a valid and rational assertion of

basic human dignity in the nightmare world of indefinite detention without trial at Guantánamo

Bay, any restriction must be, at the very least, minimally intrusive and painful. Restricting force-


32

feeding to situations where a detainee is “at risk of near-term death or great bodily injury,” Plata

Order at 4, is entirely sufficient to preserve lives and prevent suicide, and thus constitutes a ready

alternative to the far more expansive Guantánamo force-feeding protocols. See Lovett, supra

(comment by California state prison official that two-month hunger strike, without force-feeding,

ended “ ‘before any inmates became seriously ill’ ”).

E. The Guantánamo Bay force-feeding practices and protocols are unreasonable because “ready alternatives,” as exemplified by U.S. Bureau of Prisons regulations, can achieve the government’s legitimate interests.

The March 2013 protocols purport to have been developed “utilizing procedures adopted

from the Federal Bureau of Prisons.” Medical Management of Detainees, Exh. D, supra at 1.

This statement is false and misleading. In truth, the Guantánamo Bay force-feeding protocols

differ substantially from the regulations governing the U.S. Bureau of Prisons, in at least six

ways:

First, the Bureau of Prisons regulations authorize forced medical treatment of an inmate

only when “a physician determines that the inmate’s life or health will be threatened if treatment

is not initiated immediately.” 28 C.F.R. § 549.65(a) (emphasis added). This is consistent with

the D.C. Circuit’s observation in Aamer v. Obama that most courts have concluded that “absent

exceptional circumstances prison officials may force-feed a starving inmate actually facing the

risk of death.” Aamer, 742 F.3d at 1041 (emphasis added). In contrast, the Guantánamo Bay

protocols also authorize force-feeding in situations short of near-term death or great bodily

injury.

Second, the Bureau of Prisons regulations restrict the use of restraints to “only that

amount of force necessary to gain control of the inmate.” 28 C.F.R. §§ 552.20, 552.22(c). This

effectively requires that the level of restraint be the least restrictive necessary. In contrast, the


33

Guantánamo Bay protocols prescribe the routine use of a “chair restraint system”—the most

restrictive form of restraint—for all detainees who are being force-fed, regardless of necessity.

Medical Management of Detainees, Exh. D, supra at 16, 18-19.

Third, the Bureau of Prisons regulations call for restraint systems using just four points of

restraint. 28 C.F.R. § 552.24. In contrast, the restraint chairs used at Guantánamo Bay are more

constricting, with the detainee forcibly strapped down tightly at his hands, legs, waist, shoulders,

and head. Stafford Smith Decl. ¶ 38.

Fourth, the Bureau of Prisons regulations vest a physician with the authority to decide

whether to force-feed an inmate. 28 C.F.R. § 549.65(c); see U.S. Dep’t of Justice, Program

Statement No. P5562.05 at 7 (July 29, 2005), available at

http://www.cbsnews.com/htdocs/pdf/BOP_FBI_hungerstrikepolicy.pdf (“Only the physician

may order involuntary medical treatment.”). In contrast, the Guantánamo Bay protocols vest the

JTF-GTMO Commander with this decision-making authority. Medical Management of

Detainees, Exh. D, supra at 4.

Fifth, the Bureau of Prisons regulations prohibit the use of restraints on an inmate’s face.

28 C.F.R. § 552.22(c)(h)(2). In contrast, under the Guantánamo Bay protocols, “a mask is

placed over the detainee’s mouth” during force-feeding. Medical Management of Detainees,

Exh. D, supra at 18.

Sixth, the Bureau of Prisons videotapes force-feedings as a protection against abusive

treatment. Program Statement No. P5562.05 at 7. Videotaping is not required by the

Guantánamo Bay protocols.


34

Plainly, there are ready alternatives to the Guantánamo Bay force-feeding practices and

protocols, as exemplified by the Bureau of Prisons regulations, which demonstrate that the force-

feeding at Guantánamo Bay is not reasonable, but is “an ‘exaggerated response’ to prison

concerns.” Turner at 90.

F. The Government has such complete control over the Guantánamo Bay detainees that hunger-strikers present no threat to institutional security.

The Government will likely contend that the force-feeding at Guantánamo Bay is

reasonably related to the legitimate interest in preserving prison security. But surely no federal

prison is more secure than the Guantánamo Bay detention facility. The Government might

suggest that any death of a hunger-striking detainee will undermine security there, but

institutional security surely was not undermined by the suicides that have occurred. (Indeed,

evidence can be adduced in this proceeding that the tragic 2012 suicide of detainee Adnan Latif

was provoked, in part, by the gratuitous pain and suffering that had been inflicted through his

force-feeding.) Nor has there been any indication of security breaches when prisoners have been

killed during interrogations at various other facilities since 2001.

The Government has absolute and unfettered control over these detainees, unchecked by

anything other than the writ of habeas corpus. Institutional security at Guantánamo Bay would

be threatened only if the detainees were able to wrest away a degree of that control—which

could happen if some detainees could be coerced into joining a hunger strike. But the Plata

Order prevents such loss of institutional control by authorizing force-feeding when it is fairly

determined that an inmate is hunger-striking under coercion. This safeguard is a ready

alternative at Guantánamo Bay.


35

G. Even if the force-feeding protocols were to be upheld, this Court should grant habeas relief because, in practice, the Government is deviating from those protocols.

Even if this Court were to conclude that the Guantánamo Bay force-feeding protocols

meet the Turner standard, the Court should still grant habeas relief because, in actual practice,

the Government is deviating from those protocols, for purposes that must be seen through the

prism of General Craddock’s desire to inflict suffering in order to coerce detainees to stop

hunger-striking. For example, appropriately sized feeding tubes were replaced with

unnecessarily thick (and consequently painful) feeding tubes. Compare Medical Management of

Detainees, Exh. D, supra at 15 (specifying size “10 French or 12 French feeding tube”) with

Exh. A ¶ 41 (detainee describes use of size 14 French feeding tube). And so-called “chronic

enteral feeders” are being force-fed in restraint chairs instead of in single-point restraints.

Compare Medical Management of Detainees, Exh. D, supra at 19 (“Detainees who are chronic

enteral feeders and are living in communal blocks” are to be force-fed “with the detainee in

single point leg restraint”) with Exh. A ¶¶ 97, 98 (detainee reports that compliant detainees are

nevertheless being force-fed in restraint chairs).

At a minimum, if this Court were to uphold the Guantánamo Bay force-feeding protocols,

the Court should order the Government to comply with those protocols.

II. DEPRIVATION OF COMMUNAL PRAYER VIOLATES THE RELIGIOUS FREEDOM RESTORATION ACT (RFRA).

The right of religious free exercise is enshrined in the First Amendment and further

protected by the Religious Freedom Restoration Act (RFRA), which imposes a heightened

standard of review where government substantially burdens “a person’s” religious exercise. 42

U.S.C. § 2000bb-1. This protection includes the right of prisoners to pray communally. “It is

well established that prisoners have a constitutional right to participate in congregate religious


36

services. Confinement in keeplock does not deprive prisoners of this right.” Salahuddin v.

Coughlin, 993 F.2d 306, 308 (2d Cir. 1993) (citation omitted); see also Makin v. Colorado Dep’t

of Corrections, 183 F.3d 1205, 1213 (10th Cir. 1999) (denying Muslim prisoner the ability to

observe the Ramadan fast infringes his right to exercise his religion freely).

Petitioner contends the Government violated this right in 2013 by depriving the hunger-

striking Guantánamo Bay detainees of the ability to perform communal tarawih prayers during

Ramadan.5 The Government threatens to do so again in 2014.

Petitioner acknowledges that a panel of the D.C. Circuit has held that Guantánamo Bay

detainees are not protected “person[s]” within the meaning of the RFRA. Rasul v. Myers, 563

F.3d 527, 532-33 (D.C. Cir. 2009); accord, Aamer, 742 F.3d at 1042-43; but cf. Rasul at 533

(Brown, J., concurring), (“There is little mystery that a person is an individual human being . . .

,” and “[u]nlike the majority, I believe Congress [did not specifically intend[] to vest the term

persons with a definition . . . at odds with its plain meaning.”) (citations and internal quotations

omitted) (second and third brackets in original). But Rasul, and the precedents upon which it

relied, predated Citizens United v. FEC, 558 U.S. 310 (2010), which espoused a dramatically

expansive view of the scope of constitutional protection for “persons”—in that case, for

corporate personhood.6

In Citizens United, the Supreme Court expressly declined to decide the question of

whether the First Amendment’s protection for “persons” extends to “foreign individuals or

associations.” Citizens United, 558 U.S. at 362; see generally Bluman v. FEC, 800 F. Supp. 2d

5 The D.C. Circuit rejected this argument in Aamer, 742 F.3d at 1042-43. We assert the argument here in order to preserve it for appellate review. 6 This term the Supreme Court will consider whether a for-profit corporation may, based on religious objections, deny its employees health coverage for contraceptives. Sebelius v. Hobby Lobby Stores, Inc., No. 13-354, cert. granted, 134 S. Ct. 678 (Nov. 26, 2013).


37

281, 292 (D.D.C. 2011) (federal ban on political contributions by foreign nationals held

constitutional, but “we do not decide whether Congress could prohibit foreign nationals from

engaging in speech other than” such contributions). Thus, Citizens United revives the issue

addressed in Rasul and makes it an open question whether RFRA’s protection extends to non-

resident aliens.

Although the RFRA was enacted 17 years before Citizens United, it implements the Free

Exercise Clause of the First Amendment, see Rasul, 563 F.3d at 534 (Brown, J., concurring), and

Citizens United espoused “‘ancient First Amendment principles.’” Citizens United, 558 U.S. at

319 (quoting Fed. Election Comm’n v. Wis. Right to Life, Inc., 551 U.S. 449, 490 (2007)).

Citizens United cited 20 Supreme Court cases—predating the RFRA—for the proposition that

“[t]he Court has recognized that First Amendment protection extends to corporations.” Id. at

342. Those 20 pre-RFRA cases underlying Citizens United, and thus Citizens United itself, have

a bearing on the meaning of “person” in the RFRA. And given that those 20 pre-RFRA cases are

First Amendment cases, they should have a greater bearing on the meaning of the RFRA—

which, after all, implements the First Amendment—than the Fourth and Fifth Amendment cases

on which Rasul relied. See Rasul, 563 F.3d at 533.

A federal district court recently afforded the protections of the Free Exercise Clause to

non-United States citizens who were detained in immigration custody after the terrorist attacks of

September 11, 2001, holding the detainees had a Bivens remedy for violation of their free

exercise rights while confined. See Turkmen v. Ashcroft, 915 F. Supp. 2d 314, 351-55 (E.D.N.Y.

2013). That holding is consistent with affording the protections of the Free Exercise Clause, as

implemented by the RFRA, to the Guantánamo detainees.


38

Moreover, “because intentional burdening of religious practices is involved here,” the

infringement on the detainees’ religious free exercise cannot even be justified as reasonably

related to legitimate penological interests, but can be justified only if such burdening “advances

interests of the highest order and is narrowly tailored in pursuit of those interests . . . .” Turkmen,

915 F. Supp. 2d at 354 n.27, 355.

It hardly advances domestic and international respect for American democracy if the

Supreme Court treats corporations as “persons,” but the President insists that human beings

detained at Guantánamo Bay who wish to practice their religion are not “persons” entitled to the

fundamental protection of religious free exercise. We submit that it is in the Nation’s best

interest to respect the religious beliefs of all persons it incarcerates—even, and perhaps

especially, the Guantánamo Bay detainees. Citizens United reopens an issue that a panel of the

Court of Appeals decided in a manifestly and tragically incorrect manner. The right of religious

free exercise is a core American value, and to deprive the Guantánamo Bay detainees of that

right does great damage to America in the eyes of the world in general and the world’s Muslims

in particular. The affront to human dignity in failing to accord these men the status of “persons”

is incalculable.

III. PETITIONER MUST BE AFFORDED THE PROTECTIONS OF INTERNATIONAL LAW PURSUANT TO THE TREATY OF FRIENDSHIP AND COMMERCE BETWEEN THE UNITED STATES AND PAKISTAN.

As a separate and independent basis for challenging his force-feeding and denial of

religious free exercise, Petitioner, as a Pakistani national, asserts the protections of international

law pursuant to a treaty between the United States and Pakistan.


39

In 1959, the United States entered into a treaty with Pakistan which provides: “Nationals

of either Party within the territories of the other Party shall be free from molestations of every

kind, and shall receive the most constant protection and security, in no case less than that

required by international law.” Treaty of Friendship and Commerce Between the United States of

America and Pakistan, art. III, 12 U.S.T. 110 , 404 U.N.T.S. 259 (Feb. 12, 1961), available at

http://tcc.export.gov/trade_agreements/all_trade_agreements/exp_005355.asp). Thus, petitioner

is entitled to the protections of international law, which include both the right not to be force-fed,

see supra at 23-24, and the right to pray communally, see International Covenant on Civil &

Political Rights, Art. 18, para. 1 (1976), available at http://www.refworld.org/

pdfid/3ae6b3aa0.pdf (right to freedom of religion includes “freedom, either individually or in

community with others . . . , to manifest [one’s] religion or belief in worship, observance,

practice and teaching”) (“ICCPR”). Moreover, Petitioner has the right not to be tortured. ICCPR

art. 7; Convention Against Torture art. 2.7

Because Petitioner is plainly a “person” within the meaning of the provisions of

international law protecting his right to pray communally, he must be afforded that right pursuant

to the U.S.-Pakistan treaty, regardless of whether he is considered a “person” for purposes of the

First Amendment and the RFRA.

7 Congress has prohibited the Guantánamo Bay detainees from invoking the Geneva Conventions, see Pub. L. 109-366, § 5(a), 120 Stat. 2600 (2006), but not other provisions of international law.



40

IV. PETITIONER MEETS THE CRITERIA FOR GRANTING A PRELIMINARY INJUNCTION.

In deciding whether to grant a preliminary injunction, this Court is required to consider

four factors: (1) whether Petitioner has made a strong showing that he is likely to prevail on the

merits; (2) whether Petitioner would be irreparably injured without such relief; (3) whether such

relief would substantially harm the Government; and (4) where the public interest lies. Winter v.

Natural Res. Def. Council, Inc., 555 U.S. 7, 20 (2008).

As demonstrated above, each of these criteria favors Petitioner. Petitioner is likely to

prevail on the merits, given that: (1) there are ready alternatives to, and thus there is no

legitimate penological interest in, Petitioner’s current force-feeding; (2) depriving him of the

ability to pray communally during Ramadan violates the First Amendment and RFRA; and (3)

both violate the U.S.-Pakistan treaty, which affords Petitioner the protections of international

law. Without an injunction, Petitioner will continue to be irreparably injured by serious

violations of constitutional and human rights—most notably by his continuing to suffer

grievously and unnecessarily harsh practices in his force-feeding. In contrast, the Government

can hardly be injured by following ready alternatives to current force-feeding practices or by

allowing Petitioner to pray communally. And surely the public interest cannot lie in continuing

to pile human rights violations upon human rights violations at Guantánamo Bay. The Nation’s

best interest lies in honoring international law, rules of medical ethics and basic human decency,

as well as respecting the right of religious free exercise.


41

CONCLUSION

For the foregoing reasons, Petitioner respectfully requests this Court to issue a

preliminary injunction granting the following relief:

1. Enjoin Respondents from performing wrongful and gratuitously painful practices

in the force-feeding of any detainee at Guantánamo Bay, including but not limited to (a)

unnecessary forcible and violent removal of detainees to the force-feeding location, (b)

unnecessary and degrading genital searches, (c) unnecessary use of restraint chairs, (d)

unnecessary insistence on force-feedings twice per day, (e) insertion and withdrawal of feeding

tubes twice each day, (f) use of unnecessarily thick feeding tubes, (g) use of a dangerous and

unreliable method to determine placement of feeding tubes, (h) unnecessarily rapid force-

feeding, including any form of force-feeding that resembles the “Water Cure” form of torture,

and (i) the use of over-feeding and anti-constipation medication to induce defecation during

force-feeding.

2. Enjoin Respondents from force-feeding any detainee at Guantánamo Bay unless a

physician determines that, as a result of hunger-striking, the detainee is actually facing an

imminent risk of death or great bodily injury.

3. Declare the current Guantánamo Bay force-feeding protocols to be invalid, and

direct Respondents to promulgate new protocols forthwith that conform to standards as

exemplified by the U.S. Board of Prisons regulations.

4. If the Court determines that the current Guantánamo Bay force-feeding protocols

are valid, issue an order directing Respondents to comply with those protocols.

5. Issue an order directing Respondents to allow all hunger-striking detainees at

Guantánamo Bay, or at least Petitioner as a Pakistani national, to perform the Islamic tarawih

prayers communally during Ramadan in 2014.


42

Petitioner also requests an immediate emergency order requiring Respondents to

forthwith disclose to Petitioner’s counsel the current SOP that governs the use of restraint chairs

in the force-feeding of Guantánamo Bay detainees, as well as any other as-yet-undisclosed SOP

on force-feeding.



/s/ Cori Crider REPRIEVE Clive Stafford Smith (LA Bar #14444) Cori Crider (NY Bar #4525721) Alka Pradhan (D.C. Bar #1004387) P.O. Box 72054 London EC3P 3BZ United Kingdom 011 44 207 553 8140 [email protected] [email protected] [email protected]





MOHAMMAD AHMAD GHULAM RABBANI, ) ) Petitioner/Plaintiff, ) Civ. No. 05-1607 (RCL) ) v. ) ) BARACK H. OBAMA, et al., ) ) Respondents/Defendants. ) __________________________________________)

DECLARATION OF JON B. EISENBERG

Pursuant to 28 U.S.C. § 1746, I certify that the following is true and correct to the best of my knowledge:

1. My name is Jon B. Eisenberg. I am one of the attorneys for Mr. Mohammad Ahmad Ghulam Rabbani (known as Ahmad Rabbani). I am also counsel for Shaker Aamer in Aamer v. Obama, 742 F.3d 1023 (D.C. Cir. 2014). I make this declaration in support of the above-captioned matter.

2. In late November of 2013, during the pendency of Aamer v. Obama in the D.C. Circuit,

Government counsel Daniel J. Lenerz advised the D.C. Circuit that publicly-available written protocols dated March 5, 2013 governing the force-feeding of hunger-striking detainees at Guantánamo Bay had been revised. Subsequently, at my request, Mr. Lenerz provided me with two sets of the revised protocols—the first dated November 14, 2013, and the second dated December 16, 2013. Mr. Lenerz advised me that the Government considered both sets of revised protocols to be “protected information” which may not be disclosed publicly.

3. Upon reviewing the November 2013 revised protocols, I determined that, unlike the

March 2013 protocols, the November 2013 protocols did not address the use of restraint chairs in the force-feeding process. In mid-December of 2013, after I brought this omission to the attention of Mr. Lenerz, he advised me that a separate written SOP (“standard operating procedure”) now governs the use restraint chairs, but that Government counsel “will not agree to provide you with that SOP . . . .”

4. In email exchanges on March 7, 2014, I asked Government counsel Andrew Warden to

provide me with a copy of the separate written SOP that now governs the use of restraint chairs, as well as any other as-yet-undisclosed SOP that currently governs the process of enteral feeding and the use of restraints, but Mr. Warden responded that the Department of Defense “will not produce any additional SOPs.”


2

5. On March 10, 2014, Mr. Warden emailed me a redacted copy of the December 2014 protocols for public disclosure.

I declare under penalty of perjury that the fore going is true and correct to the best of my knowledge. March 27, 2014 JON B. EISENBERG

1970 Broadway, Suite 1200 Oakland, CA 94612 (510) 452-2581

Jon B. Eisenberg



MOHAMMED AHMAD GHULAM RABBANI ) )

Petitioner/Plaintiff, ) )

v. ) )

BARACK H. OBAMA, et al., ) )

Respondents/Defendants. )

Civ. No. 05-1607 (RCL)

DECLARATION OF CLIVE STAFFORD SMITH

Pursuant to 28 U.S.C. § 1746, I certify that the following is true and correct to

the best of my knowledge:

1. My name is Clive Stafford Smith. I am the founder and Director of Reprieve, a

not-for-profit human rights organization based in London.

2. I am counsel to Mr. Rabbani and make this declaration in the above-captioned

matter. I do not mean for this declaration to be in any way comprehensive of the

mistreatment or injury Mr. Rabbani has suffered during his hunger strike at

Guantanamo Bay.

3. I am making this declaration based on what my client has told me. It is important to note that I have not had the opportunity to pass this declaration by Mr. Rabbani

himself to check its accuracy. While I try to take notes as accurately as possible

when we talk, I sometimes do not get the notes back from the Privilege Review

Team (PRT) for weeks after I visit Guantanamo Bay, which makes it difficult to

remember the precise context of our discussion. When I talk to him on the

telephone, we have limited time and in recent months he has been intimidated by

the humiliating "genital searches" and therefore sometimes does not come to

phone calls. Thus, if there should ultimately be anything inconsistent between this declaration and the one that Mr. Rabbani subsequently executes, the latter should

be considered more authoritative.

4. With these caveats, though, I am confident that the broad facts set forth in this

declaration are accurate to the best of my knowledge and belie£

1


The precipitants of Mr. Rabbani's hunger strike

5. Mr. Rabbani wishes to bring an action to prevent the intentionally painful manner in which his force feeding is conducted. He wishes to do so to protest the treatment he has received since beginning his hunger strike.

6. Mr. Rabbani is a Pakistani national who was born, and lived most of his life in Saudi Arabia. He is married with three children. His family still resides in Pakistan. He is divorced from his first wife, with whom he had two children; he has a son with his second wife, who continues to await him in Pakistan. He has been imprisoned at the U.S. Naval Station at Guantanamo Bay, Cuba ("Guantanamo) without charge for over nine years. The U.S. military has assigned Internment Serial Number (ISN) 1461 to Mr. Rabbani.

7. Prior to being taken to Guantanamo, Mr. Rabbani was held at the Dark Prison in Afghanistan. This was a particularly notorious prison being run by the United

States, with some Afghan assistance, where Mr. Rabbani underwent harsh torture. He was also held at Bagram before being rendered to Guantanamo Bay.

8. When the recent, widespread hunger strike started in Guantanamo Bay in February 2013, Mr. Rabbani was one of the first detainees to refuse food. He joined the peaceful protest primarily because he believed that he should not be

detained at Guantanamo Bay for nine years without a trial, with the possibility of his detention stretching into the indefinite future. For all this time, he has not been able to see his wife and his three children.

9. He was frustrated at a number of other things, including the following:

a. the fact that roughly half of the prisoners have been cleared but have not been transferred from Guantanamo;

b. the constant and intentional disrespect for his, and other prisoners', religious sensitivities, including the mistreatment of the Qur'an, the "genital" searches (called "scrotum searches" in the prison) that are done

to humiliate prisoners, the problems caused at prayer time, and so forth; c. the fact that he had to make roughly fifty requests, without success, to get

his legal materials back; and d. the fact that the colonel apparently ordered the destruction of all his

artwork that he had labored to create over many years.

I 0. There is also the arbitrary manner in which the authorities address issues, which often results in unnecessary punishment of prisoners for trivial reasons.

2


There are many examples of this. The soldier tells you that you have too many bottles of water, or too much salt, or clothes, or cups - or some other such trivial

reason - and whether or not the soldier is justified, the reason is stupid. There is

no need to bring the force team. But from stupidity, or self-importance, the officer

in charge can call the force team. Sometimes, it even happens for stupid medical

reasons: for example, they used to weigh us hunger strikers in the morning and

evening, on our way to be force fed. If the prisoner refused to give them the

weight, they could call the force team. This is idiotic: if you have been weighed in

the morning, and you were 11 Olb, then it's impossible for your weight to have

dropped to 1 OOlb by the evening. This doesn 't require the force team to be called ...

II. Mr. Rabbani might not have taken part in a hunger strike had his experiences not been so frustrating and so long-lasting. However, he has now been in U.S. custody for a total of eleven years, he has been tortured, and he has been forced to undergo endless frustrations and mistreatment without the prospect of freedom or a fair trial.

The Force Feeding Methodology in Use in Guantanamo Bay

12. Force-feeding at Guantanamo is implemented if hunger strikers fall below a specified weight, set depending on each detainee's height. Mr. Rabbani has described to me how he is force-fed, twice daily, for weeks or months at a time. When he reaches an "acceptable" weight, the force-feeding ceases for a few weeks until, once again, he falls beneath the specified weight. At that point, the force-feeding resumes. Mr. Rabbani has described this process to me as neither being allowed to live nor being allowed to die. He finds the oscillating between

force-feeding and being left alone as much harder than one thing or the other- it is, he believes, like being a dog that is sometimes left to its own devices and then randomly kicked and beaten.

13. Before hunger striking, Mr. Rabbani's average weight was about 167lbs. By May of2013, he weighed only 106lbs. Currently his weight is between 109 and 110 lbs. He continues to vomit and cough blood on a regular basis due to his poor health.

14. Mr. Rabbani objects to being force fed at all. It is his belief that he has the right to non-violent, peaceful protests. Indeed, he is particularly disconcerted that it appears only to be physically violent protests that obtain a positive response from the JTF-GTMO authorities. Thus, some of the prisoners throw urine or feces in order to achieve their goals. This often achieves results. Mr. Rabbani, on the other hand, does not wish to resort to such means. He has tried other peaceful means of protest, such as the simple refusal to go out to the rec yard. The authorities do not

3


respond to this- after all, it just makes their job easier, as nobody has to take him to the rec yard.

15. Mr. Rabbani therefore sees no alternative for him but to go on hunger strike as a peaceful form of protest that does demand some kind of response from the

authorities. He does not wish to be force fed at all; however, his strongest objection is to the fact that the force feeding is gratuitously painful.

Step One: The FCE Team

16. This begins with the forcible manner in which the prisoners are taken to the force feeding chair. Mr. Rabbani has been forced to the Chair with the Forcible Cell Extraction (FCE) team on many occasions. He describes how five or six men

force their way into his cell, force him down on the ground, kneel with their weight on his back, force shackles onto his wrists behind his back, force shackles onto his ankles, and then drag him bodily out of the cell, carrying him like a sack to the force feeding room. It has caused him great physical pain - after each FCE event, he would have pain in his back for days. He simply cannot withstand the

pain twice a day any more, so he is now walking to the force feeding Chair rather than go through the FCE process. However, this is not a voluntary act, as he only walks because he cannot stand that part of what is a desperately painful process. Additionally, as described below, he periodically continues to be forced to his force-feeding by the FCE team.

17. Meanwhile, he has to witness others being taken by the FCE team each day, and he describes how this has the equivalent impact on him as torture in the 'second degree' - where he must witness what happens to others, knowing that it will happen to him unless he complies with the demand that he should walk to his force feeding.

18. For example, in a recent letter to me he described the mistreatment of others as follows: The authorities have been bringing the force team to one fellow here for more than a month and a half. The start of the problem was simple: the detainee is lame and cannot walk without his crutches. However, his crutches were taken away because he was on hunger strike, as a punishment. Therefore, he wasn't able to walk to the feeding room.

19. To begin with the other detainee drank the Ensure in his cell, to avoid being taken to the feeding room by force. However, one day the soldiers brought him two cans to drink. He drank a whole can, but when he started to drink the second can, he was on the verge of vomiting. He tried to take in what he could, but when he gave the second can back, there was a small amount left in it. The corpsman left, and the prisoner was relieved, and went to sleep.

4


20. After a few minutes, though, the corpsman returned with a third can, and told him

that he had to drink it.

21. The brother protested, saying that he had drunk two cans. The corpsman replied

that he hadn't finished the second can.

22. "Fine," the detainee replied. "The second can was around nine-tenths empty. So I

will drink one-tenth of this can." However, the corpsman told him he would have

to drink the whole can, even if it made him nauseous all over again.

23. The detainee's neighbour, who had seen how much was left in the cup, intervened

and complained to the corpsman and to his superiors. But they refused to listen,

and said that the detainee had to drink the whole can. They then brought the FCE team, and fed him by force.

24. This so offended the detainee's sense of justice that he began to resist. At first, he

resisted passively, but when they saw him resisting, the FCE team began to hurt

him: they hit him, and subjected him to the awful 'Scrotum Searches'. After this,

he began to resist more.

25. Twice a day, now, he was taken by the FCE team to be force fed. Many times they hit him; then he struggled to resist them. This was how the government wasted

time and effort, and all this because of the authoritarian way in which the

corpsman (who is meant to be a medical officer, treating prisoners) brought in the FCE team to force the detainee to drink the third can.

26. Mr. Rabbani recently described the suffering of another detainee who is, for

religious reasons, extremely sensitive to the presence of women. He is one of the

detainees who has been on hunger strike for a long time, though he took a brief

hiatus from his hunger strike, only to resume when he felt that the mistreatment of

prisoners forced him to take up his protest once more.

27. The prison administration knows that this detainee is extremely sensitive to the

presence of women. For this reason, the detainee refuses to be force fed by women

- whether they are corpsmen or nurses. In the past, the prison administration used

to bring him a male nurse; if not, he would refuse, and they would take him with

the FCE team and feed him by force.

28. So, now, for several months since he rejoined the hunger strike, this detainee has

asked whether the nurse is a man or a woman. If it is a man, then he walks to be fed without the FCE team, but if they are going to force him to be fed by a

woman, he refuses and had to be taken by force with the FCE team. Then, an

officer told his men not to tell the brother if he asked them for this information.

5


From that point onwards, of course, this meant that the detainee would only come out of his cell with the FCE team - to the point that, even if they tell him that the nurse is a man, he still won't go without the FCE team being called because he just does not trust them to be honest any more. As described by Mr. Rabbani: "Now they harass him, and oppress him, and hit him when the FCE team arrives,

such that the brother has become a fighter. Every day they hit him ... He always ends up beaten, and crying out."

29. Mr. Rabbani insists that even the cameraman involved in these events is complicit in covering up the worst of the abuse. He describes a recent incident involving this detainee, where the FCE team throttled him. Afterwards, he was vomiting blood because he had essentially been strangled. The detainee asked the cameraman and the medical staff to film him with his injuries, but they refused and went away from him to a place where he heard the corpsman saying to the camera that the prisoner was well.

30. Mr. Rabbani has identified other detainees who are currently going through the FCE process when they are taken to the Chair. He said that there were some nine men who were being FCE'd for each force feeding. They include:

a. Muaz (ISN 028): He is being FCE' d every day. He has lost roughly I 00 lbs during his strike. He is keen that his hunger striking should be brought before the courts. He is vomiting a lot during his force feeding.

b. Khalid Adewi (ISN 242): He is being FCE'd every day. He has asked Mr. Rabbani to secure undersigned counsel's assistance to bring his plight before the courts. (I am working to make that happen but have not been able to establish contact with him yet.)

31. Mr. Rabbani gives many similar ~xamples of mistreatment on the way to forcefeeding, some of them involving the now-infamous 'Scrotum Searches', which got so dire that despite the pain Mr. Rabbani endured the FCE team again to protest.

He recently wrote to me about another one that involves the 'Scrotum Searches' in greater detail. They had been taking one detainee to be force-fed for around three months. In recent months, these 'Scrotum Searches' have been introduced as a form of intimidation, in an effort to prevent prisoners from talking to (particularly) their lawyers, and their families. This is meant to try to censor the truth from coming out of Guantanamo Bay, so that the world does not hear what is happening, particularly with respect to the hunger strikes.

32. 'Scrotum Searches' are employed whenever a prisoner leaves his camp to go and meet a lawyer, or for a call. The prisoner is searched, including his genitals. When the movements were inside the camp, they continued to use a normal search,

6


which is the one which has been used for years- namely, from the knees to the

floor, and from above the genitals upwards.

33. Around the start of2014, though, they adopted the full body search procedures for internal detainee movements as well, including force-feeding. A few detainees resisted this and they stopped the search. The soldiers said that they had made a mistake, and that these were the procedures for external movements only. Mr. Rabbani, for one, stopped resisting. However, two other detainees were searched in this way again. One of them said to the soldiers conducting the search: "I will go to be fed, but only with an ordinary search." Even so, they insisted upon carrying out a Scrotum Search. The prisoner requested to see the officer in charge but they still insisted upon carrying out a Scrotum Search without any reason. Since he refused, they brought the FCE team, and gave him a truly awful searchand from that day on, he has continued to refuse to go to force feeding without the FCEteam.

34. Sometime in January, Mr. Rabbani was coming back from being fed- an internal prison movement. The soldiers subjected him to a Scrotum Search. Naturally, he started to object vehemently. The soldier initially apologised, and Mr. Rabbani

accepted the apology. But then in February it happened again: one of the soldiers searched him in this awful way as he was going to be fed - so Mr. Rabbani refused to return, and was subjected to the FCE team.

35. The same soldier later gave Mr. Rabbani another variation on the Scrotum Search, and pulled hard on his chains, dragging him by force - "as if he were pulling a cow," to use Mr. Rabbani's precise words. When he sat Mr. Rabbani down in the feeding chair, he pulled the straps very tight as another form of abuse.

36. The antagonism between Mr. Rabbani and this soldier only got worse and so Mr. Rabbani made repeated requests that he be moved by others. However, wherever he turned, he seemed to find this soldier taking part. For a while the block commander was using the problems he had with this officer as a way to taunt him.

Step Two: The 'Torture Chair'

37. Mr. Rabbani has described to me the room in which the hunger strikers are forcefed as a classroom-type set-up with five or six feeding chairs in the room. On the side of the room there is a toilet which is foul-smelling. This stench makes Mr. Rabbani nauseated and he finds it difficult to inhale this odor during his feedings and not vomit.

38. Once the prisoner is at the feeding room, he is strapped into the force feeding chair, dubbed the 'Torture Chair' by the prisoners.

7


39. The detainee is strapped to this chair in a number of places: one on each hand, one on each leg, two straps across the shoulders, one across the waist and

generally one across the head.

Step Three: The Tube

40. A tube is then fed through the nose and into the stomach- assuming that it is done correctly. If the detainee is seen to be resisting the feeding, by shaking his head for instance, the FCE team is called in to hold his head still and squeeze his neck so that even that cannot be lifted. Pressure points are used around the head to make it particularly painful, in order to force the prisoner into compliance.

41. This tube is often much bigger than it used to be. Back in 2005, the authorities often used a Number 8 tube, which had two advantages- that it was easier to put

in, and that is made the force-feeding slower, thereby provoking less nausea. However, one of the gratuitously painful innovations brought in by General Bantz J. Craddock to make it less 'convenient' for prisoners to go on a peaceful hunger strike was to start using a larger tube, often a Number 14. This is very painful on

the prisoner's nose, as well as allowing for much faster feeding.

42. Mr. Rabbani reports that there is generally no doctor present for force feeding. Only the most rudimentary precautions are taken to ensure that the tube is inserted

into the right place - and not the lung.

43. Mr. Rabbani reports how one nurse, often tasked with force-feeding men on hunger strike, did not know how to properly feed the tube down into the men's stomachs. Instead she would manoeuvre the metal tip of the tube so that it pressed into the men's organs. After many incidents of this painful process, she was removed from force-feeding duty for about 20 days. When she returned to the same job, her skills at placing the tube had still not improved.

44. Upon her return she incorrectly fed the tube down Mr. Rabbani's throat so that the tip of the tube continued to dig into his organs. Mr. Rabbani remembers her hands trembling as she continued to push the tube into him while he was screaming, attempting to tell her that the tube had been incorrectly fed down his throat. His screams were so loud that many soldiers gathered to see what was happening, but the nurse continued to drive the tube in him. Mr. Rabbani, still strapped to the chair and unable to move, could not fight against the tube which continued to press into his organs and eventually he fainted.

45. When he awoke, Mr. Rabbani requested the translator to explain what had happened. He requested a new nurse be brought in to properly place the tube and feed him. His request was refused and he was told that there was no one else who

8


could perform the procedure. The nurse continued her work, her hands still shaking and trembling.

46. Mr. Rabbani often suffers from throat and stomach infections as a result of his multiple force-feedings, especially from those performed in this way.

Step Four: Inserting and removing the Tube

4 7. One modification introduced at the time of General Craddock was to require that the tube be inserted and removed at each feeding. Prior to this, the prisoners had been told that it would be more dangerous to do this, both because the tube could be inserted in the wrong place, and because constant insertion and removal of the tube would cause more damage to the prisoner's organs. The change came about in late 2005 or early 2006 as one of the means of making is less 'convenient' (i.e., more painful) for the prisoners to continue with their peaceful protest. Mr. Rabbani is, of course, aware of this, and feels particularly aggrieved that it is being done in a manner that he understands to be intentionally and gratuitously painful.

48. This factor is all the more troubling for Mr. Rabbani because, as noted below, it is clear that he does not need to be fed twice a day to maintain his body weight. Thus, he could halve the pain and suffering caused by the repeated insertion and removal of the tube if only he were fed once a day.

Step Five: The Feeding

49. The liquid nutrient is forced into Mr. Rabbani much faster than it should be. Indeed, in order to get it over faster, during some force-feedings, corpsmen overseeing Mr. Rabbani' s feedings squeeze the liquid feed bags to increase the speed at which the liquid is pumped into Mr. Rabbani's stomach. Other times, the nurses themselves squeeze the bags to speed the process. The quicker the liquid enters the stomach, the more painful the stomach is as it is forced to expand much more rapidly than is natural.

50. In another instance, a male nurse was preparing the feeding mixture for Mr.

Rabbani. Mr. Rabbani asked this nurse to add more water to the mix so that the feed so it would not be so viscous. The nurse turned his back to Mr. Rabbani, thinking that Mr. Rabbani could not see the mix being made. Instead of following Mr. Rabbani' s wishes, he added an extra bottle of the feeding liquid which would not only slow the feeding process, but over-satiate Mr. Rabbani. The oversatiating causes more pain even than usual. The only remedy Mr. Rabbani had was to call for a translator and request an official report be written about the incident.

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Step Six: Vomiting and Starting Over

51. Forcing the food in too fast makes it much more likely that the detainee will vomit. If a detainee vomits at any time during or after a feeding, the process is repeated. It does not matter how much of the feeding liquid is expelled, the full two cans of nutritional supplement is pumped back into the detainee's stomach.

52. Some of the prisoners are allowed to take in their liquid for as long as 2 hours. This is not the case with Mr. Rabbani, who is generally required to go through the whole process in 20 minutes or a maximum of half an hour.

53. The other prisoners tell Mr. Rabbani that this is very bad for his intestines, and that he should take it much more slowly. Mr. Rabbani has tried to insist on it being slower, but generally his complaints are ignored.

54. Generally, Mr. Rabbani receives two cans of Ensure with 250 calories each, for a total of 500 calories, at each feed. The cans are 8 fl oz (236 ml) each, and when they prepare it they add water to it, normally between 200 and 300 ml with each can. Therefore, the nutrient part of the force-feeding includes around I 000 ml of

liquid.

55. Beyond this, he may be given more liquid to wash through the feed, and even more liquid with a laxative medication that is designed to loosen his bowels. In addition to adding to the liquid being forced into him, this contributes to the most humiliating aspect of the whole process, which is when he defecates on himself.

Step Seven: The Humiliation of Defecating On Himself

56. Because of the speed at which the feeding mixture is pumped into Mr. Rabbani' s body, he often needs to use the toilet during the feeding process. Instead of letting him utilize the toilet located in the room, Mr. Rabbani is forced to wait until the tube can be removed from his stomach and he can be escorted back to his cell.

57. Unable to hold his bowels for this amount oftime after being fed, Mr. Rabbani is sometimes forced to defecate on himself.

Step Eight: The Impossibility of Ending His Force-Feeding

58. In the summer of2013 Mr. Rabbani was told that he must consume 3,000 calories per day to avoid force-feeding. Various foods were assigned point values where 100 points was equivalent to 1,000 calories. For instance, one can of Ensure was 25 points, a piece of fruit was 5 points, milk was 20 points, and baklava was 40 points. Especially in his weakened state, Mr. Rabbani could not physically consume 3,000 calories per day. Still the medical staff repeats that this the only

10


way Mr. Rabbani will be able to end his force-feeding.

Step Nine: Interference With Religious Beliefs

59. The force feeding procedure interferes unnecessarily with Mr. Rabbani's religious beliefs. During Ramadan 2013, a holy month of fasting and religious observance for Muslims, Mr. Rabbani fainted during one of his forced feedings. When he came to, he spent the rest of the day vomiting.

60. There is no medical need for him to be force fed twice in a 24 hour period under any circumstances. This is particularly true during his religious observance of Ramadan. He anticipates that disrespect will be shown for his religious beliefs again this year.

61. The 'Scrotum Searches' additionally violate his religious beliefs.

Step Ten: Additional Punishment For a Peaceful Protest

62. Mr. Rabbani states that the force feeding process is punishment itself for his peaceful protest.

63. However, he states that the authorities have imposed a series of other gratuitous punishments on prisoners who have the temerity to engage in a hunger strike.

64. Mr. Rabbani is being held in Camp V Echo, which is the worst place in the whole prison. Mr. Rabbani describes how others who go on hunger strike in Camp VI are punished with a spell in Camp V Echo, to teach them what is in store for them if they go on strike. However, he has himself been held there for months, being punished month-in, month-out for his peaceful protest.

65. He gave me the following description of the current conditions in Camp V Echo on January 3, 2014:

The dreaded Camp V Echo block is back in use. There are ten of us being held there, mainly disciplinary punishment for being on hunger strike. I am here for being on hunger strike. It is a peaceful protest that merely asks that each person should get a fair trial. or be set free. That does not sound too much to ask. Indeed, President Obama says that Guantanamo Bay should be closed altogether. so he takes a stronger position than this. But that is no reason for Colonel John Bogdan to respect our right to peaceful protest.

Everyone brought in from Camp VI for going on strike gets a few days here, to taste what it is like to disobey Colonel Bogdan's wishes, before being moved to another part of Camp V. Six new men were brought in a few days ago from Camp VI for their boot camp here.

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My cell in the dreadful Camp V Echo is constructed in a strange manner. It is designed to torture the person who is held there. All the surfaces made of steel. The bed is steel. The walls are steel. The floor is steel. The ceiling is steel. There is no toilet, but the hole in the ground is made of steel.

I sent a letter to my lawyer with a drawing of the cell, but this was apparently censored because somehow it would be a threat to national security for anyone to know where I am in Guantimamo- as if they could break me out of here with thousands of heavily armed American troops all around!

I have to sleep on a steel slab. For the last 3 months I have been asking for an isomat, but I have not had one for three months. Even the doctor prescribed that I should have not one but two isomats. Indeed, then another doctor agreed with him, so two doctors said this. They repeatedly said it. But the Colonel here refused to let me have them. Colonel John Bogdan overrules doctors when it comes to medical matters.

It is also very cold. I can only sleep by putting a blanket below me. The guards wear a thick uniform, and so they put the temperature down to make themselves comfortable. It is sometimes as low as 63 or 64 degrees, which is good for them, but very, very cold for us.

It is all very hard on me, but particularly on my back. I have severe back pain creating a serious problem with using the toilet. The pain I am having is very strange. I like to exercise and play different sports. I have never had this pain. It has come on because of the cold, because of the steel bed, and because of the very strange toilet facilities in Camp V Echo.

There is only a hole in the ground For the last ten years, even here in Guantimamo, I have been using the normal modern toilet seat, the style that is used all over the world. Back in Pakistan, which is considered a Third World country by the United States, I had a modern toilet before I was locked up by the Americans. Now, because I am on hunger strike, I am being forced to use a hole in the ground

Even that is not one that a normal person can use. It is built in so close to the wall that there is no space to put one foot on one side of the hole. Therefore I have to find some other way to do this. It is truly terrible, but the method I had to use to relieve myself was to use the food container. I can place that underneath me so I can put both feet either side. I have to use the food container!

All I am asking is for a stool so I can sit on it over the hole. Imagine for the last three months I have been asking for a stool like this, but the only thing I can do is to give them a polystyrene plate every three or four days, foil of my number two. I have no other choice. It is disgusting for them, and more disgusting for me, but that is what I am reduced to doing. I wish it was not so, but I have no choice. Doubtless, Colonel Bogdan views this as more evidence of my 'resistance ' to his will.

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A few days ago I woke up and saw the entire wall was covered with condensation as it was so cold. It was like dew on a winter morning. I found the blanket wet. I shouted to the detainee next door to me (I cannot tell you his name as that is apparently classified): What's wrong? Why is it so wet? He said his blanket was soaked too. It was the cold and the humidity.

66. Of particular relevance to Mr. Rabbani in all this is the lack of a proper toilet. More recently he has written to me again on this point:

Since I go to the toilet with difficulty, every time I go to the toilet it's possible I

will spend half an hour, and after half an hour nothing comes out. Because of this,

sometimes I repeat this operation three or four times until I can fulfil my need. So

I asked for a chair for the toilet. Basically I need accommodation where there is a

chair for the toilet, or at least a room with a toilet, and not a room without a toilet but just a hole close by the wall. There is no place to put your feet in this cell,

which was planned for torture, but I have now spent no less than six months here.

My back could not stand these long periods of sitting, so I was forced to lean

against the wall. But the wall is metal. So, after a while, going to the toilet became a mental obstacle for me because of the pains in my back which afflict me after

going to the toilet.

67. Mr. Rabbani's right to something as basic as a toilet chair has apparently been conditioned by the doctor on his complying with the authorities' order that he go to force feeding. Mr. Rabbani told him that the doctor said he could only have the toilet chair if he went two weeks without being FCE'd. This was on January 28'h, 2014. The doctor said that he would not otherwise get the chair and that he was required additionally to be compliant with the rules.

68. Mr. Rabbani thought this was very wrong, but because he was already suffering too much from the FCE team, he went along with it. However, when he eventually got the chair for complying, it did not fit. Also, the toilet chair did not have a seat or basket below it. When he queried what was going on, he was told that he was "approved just for the chair". He was upset, and asked, "you are mental or

what? It does not fit!" He explained how the excrement would land on floor.

69. The nurse later said that the rest would arrive on the next day. Days went by and nothing arrived. Several days later a plastic tub came, but there was no chair. The next day the fitting for the tub arrived, but again there was no chair. Even when coerced into complying with the military regime, Mr. Rabbani was still denied materials that were medically necessary for an extended period.

70. In addition to this Mr. Rabbani describes other punishment that is meted out to those on hunger strike:

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When I started this hunger strike, the colonel used every method he could to

overstep all the boundaries. He picked a fight with us over everything in our

religion, angering us by searching the Qur 'an, and searching our genitals, by

causing problems in our prayer and in our fasting. He removed all our medical

equipment, all our personal books, and all the things that our families had sent us.

He destroyed all the art work over which we had toiled for years. He removed all

our privileges- or, rather, he even removed all our rights. He did to us what no

previous camp commander had dared to, and even took away all the things we are

allowed by law. Can you imagine? This colonel removed glasses from a man who

has worn them since his childhood. They took an amputee's prosthesis away. They

took a lame man's crutches and wheelchair away. These things are like a person's

own limb. Glasses are their eyes. A prosthesis allows a man to stand up. Crutches

support the lame man.

As for the prayers, he wrongs us in our religion, and by the way he searches our

genitals. I've already made you aware of how they carry out the searches just to

humiliate us and not for reasons of security. He even searches the copies of the Qur'an.

* * *

[Then there] is the issue of exercise, which took place during the night for more

than three months. For that whole time, I did not see the sun. My time for going out for exercise was either midnight or three in the morning- i.e. they attacked

my sleep regimen, and deprived me of the sunlight, even while knowing that the exercise area was free all day long. And after over thirty polite and courteous

requests, they did not fix the problem.

Step Eleven: Including Unknown drugs in the Force-Feeding Mix

71. Usually Mr. Rabbani is not told what has been put in the feed bag, but he suspects

that oftentimes it includes some sort of drug because oftbe pain and symptoms he experiences afterwards. He relates that most times after being force-fed, he suffers pain, colic, dementia, numbness, and hallucinations. On days when Mr. Rabbani is not force-fed, he does not experience these same symptoms.

72. At one point in summer 2013, Mr. Rabbani watched a nurse mix some feeding material and observed as the liquid turned an odd color. He raised his concerns with the nurse, convinced that she had mistakenly mixed in a wrong drug but she

assured him that he was incorrect. His suspicions grew when that same nurse arrived on the cell block to speak with one of the officials. Shortly after his feeding, Mr. Rabbani experienced a terrible headache and then passed out asleep for many hours.

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73. The guards at Guantanamo also mock the hunger strikers. Mr. Rabbani has reported that sometimes the guards will steal the detainees' food and record that they have eaten. At the designated feeding times, these detainees are taken to be fed only to be told that they are "clear," meaning they do not need to be tube fed for that day since they have eaten sufficient amounts of food. Although the guards do this to mock him, Mr. Rabbani actually prefers to feel the pangs of hunger for the day than suffer another force-feeding.

Step Twelve: Lack of Medical Involvement To Alleviate the Force-Feeding Process

74. Mr. Rabbani has described experiencing double vision, issues with coordination, and memory loss. He has stated that the worst side effect from the force- feeding is the severe stomach pain due to the lack of fiber in the feeding liquids used.

75. Rather than provide assistance, Mr. Rabbani complains that the doctors at Guantanarno deride and ridicule him for being on hunger strike. One doctor stated that he had no authority to do anything for Mr. Rabbani.

76. Mr. Rabbani continues to be forcibly fed with Ensure, or a similar high-calorie liquid substance, twice daily. He approached the medical staff about the pain and severe gas he experienced with these feedings, and asked that he be force-fed with another liquid nutrient. In response, the medical professional told him to end his strike.

77. He has related to me that he often thinks about smashing his head against the wall because of the severity of his pain he undergoes.

78. Indeed, because the doctors would do nothing for Mr. Rabbani, he refused a medical appointment. The FCE team was sent in to take Mr. Rabbani forcibly to see the doctor. In the process, Mr. Rabbani was violently hit in the chest and one of his teeth was knocked loose.

79. In early May 2013 Mr. Rabbani fainted and was taken to the hospital for force

feedings. There, he was strapped down. He was fed a total offour times over 24 hours, two of them within two hours' time. He remained in the hospital for five days.

80. Upon his release from the hospital, Mr. Rabbani returned to an empty cell. He asked for his personal items which had been removed during his absence, including his false teeth, prescription eyeglasses, and family photos.

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81. Mr. Rabbani has repeatedly pointed out to the medical staff that his weight when fed twice daily does not fluctuate when he is only fed once daily. He has asked the staff to therefore only force-feed once per day in order to ease the suffering he

endures. His pleas go ignored and he continues to be force-fed twice in one day.

In Conclusion

82. On this occasion, Mr. Rabbani has been on hunger strike since February 6, 2013.

83. As he stated to me in a recent letter:

Imagine yourself as a prisoner. You have a call every two or three months, when

you speak to your aged mother or your sick father, or your family, or to your wife

(who's more like a widow), or to your children (who are more like orphans). As

you are on your way there, they subject you to that insulting search. When you get

there, they tell you that they have cancelled the call. Or you make the call, and the

sound is very bad throughout, and the picture very unclear.

After all this - the bad quality line, the horrible search, the ill treatment, the cuffi

and the chains, the hand chains and the leg chains, and the endless restrictions in

the call itself- you hear that your mother has died, or your father, or your wifo,

or your children, or one of your brothers, or a dear relative, or a friend. There is

no consideration for your sadness. No, to the contrary, as you return from the call

to your cell, crying from sadness, they welcome you by searching your genitals.

After this shock, there is nothing but humiliation.

84. Mr. Rabbani does not wish to die, but has no intention of stopping his peaceful protest until his request for a fair trial or release is granted.

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I declare under penalty of perjury under the laws of the United States of America that the

foregoing is true and correct to the best of my information and belief.

n this 26th day of March, 2013.

CLIVE A. STAFFORD SMITH

Reprieve P.O. Box 72054

London EC3P 3BZ

Tel: +44 (0)20 7553 8180

[email protected]

Counsel for Petitioner (licensed in the State of Louisiana)

17


Exhibit A


Case 1:04-cv-01194-UNA Document 1001-5 Filed 03/11/14 Page 1 of 13


IMAD ABDULLAH HASSAN

Petitioner/Plaintiff,

v.

BARACK OBAMA, et al.,

Respondents/Defendants.

) ) ) ) ) ) ) ) )

Civ. No. 04-1194 (UNA)

DECLARATION OF CLIVE A. STAFFORD SMITH

Pursuant to 28 U.S. C. § 1746, I certify that the following is true and correct to the best of my knowledge:

1. My name is Clive Stafford Smith. I am an attorney licensed to practice law in the State of Louisiana, as well as in the United States Supreme Court and various inferior federal courts. I have been licensed in Louisiana since 1984.

2. I am the founder and Director of Reprieve, a not-for-profit human rights organization based in London.

3. I am counsel to Mr. Hassan Abdullah Hassan listed in this action as I mad Abdullah Hassan, and known to me more familiarly as Emad. I make this declaration in support of the above-captioned matter. I do not mean for this declaration to be in any way comprehensive of the mistreatment or injury Mr. Hassan has suffered during his hunger strike and subsequent force-feeding at Guantanamo Bay.

4. It should be noted that I have not had the opportunity for Mr. Hassan to review this declaration for its accuracy. While I try to take notes as accurately as possible when we speak, I sometimes do not get my notes back from the Privilege Review Team (PRT) for several days or even weeks after I visit Guantanamo Bay, which makes it difficult to remember the precise context of our discussion. When I speak with Mr. Hassan on the telephone, we have even more limited time.

5. I am writing this declaration some three weeks after my last meeting with Mr. Hassan. If there should ultimately be any inconsistencies between this declaration and one that Mr. Hassan subsequently executes, the latter should be considered more authoritative. If I become aware of inconsistencies, I will amend or

1



supplement this affidavit promptly.

6. With these caveats, I am confident that the broad facts ·set forth in this declaration are accurate.

7. Mr. Hassan was born in Aden, Yemen on June 26, 1979. He is an intelligent man who has learned quite good English while in US detention.

8. Mr. Hassan wishes to file a motion challenging the force feeding process that has been applied against him, and others.

Brief background to Mr. Hassan's arrival in Guantanamo Bay

9. While Mr. Hassan feels that he has a duty peacefully to protest the treatment of all prisoners in Guantanamo Bay, he is also motivated by the injustice that has been, and continues to be, inflicted upon him personally. Therefore, a brief statement of the manner of his transport to Guantanamo Bay and his treatment there is significant to understand his motivations.

10. In June 2001, Mr. Hassan travelled from his home in Yemen to Pakist~ in order to attend university at Faisalabad. He wished to study so as to be able to help his country, Yemen, where people do not often receive higher education.

11. In February 2002, following the September 11 attacks on the United States, Mr. Hassan was rounded up with many other Arab men by the Pakistani security forces, and handed over to Americans for a bounty payment.

12. I am aware of no reliable evidence that Mr. Hassan was ever even in Afghanistan until the U.S. took him there against his will.

13. Mr. Hassan was detained in Bagram and Kandahar before arriving in Guantanamo Bay in June 2002.

14. Mr. Hassan has undergone what can only be described as torture, or cruel, inhuman and degrading treatment, on a number of occasions since his detention. This has included, in my view, the manner in which he has sometimes been force fed against his will.

15. Mr. Hassan has been cleared for release since 2009.

16. Mr. Hassan is approaching his thirty-fifth birthday. He has been held without trial by the U.S. for roughly twelve years, since he was just twenty-two. He has missed the opportunity to pursue his education, he has been unable to get married and raise a family and he has generally been denied all of his rights and freedoms for one third of his life, and almost all of his adult life.

2



Reasons for striking

17. Mr. Hassan informs me that he is on a hunger strike because- similar to President Obama- he believes that it is wrong for the U.S. to detain prisoners, without charge or trial in Guantanamo.

18. His hunger strike is a peaceful protest, based in part upon the example of a number of people who he respects, including Mahatma Gandhi.

Hunger strike and force-feeding

19. Before Mr. Hassan arrived in Guantanamo, his average weight was somewhere around 119 pounds. He is 5'3" tall. He had no medical problems except for a degree of asthma as a child.

20. Mr. Hassan did not have any intestinal problems before he was taken to Guantanamo.

Variations among the staff

21. Mr. Hassan is emphatic that not all the staff take part, or wish to take part, in what he describes as "the torture."

22. In 2005, for example, he describes one doctor who took detainees' medical problems seriously and followed medical procedures to diagnose or assess his patients. Mr. Hassan met with that doctor twice. Once, this doctor visited Mr. Hassan's cell and told him that he (the doctor) was being ordered to participate in what he referred to as "the crime" of force feeding and that he would not participate if he had the choice. The doctor apologized to Mr. Hassan for his pain and suffering.

23. Mr. Hassan reports that a number of the staff apologize for the manner in which he is force fed. For example, more recently, one of the NCOs said, "I don't make the rules. I am only a sergeant."

24. A military person who is very abusive may change, too. Mr. Hassan tells the story of a guard who "changed 180 degrees.". Originally, everyone had to be alert when the guard would come onto the block, as he was someone who would summon the FCE team or impose punishment for any minor thing. If a prisoner left a small amount of rubbish in his cell, or even just stared at the guard, it would be, "Discipline! Seven days!" The guard made it clear that he felt that by being super tough he would gain promotion.

25. However, Mr. Hassan was taken to hospital over Ramadan, and when he came back after a month he found that the guard had totally changed. He was a different person. He would take food from one prisoner to another, rather than waste it.·He

3



would make copies of the news received by one prisoner, so that the others could share it. He would even accept the offer of a small piece of chocolate from a prisoner- something that he would previously have rejected with great suspicion. As a result of this change, no prisoner gave him any trouble: he showed the prisoners respect, so they showed him respect in turn.

26. In short, Mr. Hassan insists that not all the guards are the same, and he does not wish to tar everyone with the same brush. That said, though, he lays the blame for his torturous experience on the authorities who have gone out of their way to torture him, and to inflict cruel, inhuman and degrading treatment (CIDT) on him.

2005-2006 Hunger strike

27. Mr. Hassan took part in a short hunger strike in June and July 2005, which he had ended when the Colonel agreed to comply in various ways with the Geneva Conventions, including allowing the prisoner counsel.

28. Mr. Hassan then began his first major hunger strike around August 8, 2005, precipitated by the JTF -GTMO authorities reneging on their promise to allow the council.

29. He continued this strike for around nine months, until February 6, 2006.

30. The force feeding began for him around August 25, 2005. He was initially force fed in the detainee hospital. There were, at that time, some 32 prisoners on strike who faced force feeding.

31. The process used included the following:

a. The feeding tube was inserted and left in for a month because, as the SMO (senior medical officer) explained to the detainees, it was not safe to put in and take out as this could cause medical complications, and could hurt the esophagus and the stomach.

b. The feeding took place in the detainee hospital for the medical safety of the prisoners.

c. Tubes that were best suited to the detainee were used for feeding. Mr Hassan was generally given a Number 8 tube.

32. Around November 2005, six of the hunger strikers (including Mr. Hassan) began to be treated in a different way. This was an experimental process that was done to them in a gratuitously unpleasant way. The process included the following:

a. The detainees were strapped to hospital beds for feeding.

4



b. Larger size tubes were used. These tubes were too big to go into the men's nostrils without undue pain.

c. The tuhes were also pulled out more often. This process caused blood to flow like cutting a vein.

d. At this time, a funnel was used to channel the liquid into the tube.

33. This procedure appeared to Mr. Hassan and others to be a form of Waterboarding. Indeed, one detainee (Hisham) could not breath when the authorities did this to him. When it was done to Hisham again the next night, he passed out and was taken to the main hospital where he was in critical condition. He was on oxygen and a heart monitor. One of the JTF -GTMO staff informed Mr. Hassan and others, "He is in God's hands." Fortunately, after two days he was stable.

34. This force feeding experiment was terminated after this life-threatening incident.

35. Around December 2005, Papa Block was turned into a hospital and the men being force fed were split up, with roughly 18 in P Block and 14 in the Hospital.

Torturous methods for making it less 'convenient' to go on a peaceful hunger strike

36. Some time in late 2005 or early 2006, the military decided that they would use other means to try to put an end to the peaceful hunger strikes.

37. The detainees were told that they were to stop the hunger strike, and agree to eat, or new methods would be used on them that they would not like.

3 8. It is common knowledge among the detainees that the Guantanamo authorities have varied the manner of the force feeding process because they want - in the word of one American general - to make it less "convenient" for the prisoners to go on hunger strike.

39. The techniques used to make it more painful are varied.

40. One, they began pulling the tube out after each feeding and forcing it back in for the next feeding. This took place twice a day.

41. Two, they would use larger tubes. While they had generally used a Number 8 tube on Mr. Hassan, they started using Number 14 tubes, which barely fit in his nostril.

42. Three, they began using what came to be known as the "Torture Chair". Mr. Hassan believes he was the first detainee who was fed on the Torture Chair; his hands, legs, waist, shoulders, and head were strapped down tightly.

5



43. The first time it happened, he was shocked and he fought to resist. He was able to shake his head until the staff used the pressure points under his jaw and behind his ears to keep him still. They also pushed his fingers back, and pulled at his nostrils.

44. At this time, there were no cameras used during the force feeding process, so there was no record made of these torturous forms of abuse.

45. The next day- the second day of his 'Torture Chair' experience- the JTF-GTMO staff forcibly gave him a sedative to keep him from resisting.

46. Four, on the Torture Chair the men were also given an anti-constipation drug which would cause them to defecate on themselves while still being fed. They were not given clean clothes. Mr. Hassan says that he finds it difficult to talk about this even today, several years later. "I could not think someone who called himself human did this to me," he said to me on February 5, 2014.

47. People with haemorrhoids would leave blood on the chair and the linens would not always be changed before the next feeding. In Mr. Hassan's words, "The staff showed us no mercy."

48. Five, they began forcing much more liquid into the prisoners. They began feedings with 1500ml of formula called Two-Cal- four cans in the morning and four in the night, each time mixed with 700ml of water. Once each force feeding was finished, they filled the feeding bag with 50ml of an anti-constipation medication and 450ml of water. This method would accelerate the stomach function and made the men defecate on themselves in the feeding chair. Then the staff added another 700ml of water. When Mr. Hassan dared to ask why they were prolonging his suffering, a medical professional answered sarcastically, "to wash the feeding bag."

49. The amount and speed of the force feeding has varied over time and with the detainee. Mr. Hassan is currently facing a regime that is applied in various forms to only five prisoners, as mentioned below. However, I represent a number of other prisoners who are on hunger strike at this time, and I spoke within the last week to another individual who informed me about his current force feeding. He currently receives two cans of Ensure at each feed. The Ensure is 8 fl oz (236 ml) each, and when they prepare it they add water to it, normally between 200 and 300 ml with each can. Therefore, the nutrient part of the force-feeding includes up to about 1100 ml of liquid. If he is then given the anti-constipation medicine (which he may be given) that would add another 500 ml of liquid. This may then be flushed through with a final draught of water as mentioned above, with the whole process (involving perhaps nearly 2300 ml) taking roughly 20 minutes, and rarely more than 30 minutes. This detainee has repeatedly requested that the process should be slowed down, over two hours, as is done with some prisoners, but his plea has fallen on deaf ears.

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50. Six, t~ey sped the process up. This process was completed in 30-45 minutes, which is much faster than before, and much more painful because of the speed. After this, Mr. Hassan and the other strikers would be left in the chair for upwards of two hours. This was particularly difficult. Finally the staff would pull the tube out of the nose again, ready to force it back in for the next session.

51. If Mr. Hassan vomited on himself at any time during the procedure, what he terms "the atrocity" would start all over again. He would not usually be allowed to wash the vomit off before it began again.

52. Because of his weakened state, Mr. Hassan must be fed slowly. If he is fed faster, he vomits up what has just been pumped into his stomach and suffers severe gastric pain.

53. If a detainee refused to go to the Chair, he would be compelled to go to his feeding session with the FCE (forcible cell extraction) team. This takes 30 minutes, leaving only one and a half hours left for the feeding.

54. All of this happened to Mr. Hassan and other prisoners every day, twice daily.

55. Early on in this new and more abusive phase, the military authorities took Mr. Hassan and two others to another block so that others would see what was being done to them. This was obviously done as a deterrent to scare others into not hunger striking.

56. Also the medical staff had stated that Mr. Hassan's left nostril should not be used for the force feeding. However, the JTF -GTMO staff who were doing the force feeding ignored this and used the left nostril.

57. One morning, Mr. Hassan was taken in a van to meet his lawyers. He found himself vomiting in the transportation vehicle. It was such a terrible experience that he decided to stop his hunger strike. It was more than Mr. Hassan could take. He ate dinner, and the escorts told the block guards that he ate dinner so there was no reason to force feed him. The block guards informed the nurse.

58. It was, Mr. Hassan reports, as if the nurse did not hear the words. The nurse said 'Put him on the chair!' Mr. Hassan spent five hours on the feeding chair, and a number of cans of liquid were emptied into his stomach between the hours of7:00 PM and midnight. The guards then took him back to his cell.

59. A guard told Mr. Hassan a doctor would see him. He had not seen a doctor for a long time. This doctor arrived as Mr. Hassan was being strapped to the feeding chair and asked him whether he would end his hunger strike. Mr. Hassan told the doctor that he had wanted to see a doctor for a long time due to his ill health and

7



stomach problems, but the doctor cut Mr. Hassan off and asked again if he would end the strike. Mr. Hassan did not reply.

60. The doctor then began pushing a size 14 tube into his nose, a process that took about ten minutes. The doctor continued asking whether he would end his hunger strike. It was extremely painful, and at one point one of the guards pointed at the blood on the tube. Finally, the doctor forcefully pushed the tube in, and the tube hit the back of Mr. Hassan's nose. Mr. Hassan was determined not to scream, but his eyes were running. Mr. Hassan says that is it difficult to describe what he endured in those moments, either physically or mentally.

61. The new abusive force feeding method in early 2006 went on for many days. At one point, Mr. Hassan asked the nurses if they were enjoying this, and they laughed as if he were joking, and said "yes."

62. Mr. Hassan told them that one day they would face judgment. This had no effect on them. Indeed, there was one nurse in particular who seemed to enjoy the pain that he was inflicting ..

63. One of the hunger striking detainees was moaning while he was going through this process. The guards told the detainee to be quiet. The sadistic nurse said, "Let him moan."

64. A female guard questioned him about how he seemed to take pleasure in this, and he replied, "It's none of your business."

65. For a while this went on as if it were a formal experiment. The detainees were under 24 hour surveillance, and the JTF-GTMO staff were taking close notes.

66. The JTF -GTMO staff added an additional element of sleep deprivation. They would come to the detainees' cells and knock on the cell window every five minutes or so. If the detainee did not respond, they would come into the cell.

67. The air conditioning was turned up and the detainees were deprived of a blanket. This was particularly difficult for the hunger strikers, as they inevitably felt the cold more than someone who was eating.

68. Mr. Hassan has explained to me that the pain of the new Torture Chair regime was the reason why many of the hunger strikers stopped their protest at this time. Mr. Hassan himself resisted the pain for 37 days during that strike.

69. Only a few other detainees withstood it for this long, including the three men who ended up committing suicide in 2006. It seems that this experience led to them committing suicide. "I did not consider suicide," Mr. Hassan told me on February 5, 2014. "Others did talk about this. I do not blame them for it, though I do not believe in doing it myself."

8



70. Mr. Hassan describes what sound like hallucinatory episodes during this process. "As you spin a glass at speed, it becomes a blur of colors," he told me on February 5, 2014. "That is what I would see."

71. At about this time, Mr. Hassan's weight fell to around 78 lbs. This was the lowest weight he has recorded thus far.

72. After roughly two weeks of this process, Mr. Hassan developed pancreatitis. Indeed, since that time, as a result of his force feeding, he has suffered from pancreatitis on more than one occasion. Pancreatitis is a life threatening condition.

73. On this first occasion, Mr. Hassan was taken to the big hospital for five days or so. He was placed on an IV, and was given some kind of drug that he assumes was an antibiotic. He cannot know for sure, and he does not know what drug it was, as the medical staff refused to tell him (the patient) what the drug was that they were giving him.

74. For about three days, he could not sleep for the pain that he was going through. The pain he suffered then was unlike any other pain he had ever experienced. He understood from some of the staff that he came close to dying from this infection.

75. Mr. Hassan spent another seven days in the detainee hospital. When he was 29 days into the new, even more abusive procedures, they punished him by taking him to Oscar Block and they started force feeding him again.

76. Mr. Hassan reports that at this time a sympathetic nurse tried to persuade him to give up his protest. "680, you have to stop now. They will send you back to Oscar, and do the same to you as before."

77. This is what happened. By then there were eight strikers in Oscar Block who were under a strict punishment regime. They were not allowed to talk to each other, upon pain of discipline. The JTF-GTMO authorities used loud fans to prevent any talking. The detainees were refused the right to communal prayer so long as they were on hunger strike. The guards would bang the cells all day and all night to prevent sleep. The air conditioning was turned to very cold again.

78. Mr. Hassan did manage to get a message to the other strikers. "They will not stop. They will keep on torturing you."

79. Mr. Hassan ended this hunger strike on February 6, 2006. His decision to end the strike was not voluntary, but was caused by his abusive treatment at the hands of the JTF-GTMO authorities.

Mr. Hassan's non-violent hunger strike protest from 2007 to the Present Day

9



80. In July 2006, Mr. Hassan was taken to Romeo Block with Ahmed Errachidi, a Moroccan detainee who had lived in the United Kingdom where he had been committed to a mental hospital due to his bipolar disorder. Along with Mr. Errachidi, Mr. Hassan was accused of trying to talk other detainees into another peaceful protest at their treatment.

81. Mr. Hassan again stopped eating for a time. However, the JTF-GTMO authorities sent their 'cultural advisor' to him to persuade him to eat again, telling him that he would end up back in hospital.

82. Other prisoners told Mr. Hassan of the new force feeding procedures that had been introduced since February 2006.11 continued to be as abusive as before but now the prisoner would be left in the Chair for two hours.

83. Mr. Hassan was given a disgusting form of food in Romeo, a mashed up loaf of indeterminate food. He did not know what it was. He did eat some of it at the time, though.

84. Mr. Hassan once again began hunger striking in 2007.

85. Mr. Hassan has been on hunger strike continually since that time. At this point, Mr. Hassan has been on what has been a continuous hunger strike for almost seven years.

86. Throughout the past seven years, Mr. Hassan has suffered with chronic pancreatitis and multiple hospitalizations stemming from the force feeding techniques. .

87. Mr. Hassan has suffered from pain that has been caused by particular variations in the hunger strike procedure. For example, his illness has included attacks brought on by use of the nutritional supplement Jevity, which contains high levels of fat -a trigger for pancreatitis.

88. Pulling out the tube now is much harder on Mr. Hassan than before. One nostril is sometimes totally closed, and he has sinus problems in the other. For example, one evening it was particularly difficult to get it into the right nostril. There was a new nurse as well; the tube went the wrong way (coming out into his mouth), which was very painful.

89. The force feeding regime has not got any less torturous since the introduction of the gratuitously painful process initiated in late 2005 or early 2006. This process has contributed substantially to at least four suicides in Guantanamo.

90. The fourth was Adnan Latif. Mr. Hassan knew him well, and had been in the same cell block as him. Mr. Hassan had been teaching him English. Mr. Latif was

10



intelligent and wanted to learn to better himself. He was particularly depressed because he missed his kids so much. His son had been only about four years old when Mr. Latif was taken from him, and Mr. Latif used to gaze at his photograph every day. A mental health doctor told the JTF-GTMO authorities not to take him to Camp V for punishment, but this advice was ignored and Mr. Latif committed suicide.

Doctors ' complicity in torture I CIDT ,

91. Mr. Hassan insists that the doctors at Guantanamo do not protect his health or interests. He has related to me that the doctors' only object appears to be to find ways to make the detainees bend to the military's will.

92. They systematically make the force feeding process gratuitously painful, by forcing the liquid down the men's noses faster, by speeding up the flow of liquid, by using a bigger tube, and by pulling the 11 0 centimeter tube out of his nostril after every feed and then forcing it back in.

93. Mr. Hassan is indignant at some of the Guantanamo doctors' refusal to tell himthe patient - what medications he is being required to take.

The abuse of FCE on hunger strikers

94. Various of the hunger strikers are subjected to the FCE team to go to force feeding. They are genuinely being forced to be fed, and this involves the team of roughly a dozen military personnel. Some five of them rush into the detainee's cell, force him to the ground, shackle him, beating him in the process and dragging him out of the cell to take him to the force feeding area.

95. The FCE team had been using a 'board' to take the prisoner there. However, recently the FCE team has had new procedures and has carried the prisoner -which is much more painful on the person being carried.

96. There had been a kind of informal agreement that while the prisoners do not wish to go voluntarily for something that is clearly involuntary (force feeding), they will not have to undergo being beaten up in order to make that point. However, the JTF-GTMO authorities now often ignore this, and order the prisoner to undergo the full, worst treatment, in order to show the prisoners how the peaceful hunger strike should not be "convenient".

97. For example, recently ISN 722 (who is in a wheel chair, and whose health is very bad) was recently going to the Torture Chair, and was willing to simply go with the FCE team voluntarily However, they refused to allow this, and rushed into his cell, pinning him to the floor. They were shouting "stop resisting!" while they did this, and while they shackled him, before dragging him off to the Chair.

11



98. Currently, according to the Assistant Officer in Charge (AOIC) on February 3, 2014, if the detainee allows the FCE team to take him to the Chair 'walking' he will be allowed Rec. If, on the other hand, he does not agree to this, he will face additional punishment by having his Rec taken away.

A New Punishment regime for going on a peaceful Hunger Strike

99. Particularly after the experience of the mass hunger strike in 20 13, the military authorities are going to considerable lengths to punish prisoners who take up the hunger strike now. This punishment comes on top of the gratuitously painful practices that were being used to make hunger striking less "convenient".

100. If a detainee is found to be on strike in Camp VI, that detainee is transferred to Camp V, which is the punishment camp for those who are not considered sufficiently 'compliant' with the wishes of the JTF-GTMO authorities.

101. More specifically, the recent practice has been to take the detainee to Camp V Echo, which is the most unpleasant cell block in the whole prison. The cells in Camp V Echo are almost all steel - the bed, the floor, the walls, the ceiling and the door. The cells can be very cold, which is much harder to bear when you are on hunger strike.

102. There is no toilet, only a hole in the ground, which is close to the wall and therefore makes it particularly difficult to squat to use it. When one is on hunger strike, it is likely that the bowels will not be operating properly. This can make using the toilet difficult under any circumstances, but particularly so when forced to use a toilet that is difficult to use at the best of times.

103. Mr. Hassan and others state that there is much more that could be said about Camp V Echo. It is, they say, a terrible place.

104. Once they spend a few days in Camp V Echo, the new hunger strikers are generally moved to another block in Camp V, and they will stay there until they agree to come off their strike.

105. It is clear to the detainees that the experience, first, of Camp V Echo, and then of Camp V generally is intended to coerce the hunger strikers to give up their peaceful protest.

Special rules for half a dozen Detainees

I 06. The last time I saw him, Mr. Hassan was around 85 pounds. His health is very bad.

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1 07. There are five of the hunger striking detainees who are treated differently from the others. Mr. Hassan (ISN 680) is one of them. The others are 042, 171, 178, and 682.

108. The authorities do not require Mr. Hassan to go by FCE to be force fed, although there are currently - as of my last conversation with him - some nine hunger strikers who were being taken to force feeding by FCE.

109. For a while, Mr. Hassan would be fed only once per day. Every night around 10:00 PM, he would be fed for four hours, 10:00 PM to 2:00AM. He was sometimes allowed to sit on the soft chair instead of the tortuous feeding chair because he was unable to sit on the feeding chair for more than two hours.

The use of the drug Reg/an

110. For many months, the JTF-GTMO staff gave Mr. Hassan Reglan for his nausea. It was not a medication that he wanted because he felt that it made him feel crazy.

111. He relates that during this time, he would sit on his bed, legs folded, thinking that he was talking to the nurse, but he actually found that he was talking to himself.

112. Mr. Hassan also describes numbness in the lower part of his body while being on Reglan.

113. Treatment with Reglan for more than twelve weeks is contra-indicated. Mr. Hassan believes that he was on Reglan from 2005 until late 2007, although he was not always told when it was being given to him so this is only his best guess at the extent of his exposure to the drug.

I declare under penalty of perjury under the laws of the United States of America the foregoing is true and correct.

""'-0 this£ day of March, 2014.

CLIVE A. STAFFORD SMITH

Counsel for Petitioner

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Exhibit B


Case 1:04-cv-01194-UNA Document 1001-2 Filed 03/11/14 Page 1 of 6Case 1:05-cv-01607-RCL Document 306-5 Filed 03/27/14 Page 2 of 7






Exhibit C





Exhibit D


STANDARD OPERATING PROCEDURE: MEDICAL MANAGEMENT OF DETAINEES ON HUNGER STRIKE

SOP: JTF-JMG # 001 05MAR2013 Page1 of30

JOINT TASKFORCE GUANTANAMO BAY, CUBA SOP NO: JTF-JMG #001 JOINT MEDICAL GROUP TACMemo#01

TACMemo#02 Title: MEDICAL MANAGEMENT OF DETAINEES ON

HUNGER STRIKE

SCOPE: JOINT TASK FORCE- GTMO- JOINT MEDICAL GROUP

REFERENCES:

ENCLOSURES:

(1) General Algorithm for Hunger a Strike (2) Refusal to Accept Food or Water/Fluids as Medical Treatment (3) Hunger Striker Medical Evaluation Sheet (4) Hunger Striker Medical Flow Sheet (5) Approval Authority for Initiation oflnvoluntary Enteral Feeding (6) Clinical Protocol for the Evaluation. Resuscitation, and Feeding of Detainees on

Hunger Strike (7) Chair Restraint System Clinical Protocol for the Intermittent Enteral Feeding of

Detainees on Hunger Strike (8) Medical Equations, Calculations and Definitions (9) Management of Common Electrolyte Deficiencies (10) Medical Management ofEnterally Fed Detainees Who Terminate Their Hunger Strike (11) Procedures for Setting up an Enteral Feed (TAC Memo #1) (12) Strategy for Detainee Biting Feed Tube (TAC Memo #2)

2.BACKGROUND

Hunger strikes can be expected in any detained population. A prolonged period of time without adequate food and water will have adverse health effects. Identification and early medical management of detainees on hunger strike may prevent adverse health effects and death.

Just as battlefield tactics must change throughout the course of a conflict, the medical response to GTMO detainees who hunger strike has evolved with time. From a peak of over 100 detainees who were on a hunger strike, currently there are less than a dozen. A mass hunger strike was successfully dealt with by utilizing procedures adopted from the Federal Bureau of Prisons and the approach delineated in this SOP. However, the composition of the detainee population, camp infrastructure, and policies has all undergone significant change since the initial version of this SOP. Several of the current group of detainees has been hunger striking since 2005. This group of detainees has proven their determination and their chronic malnourishment has left them physically frail. Given these conditions, options for intervention are more limited. Maintaining




health and nutrition under these circumstances is challenging, and this SOP has been revised to reflect current tactics and practice. Much of the original instruction has been retained in the form of enclosures. In the event of a mass hunger strike, these enclosures can be utilized as they have proven efficacy under mass hunger strike conditions.

In general, utilizing the clinical judgment of the Senior Medical Officer (SMO) and the Medical Staff, vice rote adherence to an algorithmic approach, has proven usefuL Several of the detainees on hunger strike have been moved to Camp VI (a communal environment) after achieving a target weight goal (at least 70% ofldeal Body Weight). Although they continue to receive periodic enteral feeding support at Camp VI, they are also consuming food orally, and the communal support of the other detainees encourages them to eat. The incentive to earn transfer to communal living is a recent development and should continue to be encouraged.

II. POLICY

A. The DoD and Joint Task Force Guantanamo (JTF GTMO) policy is to protect, preserve, and promote life. This includes preventing any serious adverse health effects and death from hunger strikes. The Joint Medical Group (JMG) staff is responsible for providing health care monitoring and medical assistance as clinically indicated for detainees on a hunger strike. The Commander, JMG will ensure that the medical staff adheres to the procedures outlined in this document. The JMG staff will do everything within its means to monitor, preserve, and protect the health and welfare of hunger striking detainees. When evaluating and treating a detainee on hunger strike, JMG medical personnel will make reasonable efforts to obtain voluntary consent for medical treatment. When consent carmot be obtained, medical procedures that are indicated to preserve health and life shall be implemented without consent from the detainee.

B. In the event a detainee refrains from eating or drinking to the point where it is

determined by medical assessment that continued fasting will result in a threat to life or seriously jeopardize health, and involuntary feeding is required, no direct action will be taken without the knowledge and written approval of the JTF-GTMO Commander. If the JTF-GTMO Commander makes the decision to authorize involuntary feeding of a detainee, he/she will immediately inform the Commander, United States Southern Command (USSOUTHCOM) of his/her decision. In turn, the Commander USSOUTHCOM, will notify appropriate Joint Staff and Department of Defense offices of the necessity of initiating involuntary feeding of a detainee. This approval authority does not preclude the Medical Officer from performing any emergent actions deemed medically necessary to preserve life and health.

C. Definitions.

I. Hunger striker. A hunger striker is a detainee who communicates either directly or

indirectly (i.e. repeated meal refusals) his intent to undergo a hunger strike or fast as a form of protest or to demand attention. A detainee may be designated a hunger striker after missing nine consecutive meals or weight loss to a level less than 85% Ideal Body Weight (IBW). The designation of a detainee as a hunger striker is based on intent, purpose, and behavior and will be




determined by the Commander, JMG in conjunction with input from the JMG medical staff and the Commander, Joint Detention Group (JDG). In general, lack of sufficient daily caloric intake is a more useful measure to designate a hunger striker than the number of consecutive meals missed.

2. Meal. A meal is the combined or individual consumption of fluids and/or solid food

required to maintain daily metabolic requirements. These requirements vary by individual. For the purpose of this document, any consumption of calories at or around 500 Kcal is considered a regular meal. Examples would include two, eight fluid ounce containers of Ensure® or similar nutritional supplements or the meal from a regular diet.

3. Enteral feeder. A detainee on a hunger strike, who has been approved for involuntary

enteral feeding by the Commander, Joint Task Force Guantanarno (JTF GTMO)

4. Chronic enteral feeder. A detainee who has chosen to hunger strike for a prolonged period of time (generally >30 days) and has been receiving regular enteral feedings. These detainees are chronically underweight, but have generally achieved a medically stable status.

5. Enteral feeder on hold. An enteral feeder who is not receiving enteral feeding via a

Nasogatric tube (NGT). The Senior Medical Officer (SMO) will consider a change to this status when the detainee has not received an enteral feed via NGT for greater than 7 days, and is consuming an adequate quantity of oral calories. An enteral feeder on hold does not yet qualify for removal from the Hunger Strike List.

6. Hunger Striker on medical observation. A detainee on a hunger strike who has not

yet been approved for involuntary enteral feeding by the Commander, JTF GTMO. III. PROCEDURES

A. Effective management of individuals or groups who refuse to eat or drink requires a

close partnership between the JMG medical staff and the Joint Detention Group (JDG) security force. Enclosure (1), General Algorithm for a Hunger Strike, provides a simplified outline for the medical management of detainees on hunger strike. JDG Procedure #38, Hunger Striker Protocol, details the JDG role in this process.

B. Security forces under the JDG will monitor each detainee's daily intake of meals and

water. Entries will be made in the Detainee Information Management System (DIMS) to document when a meal is missed.

C. The JDG will notify the JMG medical staff of any detainee who meets the definition of a

hunger striker as outlined above; and will maintain a current missed meals list on that detainee. This list will be communicated via e-mail, phone or memorandum to the Senior Medical Officer (SMO) and the Senior Nurse Executive (SNE) or their representatives each day. Included in this list will be a running total of consecutive missed meals by each detainee who is on a hunger




strike. In addition, JDG should include in this list those detainees who may not be consuming adequate nutrition and fluids, but who have not met criteria for a hunger strike.

D. Once notified, medical personnel will evaluate each detainee considered to be on a

hunger strike. Part of this evaluation will be to determine the intent and purpose of the meal/drink refusal. The JMG-GTMO Commander , with input from the JMG medical staff and the JDG Commander, will determine whether the actions of a detainee meet the criteria for a hunger strike as outlined above. The SMO or his/her representative will forward a daily list of those detainees on hunger strike to key leadership in the JTF to include the JTF-GTMO Commander, the JTF-GTMO Deputy Commander, the Chief of Staff, the JDG Commander, the JMG commander, the JDG Operations Officer (S3), the guard force commanders and the SNE. The JMG Situation Report (SITREP) will reflect the total number of detainees on hunger strike.

E. A JMG medical provider will counsel the detainee who is on a hunger strike as to the

medical hazards of a prolonged period without food and/or water. Enclosure (2), Refusal to Accept Food or Water/Fluids as Medical Treatment, will be verbally translated at the initial assessment. The medical staff shall explain the medical risks faced by the detainee and make a reasonable effort to convince the detainee to resume eating food and drinking water. Enclosure (2) will be signed by the medical provider, witness and translator and placed in the detainee's outpatient medical record.

F. If during the course of a hunger strike, involuntary feeding is required, the Senior

Medical Officer, via the JMG-GTMO Commander, will make specific recommendations to the JTF-GTMO Commander as to the timing and requirement for such involuntary feeding. The JTF-GTMO Commander will decide whether to order the involuntary feeding of a detainee and his/her authorization will be documented via Secure Internet Protocol Router Network (SIPRNET) email. If the JTF-GTMO Commander authorizes involuntary feeding of a detainee, he/she will immediately inform the Commander, USSOUTHCOM of his/her decision. In tum, the Commander USSOUTHCOM will notify appropriate Joint Staff and Department of Defense offices of the necessity for initiating involuntary feeding of a detainee.

IV. MEDICAL EVALUATION AND MANAGEMENT

A. The medical staff will monitor the health of any detainee who is on a hunger strike.

Upon notification that a detainee is on a hunger strike, medical personnel will document the following:

I. Using Enclosure (3), Hunger Striker Medical Evaluation Sheet, a medical provider will

perform a complete medical record review, an intake (food/fluids) history, and a general physical examination to include vital signs, weight,% Ideal Body Weight (IBW), and body mass index (BMI). If clinically indicated, appropriate laboratory tests will be obtained to assess the detainee's metabolic status. Iflaboratory tests are indicated, the following are recommended: Urinalysis, serum basic metabolic profile, liver function tests (LFTs), Magnesium (Mg), phosphate (P04) and calcium (Ca). If clinically indicated, an EKG can be obtained at this time.




Once completed, Enclosure (3) will be signed by the medical provider and placed in the detainee's outpatient medical record.

2. Behavioral Healthcare Service (BHS) will perform an assessment of the mental and

psychological status of the detainee, which will be documented in the outpatient medical record on a Standard Form 600. BHS will continue to regularly evaluate detainees who continue on a hunger strike.

3. After the initial evaluation, the detainee will be evaluated on a daily basis using

Enclosure (4), Hunger Striker Medical Flow Sheet. This form is maintained electronically on the network share drive. When the detainee is removed from the hunger strike list, a copy of the flow sheet will be filed in the detainee's outpatient medical record.

B. When a JMG Medical Officer determines that the detainee's life or health might be

threatened if treatment is not initiated, the Senior Medical Officer will give consideration to involuntary medical treatment of the detainee. Involuntary medical treatment should be considered if any of the following clinical criteria are met:

I. There is evidence of deleterious health effects reflective of end organ involvement or damage to include, but not limited to, seizures, syncope or pre-syncope, significant metabolic derangements, arrhythmias, muscle wasting, or weakness such that activities of daily living are significantly hampered.

2. There is a pre-existing co-morbidity that might readily predispose to end organ damage (e.g. hypertension, coronary artery disease or any significant heart condition, renal insufficiency or failure, or endocrinopathy).

3. There is a prolonged period of hunger strike (more than 21 days). 4. The detainee is at a weight less than 85% of the calculated Ideal Body Weight (IBW). 5. The detainee has experienced significant weight loss (greater than 15%) from

previously recorded or in-processing weight. These criteria are suggested guidelines, and are not intended to replace the clinical judgment of the SMO and medical staff

C. Prior to medical treatment being administered, medical staff will make reasonable efforts

to convince the detainee to voluntarily resume eating or accept treatment. The JMG staff will explain medical risks the detainee faces if he does not accept treatment.

1. Involuntary medical treatment may include, but is not limited to, intravenous fluids, blood draws, weights, and/or administration of nutritional formulas or electrolyte solutions via an enteral feeding tube. When, after reasonable efforts, or in an emergency preventing such efforts, a medical necessity for treatment of a life or serious health-threatening situation exists, the Senior Medical Officer may recommend that treatment be administered without the consent of the detainee.

2. No direct action will be taken to involuntarily feed a detainee without the written approval of the JTF-GTMO Commander as set out above, unless a medical emergency exists. Medical staff shall document all of their counseling efforts and treatments in the detainee's medical record.




3. If involuntary enteral feeding is clinically indicated and authorized, Enclosure (5),

Approval Authority for Initiation of Involuntary Enteral Feeding, should be completed by the Senior Medical Officer and placed in the detainee's inpatient medical record.

D. If the Senior Medical Officer determines that the medical condition of a detainee on

hunger strike dictates medical intervention to preserve health or life, the detainee will be admitted to the Detention Hospital (DH) if medically indicated, or transferred to a designated feeding block for possible involuntary enteral feeding.

1. Clinical protocols for enteral feeding using a graduated continuous enteral feed infusion are found in Enclosure (6), Clinical Protocol for the Evaluation, Resuscitation, and Feeding of Detainees on Hunger Strike. If the Senior Medical Officer deems it medically safe (low risk ofre-feeding syndrome) based on the duration of the detainee's fast or hunger strike, enteral feeding may be initiated with graduated intermittent feeds as opposed to a continuous infusion.

2. Clinical protocols for enteral feeding using an intermittent infusion are also found in Enclosures (6). Enclosure (7) describes instructions for the use of the Feeding Chair Restraint system for intermittent enteral feedings and Enclosure (8), Medical Equations, Calculations and Definitions may be used to calculate caloric goals/needs.

3. Enclosure (9), Management of Common Electrolyte Deficiencies, outlines means of correcting common electrolyte deficiencies seen in individuals on a hunger strike or prolonged fast. If a hunger-striking detainee needs electrolyte correction, long-term hydration or continuous enteral feedings he must be admitted to the DH.

V. REMOVING A DETAINEE FROM ENTERAL FEEDING

A. The following guidance will be used to remove a detainee from enteral feeding:

I. A variety of methods may be utilized to transition an enteral feeder from enteral formula to a regular diet. The Senior Medical Officer will determine the method utilized for transition to regular food. In general, a 3 to 5 day period should be sufficient to transition the enteral feeder to a regular diet. If the detainee has been intermittently consuming regular food while on a hunger strike, this transition can be achieved sooner.

2. One approach is to provide 3 cans of Ensure TID for 3 days, and provide dietary

recommendation to initially consume soft or bland foods

3. Enteral formula should not be provided beyond the 3 to 5 day period unless medically necessary. This will avoid the potential for a detainee to claim a special status or continue to claim hunger strike status.

4. A hunger striker who has not received enteral feeding may be removed from the

Hunger Strike List if he eats an average of 1500 calories or greater per day for 3 days or 3 consecutive meals.

5. An enteral feeder may be removed from the Hunger Strike List if he eats an average of

1500 calories or greater per day for 7 days or 9 consecutive meals.




6. The Senior Medical Officer may also remove a detainee from the Hunger Strike List based on medical assessment that the caloric intake is sufficient for survival and it is suspected that the detainee's intent is not to hunger strike.

7. Enclosure (10), Medical Management ofEnterally Fed Detainees Who Terminate Their Hunger Strike, outlines a proposed pathway to assist and monitor detainees in their transition from enteral feeding to a regular diet, and is included for historical interest.

8. Once removed from the hunger strike list, the SMO or his/her designated

representative will notify JDG Operations (S3) personnel via phone call, SIPRNET e-mail, or in writing when a detainee is removed from the hunger strike list.




GENERAL ALGORITHM FOR A HUNGER STRIKE

Detainee misses nine consecutive meals or meets other criteria of a possible hunger striker.

Medical officer performs a physical examination and BHS performs psychological evaluation and designates detainee as a potential hunger striker. The detainee is counseled on the medical dangers of a hunger strike. Enclosures (2) and (3) are

completed and placed in detainee's medical record.

The hunger striker is monitored daily to include weight, hydration status, and general health (documented using Enclosure (4). Detainee may be resuscitated with intravenous hydration as clinically indicated. If the detainee has sufficient caloric

intake for 3 days and is cleared by a Medical Officer, he is removed from hunger strike list

If detainee continues to hunger strike and clinical criteria for the initiation of enteral feeding are met per Paragraph IV.B. of SOP 001, the detainee may be admitted to the Detention Hospital or designated feeding block if medically stable.

Authorization is obtained via chain-of-command from JTF-GTMO Commander to begin enteral feeding.

If clinically indicated, continuous or intermittent infusion of enteral feeding is initiated per Enclosure (6).

Intermittent enteral feeds are performed under physician and nurse supervision. lithe medical condition of the detainee requires closer observation, he will be kept in the Detention HospitaL

On feeding block (or Detention Hospital), medical staff closely monitors weights, laboratory tests, and general health of enterally fed detainees and evaluates and treats any side effects or complications of hunger striking. See Enclosure (6).

Involuntary enteral feeding shall be discontinued for detainees who have attained a calculated Ideal Body Weight (IBW) of 100% for fourteen (14) or more consecutive days of enteral feeding, provided that an attending physician deems this

medically appropriate.

Enclosure (1)


SOP: JTF-JMG # 001 OSMAR2013 Page 9 of30


When detainee begins to eat voluntarily, or after he is removed from enteral feeding based on 14 consecutive days of 100% IBW, he is observed closely for re-feeding syndrome or food intolerance. Begin oral feedings with a bland diet and

advance as tolerated to a regular diet.

After having sufficient caloric intake for 3 days, the detainee is removed from the hunger strike list and transferred to an observation block for further monitoring (approximately nine additional meals).

.[!.

Detainee is returned to normal detainee population. A physical evaluation is performed within 2 weeks of removal from

hunger strike list. Detainee's weight and physical condition is monitored closely for 90 days, followed by routine monitoring.

Enclosure (1)



SOP: JTF-JMG # 001 05MAR2013 Page 10 of30

Refusal to Accept Food or Water/Fluids As Medical Treatment

Detainee Number Age _ Date _

The above detainee has refused to accept food or water/fluids as medically recommended by the Medical Officer.

The grave risks of not following the medical advice directing him to eat life-sustaining food and to drink water/fluids have been explained to the detainee. He states he understands that as a direct result of his refusal to eat and/or drink, he may experience: hunger, nausea, tiredness, feeling ill, headaches, swelling of his extremities, muscle wasting, abdominal pain, chest pain, irregular heart rhythms, altered level of consciousness, organ failure and coma. He states he understands that his refusal to eat life-sustaining food or drink water/fluids and to follow medical advice may cause irreparable harm to himself or lead to his death. He states he understands that this is not a complete list of the risks involved with the refusal to follow medical advice.

He states he understands the alternatives available to him including oral food and fluid, oral rehydration solutions, oral nutritional supplements, and intravenous fluid hydration.

He states he fully understands the risks to his health if he does not accept food and water as directed above.

Translator/ Witness Signature _

Medical Provider Signature-------------------------

Enclosure (2)




Hunger Striker Medical Evaluation Sheet

Detainee Number: _ Date of Evaluation: _

Date of Onset: _ Drinking Fluids: Yes No

Number of Meals Missed: _

HPJ:

MEDS:

ALLERGIES: NKDA or--------------

PMH:

Reason for Hunger Strike?----------------------

Physical Assessment:

In processing Wt: lbs Pre Hunger Strike Wt: lbs/date: _

Current Wt: lbs %IBW BMI: %Wt Loss: _

Heart Rate: BP: / RR: T: LOC: Yes No

Other Pertinent Physical Exam and Laboratory Findings:

Assessment: Hunger Striker

I. Explained risks of inadequate intake of food and/or water to detainee. See Refosal to Accept Food or

Water/Fluids As Medical Treatment, Enclosure (2). 2. Continue follow-up as per Medical Management of Detainees on Hunger Strike SOP No. 001. 3. Other:

Medical Provider:---------------------

Enclosure (3)


STANDARD OPERATING PROCEDURE: MEDICAL MANAGEMENT OF DETAINEES ON

SOP: JTF-JMG # 001 05MAR2013

Hunger Striker Medical Flow Sheet

Detainee ISN #

Date

Heart Rate

Blood

Pressure

Drinking?

mL

Eating?

Y/N

Document caloric intake

Enteral feed and PO calories

Weight

Comments (ambulatory, coherent, alert, oriented,

verbal, etc)

Enclosure (4)


STANDARD OPERATING PROCEDURE: MEDICAL MANAGEMENT OF DETAINEES ON

SOP: JTF-JMG # 001 05MAR2013

HUNGER STRIKE Page 13 of30

NSN 7540-00 6344176 AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE Date/Time SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)

JTF-JMG, Medical Department, Guantanamo Bav, Cuba

Am;!roval Authority for Initiation of Involuntaa Enteral Feeding

Detainee ISN has been on a hunger strike and is refusing to consume life sustaining nutrition and hydration. He meets the following clinical criteria for involuntary enteral feeding.

There is evidence of deleterious health effects reflective of end organ involvement or damage to include but not limited to seizures, syncope or pre-syncope, significant metabolic derangements, arrhythmias, muscle wasting, or weakness such that activities of daily living are hampered. There is a pre-existing co-morbidity that might readily predispose to end organ damage (e.g. hypertension, coronary artery disease or any significant heart condition, renal insufficiency or failure, endocrinopathy, etc.).

There is a prolonged period of hunger strike (more than 21 days). The detainee is at a weight that is less than 85% of the calculated Ideal Body Weight (IBW). The detainee has experienced significant weight loss (greater than 15%) from previously recorded or in-processing weight.

Involuntary feeding is required to prevent risk of death or serious harm to health. Written approval to initiate involuntary enteral feeding has been obtained from the Joint Task (Note: e-mail written approval is acceptable). Force Commander as required_.IJ_er Standard QJJ.erating Procedure 001.

Medical Officer, GTMO

DETAINEE 'S !DENT!FICATION NUMBER: CHRONOLOGICAL RECORD OF MEDICAL CARE

MEDICAL RECORD STANDARD FORM 600 (rev. 9/05)

Enclosure (5)



SOP: JTF-JMG # 001 05MAR2013 Page 14

Clinical Protocol for the Evaluation, Resuscitation, and Feeding of Detainees on Hunger Strike

Once a detainee on hunger strike meets the criteria for enteral feeding, the following protocol may be initiated. After initial IV fluid resuscitation, a medically cleared detainee may have treatment initiated with intermittent enteral feedings per Phase IV vice continuous enteral feedings. In event of a mass hunger strike, isolating hunger striking patients from each other is vital to prevent them from achieving solidarity. Given the inability to isolate patients in the DH because of the physical structure of the building, initial IV fluid resuscitation lasting approximately 24 hours can occur in the DH, followed by transfer back to Camp 5 to begin enteral feeding in an environment of single cell operations. .

Phase 1: Admit to the Detention Hospital for Intravenous Fluid Resuscitation

Hospital Day #I:

Vital signs should be checked at admission and every four hours for the first eight hours, at which time the frequency can be decreased to every eight hours (if clinically stable).

If not drawn in the past two days, a complete blood count (CBC), basic metabolic panel, calcium (Ca++), magnesium (Mg++), phosphorous (phos), and creatine kinase (CK) should be obtained. A blood glucose reading (finger stick) should be documented in the Medication Administration Record (MAR).

A 12 lead EKG will be performed upon admit.

The detainee's admission weight should be recorded, with weights being recorded daily, thereafter.

Fluid resuscitation should begin with a 1-2-liter bolus of normal saline. The amount of the IV bolus will be decided after reviewing the detainee's medical history for any co-morbid diseases (This may be deferred if fluids were previously received on the block or in the clinic).

Thiamine I 00 mg IV one time (Give prior to giving any Dextrose or 05• This may have already been administered in the Clinic).

This should be followed by a standard formulation, which consists of one liter of D5 Yz normal saline with 20 mEq KCL, one vial of(water soluble) MVI, 500 mg of magnesium sulfate, one vial of trace elements, and 1 mg of folic acid. This IV formulation should be run @ 100 mlfhr for I 0 hours.

Once the formulation has infused, maintenance fluids in the form ofD5 Yz normal saline with 20 mEq KCL @ I 00 ml/hr should be started and continued until at least 48 hours after admission (Hospital Day#3)

PRN medications during Phase 1:

I) Glucose, 50 grams (050, I amp) IV if blood sugar< 60 and detainee lethargic or unresponsive.

2) Tylenol 650mg PO Q 6 hrs PRN pain, headache.

3) Mylanta 15-30 ml PO Q 4 hrs PRN indigestion, heartburn.

Phase II: Initiation of Enteral Nutrition

Enclosure (6)



SOP: JTF-JMG # 001 05MAR2013 Page 15

Days #2 and #3.

Place a I 0 French or 12 French feeding tube into the patient's stomach per standard medical practice. Viscous lidocaine should be offered for the nostril and the throat. The tube should be well lubricated prior to insertion. A linguist shall be present to assist with instructions. Once the feeding tube has been inserted, the placement needs to be confirmed. This confirmation can be achieved either by a

. standard chest x-ray or by air insufflation followed by a I 0 ml test dose of water.

The patient's head of the bed should be elevated at least 30-45 degrees while recumbent.

A blood glucose level (via finger stick) should be documented every 12 hours X 3.

The following labs should be considered on a daily basis for the initial 3-5 days after beginning enteral feeding (when the patient is at the high risk for refeeding syndrome): basic metabolic panel, calcium, magnesium, phosphorus, ALT, total bilirubin, amylase, and albumin Vital signs can be changed to daily (if patient is clinically stable).

Enteral Nutrition:

1. Place 240 ml ofPulmocare® in enteral nutrition (EN) bag. Mix one teaspoon of Morton's salt substitute (2300 mg of potassium, 2000 mg of chloride), one teaspoon (8 packets) of table salt (2300 mg of sodium) and liquid MVI, and infuse via feeding tube at 20 ml/hr.

2. After 12 hrs: If tolerating EN, mix 240 ml ofPulmocare® with 360 ml water. Mix one teaspoon of Morton's salt substitute and one teaspoon of table salt, and infuse via feeding tube at a rate of 50 ml/hr (720 kcal/day + 480 kcalfrom IV fluids1200 kcallday).

3. After 24 hrs (start of Hospital Day #3): If tolerating EN, mix 600 ml ofPulmocare® with 400 ml water. Mix one teaspoon of Morton's salt substitute, one teaspoon of table salt and liquid MVI, and infuse at 60 ml/hr (1296 kcallday). Discontinue IV fluids and IV if fluid resuscitation is complete.

PRN medications during Phase II:

I) Tylenol 650 mg POlenteral feeding tube Q 6 hrs PRN pain, headache.

2) Mylanta 15-30 ml PO/enteral feeding tube Q 4 hr PRN indigestion, heartburn.

3) Benadryl 25-50 mg PO/enteral feeding tube Q 6 hrs PRN rhinorrhea, post-nasal drip, sneezing, itchy rash, watery eyes.

4) Saline Nasal Spray 2-3 puffs each nostril Q 4-6 hr PRN post-nasal drip or congestion.

5) Phenergan 12.5- 25 mg PO/enteral feeding tube/PRIIM/JV Q 4-6 hrs PRN nausea.

6) Motrin (Ibuprofen) 600 mg PO/enteral feeding tube TID PRN pain (ONLY if nutrition is being tolerated at 20 cc/hr or more; avoid in any patient with concern for renal insufficiency).

7) Reglan I 0 mg PO/enteral feeding tube Q 3 hr X 3 doses if nauseated or bloating after tube insertion.

Phase III: Achieving and Maintaining Goal Enteral Nutrition

Day #4-6:

I. After 48 hrs of EN

Discontinue Pulmocare®.

Enclosure (6)



SOP: JTF-JMG # 001 0SMAR2013 Page 16 of30

Mix 750 ml of Boost Plus® with 250 ml water. Mix one teaspoon of Morton's salt substitute and one teaspoon of table salt and infuse via feeding tube at 60 ml/hr (1597 kcal/day).

2. After 72 hrs of EN: Increase above nutritional mixture to 80 mllhr (2130 kcallday).

3. After 96 hrs of EN: Increase above nutritional mixture to 100 ml/hr (2662 kcal/day) and discontinue table salt.

Phase IV: Intermittent Enteral Nutrition

If patient is clinically stable, nutritional supplementation can be given via intermittent feedings rather than continuous infusion.

This is usually accomplished using a daily or twice daily schedule, with an appropriate quantity of the daily calories being delivered at each feeding.

To enhance gastric motility, the following medication administration may be useful when using intermittent feeds.

1) Metoclopramide (Reglan) 10 mg via enteral feeding tube (place in feeding bag before

nutritional supplement). 2) 30 ml magnesium citrate mixed in 500 ml water via enteral feeding tube.

The Minimum recommended requirements to transition a patient to intermittent feeding are as follows:

1) 1500 total kcal/day.

2) Four cans of Ensure Plus® or Boost Plus® (or equivalent nutritional supplement). Ifpatient is not receiving at least I OOOml enteral formula per day, liquid Centrum (or equivalent) should be added daily until vitamin and mineral minimums can be achieved.

3) Labs as needed to validate normal electrolyte status.

4) Stable clinical condition.

Phase V: Discharge from Detention Hospital to Feeding Block

Once the detainee clinically demonstrates tolerance of hydration, the attending Medical Officer will determine when the detainee can be discharged from the Detention Hospital and transferred to the feeding block. The attending Medical Officer will perform a physical examination of the detainee and document in the medical record that there are no contraindications for the detainee receiving his enteral nutrition on the feeding block. Prior to leaving the DH, the detainee's feeding tube will be removed. Medical staff shall determine the minimum number of enteral feedings necessary to meet the detainee's required nutritional needs. Medical restraints (e.g. chair restraint system) should be used for the safety of the detainee, medical staff, and guard force as outlined in Enclosure (7).

Phase VI: Management of Enterally Fed Detainees Who Terminate Their Hunger Strike

When a hunger striking detainee voluntarily resumes eating or when the detainee has attained 100% of calculated IBW for at least fourteen (14) consecutive days and the attending physician deems it to be medically appropriate, enteral feeding shall cease and oral self-feeding by the detainee shall resume. The Detention Hospital medical staff will medically manage these individuals to avoid complications associated with the resumption of oral nutrition. This medical management will consist of three phases as outlined in Enclosure (I0). The first phase will consist of slowly advancing the diet. The second phase will involve the transfer of the detainee to a Transition Block for further monitoring.

Enclosure (6)




And the third phase will consist of the return of the detainee to the mainstream detention camp environment. Enteral feeding shall resume at any point if it becomes medically necessary, in accordance with the SOP. Warning: This Protocol is intended for guidance only. Changes in clinical course may necessitate variation from this protocol.

Enclosure (6)




Chair Restraint System Clinical Protocol for the Intermittent Enteral Feeding of

Detainees on Hunger Strike

At the discretion of the attending Medical Officer, intermittent enteral feedings may be initiated in the DH or designated feeding blocks. Detainees are evaluated daily by medical staff. Intermittent enteral feedings are usually done two times a day. Medical restraints (e.g. chair restraint system) should be used for the safety of the detainee, medical staff, and guard force. The following describes the chair restraint system and feeding procedures used for intermittent enteral feeding on the feeding blocks.

I. Medical provider reviews missed meals Jogged from guards and medical staff to verifY the

detainee is still refusing regularly offered (breakfast, lunch, and dinner) meals. 2. Medical staff advises the detainee that hunger striking is detrimental to his health. He is offered a

meal and given the chance to eat. If the detainee refuses to voluntarily eat a meal, the enteral feeds are initiated.

3. Medical provider signs medical restraint order to enterally feed the detainee the prescribed diet. 4. Guard force offers detainee restroom privileges (and encourages use of the restroom) before

shackles are placed on detainee. 5. Guard force shackles detainee and a mask is placed over the detainee's mouth to prevent spitting

and biting. 6. Detainee is escorted to the scale for daily weight. VerifY whether detainee has attained I 00% of

calculated IBW for 14 days or more. 7. Detainee is escorted to the chair restraint system and is appropriately restrained by the guard

force. 8. When the guard force advises it is safe, medical personnel initiate the medical restraint monitoring

procedures as per SOP 081, obtain vital signs, and document pulses and restraint placement. Using the restraint observation sheet, medical personnel will document circulation checks and detainee condition every 15 minutes.

9. A feeding tube is placed in the stomach as follows: a. Topical anesthesia (e.g. viscous lidocaine) will be applied to the appropriate nostril (unless

detainee refuses) and the feeding tube OR b. Sterile Surgical lubricant (may be substituted with viscous lidocaine or olive oil, if desired by

the detainee) is applied to the feeding tube. c. The feeding tube is passed via the nasal passage into the stomach. Placement of the feeding

tube in the stomach is confirmed using air insufflation with auscultation and a I 0 mL test dose of water.

d. The tube is secured to the nose with tape. The enteral nutrition and water that has been ordered is started and flow rate is adjusted according to detainee's condition and tolerance.

e. Typically, the feeding can be completed comfortably over 20 to 30 minutes. f. After the feeding is completed, the medical staff removes the feeding tube.

10. Upon completion of the nutrient infusion and removal of the feeding tube, the detainee is removed

from the restraint chair and placed in a "dry cell". The guard force will observe the detainee for 45-60 minutes for any indications of vomiting or attempts to induce vomiting.

II. If the detainee vomits or attempts to induce vomiting in the "dry cell" his participation in the dry cell protocol will be revoked and he will remain in the restraint chair for the entire observation time period during subsequent feedings.

12. Steps 10 and II are contingent upon adequate facility and staffing resources for the detainee census. The detainee will remain in the restraint chair for the· feeding and observation periods if either resource is inadequate.

13. The total time the detainee is in the chair restraint system (to include the feeding process and the post-feeding observation) should not exceed 2 hours.

Enclosure (7)



SOP: JTF-JMG # 001 OSMAR2013 Page 19 of30

14. The "dry cell" may be the detainee's original cell with the water source turned off temporarily for

the observation period. 15. Documentation to include a feeding tube insertion note, restraint observation forms, and nursing

notes are completed per JDG restraint protocols SOP 081. 16. Detainees who are chronic enteral feeders and are living in communal blocks may receive enteral

feedings under alternative settings. Chronic enteral feeders are notified by the corpstaffthat "It is time to feed." If the detainee declines, then no enteral feeding will take place during that session. If the detainee accepts, then the detainee is escorted to the medical clinic or media room as appropriate. The enteral feed will take place with the detainee in single point leg restraint.

Enclosure (7)




MEDICAL EQUATIONS, CALCULATIONS AND DEFINITIONS

Determination of Energy Requirements: •TOTAL CALORIE PER KILOGRAM METHOD

Classification Morbid obesity

Kcallkg 20

Starvation, Ventilated, Intensive Care Unit Ambulatory Maintenance Malnutrition/ Moderate Stress Severe Injuries/ Stress

25 25-35 30-35 35-45

•HARRIS- BENEDICT EQUATION:

Men (kcal/day)[66.47 + (13.75 x weight (kg))+ (5 x height (em))- (6.76 x age)] x activity factor x stress factor Women (kcal/day)[655.1 + (9.56 x weight (kg))+ (1.85 x height (em))- (4.68 x age)] x activity factor x stress factor

Seated work with little Jlibvement Seated work with little strenuous leisure activity Standing work Strenuous work or highly active leisure activity 30-'60 minutes strenuous.leisure activity 4-5 times/week

1.4-1.5 x BEE 1.6-1.7 x BEE

1.8-1.9 x BEE 2-2.4 x BEE 2.3-2.7 x BEE

surgery Multiple trauma Severe infection Peritonitis Multiple/long bone fractures Infection with trauma Sepsis Ct<>sed head injuey Cancer Burns Fever

xBEE 1.4xBEE 1.2- 1.6 X BEE 1.05-1.25xBEE 1.1 - 1.3 x BEE 1.3 -!.55 x BEE 1.2- 1.4 x BEE 1.3.xBEE 1.1 - 1.45 X BEE 1.5-2.1 xBEE 1.2 x BEE (per I °C >37°C)

Determination of Protein Requirements:

Condition Grams/kg/day Renal Failure/Dysfunction 0.6-0.8 (40 gram min) Dialysis Patients (moderate stress) 1 -1.2 Dialysis Patients (high stress) Sepsis Liver Failure/Cirrhosis Re-feedina Syndrome

1.2- 1.5

Multiple trauma 1.3-1.7 Catabolism 1.2-2 Post-op 1 1.5

Enclosure (8)




5

-

Determination of Fluid Requirements:

1'1 10 kg 2"" 10 kg Each kg >20 kg

.fi{A 't-:- :{··:

·•· l:.,.. lliijill!inY 100 mUkg 50mUkg 20 mUkg 50 years) 15 mUkg (>50 years) .....--"-- - - ..., /-----·-----.- ---

Young Athletic Adult 40 mUkg Most Adults 35 mUkg Elderly Adults 30 mUkg !f3 "'l:iim dlti:tre· ··········)·:·

1 mUkcal energy expenditure

Definitions: Usual Body Weight (UBW) =The greater of the following:

i. The weight of the detainee at in-processing physical exam. ii. The weight of the detainee before the hunger strike.

Ideal Body Weight (IBW) = [(Height in inches- 60) x 2.3 +50] x 2.2 %Ideal Body Weight(% IBW) = [Current Weight (pounds) I Ideal Body Weight (pounds)] x 100 % Weight Loss (% WL) = [Usual Body Weight (pounds)- Current Weight (pounds) I Usual Body

Weight (pounds)] x 100 Body Mass Index (BMI) =[Current Weight (pounds) x 703 I Height' (inches2)]

Sources: I. Gottschlich, M, eta!. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Iowa: Kendall/Hunt Publishing Company: 200 I. 2. Grant A and DeHoag S. Nutrition Assessment and Support. 4th ed., Seattle: Northgate Station: 1991. 3. Klein S et al; Nutrition Support in Clinical Practice: Review of Published Data and Recommendations for Future Research Direction. JPEN. 21:133-155, 1997. 4. Shikora S, et al. Nutritional Considerations in the Intensive Care Unit. Iowa: Kendall/Hunt Publishing Company: 2002. 5. Shronts EP ed. Nutrition Support Dietetics Core Curriculum, 2nd ed. Rockville, MD: American Society of Parenteral and Enteral Nutrition: 1993. 6. Skipper A; Nutrition Support Policies, Procedures, Forms, and Formulas. Aspen Publishers, Inc. 1995. 7. The American Dietetic Association. Manual of Clinical Dietetics, fifth edition. American Dietetic Association, Chicago, 1996. 8. Zaloga, GP. Nutrition in Critical Care. St. Louis: Mosby: 1994

Enclosure (8)




MANAGEMENT OF COMMON ELECTROLYTE DEFICIENCIES

Hypokalemia- Replace potassium with KCL elixir/tablets, I 0 milliequivalents for every 0.1 mEq/L below the normal value of 4.0 in the detainee's serum. For example, if a detainee has a serum potassium of 3.4 mEq/L, 60 milliequivalents of KCL elixir/tablets should be ordered.

Hypomagnesemia- Replace with magnesium oxide. Crush four 400 mg tablets (approximately 960 mg ofbioavailable magnesium) and mix in water before adding to enteral solution. Continue daily until normal serum Mg++ level is confirmed by lab draw. Oral magnesium may cause diarrhea. Alternatively for severe hypomagnesemia, 1-2 grams of magnesium sulfate may be infused intravenously over 30 minutes.

Hypophosphatemia- Replace with 4 packets ofNeutra-phos daily (total of I 000 mg of phosphorus, 1112 mg of potassium, and 656 mg of sodium daily) until normal serum phosphorus level is confirmed by lab draw. Oral Neutra-phos may cause diarrhea. Alternatively, for severe hypophosphatemia, 15 mmol of sodium phosphate mixed in 250 ml of Y, NS may be given over 4-6 hours. Usually, this is repeated for a total of 4-8 runs.

Enclosure (9)




Medical Management ofEnterally Fed Detainees Who Terminate Their Hunger

Strike

When a hunger striking detainee voluntarily resumes eating or when the detainee has attained 100% of calculated IBW for at least fourteen (14) consecutive days and the attending physician deems it to be medically appropriate, oral feeding shall resume. The Detention Hospital medical staff will medically manage these individuals to avoid complications associated with the resumption of oral nutrition in long-term hunger striking. This medical management will consist of three phases. The first phase will consist of slowly advancing the diet. The second phase will involve the transfer of the detainee to a Transition Block for further monitoring. And the third phase will consist of the return of the detainee to the mainstream detention camp environment.

1. RETURN TO ORAL NUTRITION.

a. When a hunger striking detainee chooses to eat or when the detainee has attained I 00% of

calculated IBW for at least fourteen (14) consecutive days and the attending physician deems it to be medically appropriate, he will first be offered a bland diet which is often supplemented with yogurt and liquid nutritional supplements such as Ensure®, Boost®, and Jevity®.

b. During this phase of graduated oral intake, the medical staff will monitor the detainee for evidence of refeeding syndrome that is often characterized by decreased serum phosphorus, magnesium, and potassium levels, as well as peripheral edema.

c. After the detainee demonstrates a consistent behavior pattern of eating (approximately nine consecutive meals), the Guard Force will consider him for transfer from the Detention Hospital to a transitional block. Prior to transfer, the medical staff will perform a complete medical evaluation to include vital signs, weight, physical exam, and serum blood chemistries to include a basic metabolic panel, complete blood count, liver function tests, and serum magnesium, phosphorus, and calcium.

d. A representative of the Behavioral Health Services will evaluate the detainee prior to transfer from the Detention Hospital.

e. Enteral feeding shall resume at any point if it becomes medically necessary, in accordance with the SOP.

2. TRANSFER OF DETAINEE TO A TRANSITION BLOCK

a. The detainee will be removed from the Hunger Strike list when he is transferred to the

Transition Block. The Transition Block will serve as place for the former hunger-striking detainee to begin to be re-assimilated back into the detention camp environment. He will be closely monitored for compliance with consumption of all of his meals.

b. The Hospital Corpsmen assigned to the Transition Block will visit the detainees daily to pass medications, assist in obtaining weights, conduct sick call, and to dispense supplemental liquid nutrition. The detainee can have up to two cans of vanilla flavored Ensure® two to three times a day. The Guard Force will facilitate the dispensing of the Ensure® using Styrofoam cups.

c. A Medical Officer will visit the detainee daily or as clinically indicated to monitor the former hunger striker.

d. The assigned Guard Force at the Transition Block will take accurate daily weights on each former hunger striker and put this information in the Detainee Information Management System (DIMS).

e. After a sufficient period of observation (9 additional, consecutive meals) that satisfies both the Joint Detention Group and the Detention Hospital Medical Staff that the former hunger

Enclosure (10)




striker is tolerating a regular diet, the detainee will be transferred back to a mainstream detention camp block.

f. Prior to transfer off the Transition Block, a Medical Officer will perform a complete medical evaluation to include vital signs, weight, physical exam, and serum blood chemistries to include basic metabolic panel, complete blood count, liver function tests, and serum magnesium, phosphorus, and calcium.

g. Prior to transfer, a member of the medical staff will counsel the detainee that a return to hunger striking would be extremely detrimental to his health.

3. RETURN TO THE MAINSTREAM DETENTION CAMP ENVIRONMENT

a. A medical provider will perform a complete medical evaluation on all prior enterally fed

detainees within approximately 2 weeks after resumption of a regular diet and re-integration into the general camp population. This medical evaluation will include vital signs, a weight, a physical examination, and blood work to include a basic metabolic panel, liver function tests, a complete blood count, and serum magnesium, phosphorus, and calcium. The results of these evaluations will be recorded in the detainee's outpatient medical record. The evaluation should also include an assessment of the detainee's need for physical therapy services. Prior enterally fed detainees found to have medical issues or to exhibit signs or symptoms associated with refeeding syndrome will have subsequent follow up visits in the outpatient clinic, as medically indicated.

b. A member of the medical staff will counsel the detainee that a return to hunger striking would be extremely detrimental to his health.

Enclosure (10)




DETENTION HOSPITAL SOP NO: TACMEMO #01 GUANTANAMO BAY, CUBA Supplemental to JTF-JMG SOP

#001 Title: PROCEDURES FOR SETTING UP AN ENTERNAL Effective Date: 05 Mar 13

FEED(EF)

SCOPE: JOINT TASK FORCE-DETENTION HOSPITAL

I. BACKGROUND

Many detainees attempt to manipulate enteral feeding (EF) times by admonishing the staff administering them that the drip rates are too fast, or directing the order of ingredients, Le.: adding milk after the Ensure TM has been given. Collectively, this has had the effect of prolonging the total time spent in the feeding chair and has given detainees a measure of control over an involuntary process. Standardization of the process for setting up enteral feeding ensures that JMG staff act in a safe, humane, and consistent manner, and will reinforce the equal treatment of detainees according to SOP.

KEY CONCEPTS:

• Personal safety of JMG staff is paramount. • Enteral feeding is being given as a lifesaving procedure. • Detainees are not to direct the contents, or order of ingredients of EF. • Detainees may not direct the speed of the EF, unless it is causing abdominal pain. • Detainees may not choose their location while being enterally fed. • There are medications which can be given (anti-emetics, pro-kinetics, phenergan, reglan,

metamucil), which can enhance comfort during EF. Detainees should be always be offered these medications if they experience discomfort.

II. POLICY

A. Upon receipt of JTF's approval for enteral feeding, feeding times and locations shall be under

the direction of the JOG Commander, meeting daily caloric requirements.

B. Enteral feeding solutions will be prepared in accordance with the JMG physician's orders and out of the line of sight of detainees. The entire EF solution as ordered by the physician will be added before connecting the bag to the EF tube.

C. An IV pole will be utilized. Place the IV pole behind the detainee and out of his field of vision,

as room allows.

D. A new enteral feeding tube (EFT) will be used for each EF unless a detainee requests to reuse a EF tube. Upon detainee request, reuse of EF tube is authorized lAW with SOP #092. The EF reservoir bag must be clearly marked with the detainee's ISN number, and is to be discarded at the end of each day.

III. PROCEDURE

A. The detainee will be placed in the feeding chair per SOP NO: JTF-JMG #001, and oriented so

that his back is to the cell door. The EF solution will be hung behind detainees as far as possible

Enclosure (11)




without impeding RN access to the EF bag. If a detainee is to be fed while laying on a gurney, a written order from a physician is required. Any such order must be included in the enteral feeding order. The detainee must be restrained by the guard staff according to JOG guidelines and the head of the bed must be elevated to at least 45 degrees.

B. The detainee should be offered a chance to use the toilet before being placed in a feeding

chair. If he must use the toilet during enteral feeding, and line-of-sight cannot be maintained, the EFT must be removed and re-started to finish the EF.

C. The goal is to complete the EF within times outlined in SOP NO: JTF-JMG #001. If the

detainee complains that EF is being instilled too fast, first ensure that it is being administered per established SOP. The RN should ask if the detainee is nauseous, or is having pain.

I. If detainee is experiencing nausea, the RN should offer the detainee any PRN nausea or pro-kinetic medications available as ordered.

2. If the detainee complains of pain, assess the detainee to ensure that the NG tube has been properly placed and functioning normally. Inform the detainee that the EF is being given under safe, acceptable, and humane guidelines, and is being given under a doctor's orders. Palpate abdomen for overly distended stomach. Slow until complaint of pain is resolved. The EF will not be discontinued if there is any EF solution remaining in the bag unless the 2 hour time limit has been reached. Do not allow the detainee to manipulate the flow of the EF; secure the EFT so that the detainee cannot reach it with his hands.

3. If detainee attempts to change the order or ingredients of the EF, inform him that the EF is being given under a doctor's order, for medical necessity, and will not be changed by the RN.

4. The following standard responses will be used to respond to detainee questions or protests of ingredients to EF:

(a). If the detainee requests that certain items be added to the EF, or if the detainee asks why he cannot be given certain ingredients in the EF the nurse will reply:

"This is the formula that the doctor has ordered for your nutritional requirements. I am not permitted to make any changes to the order".

(b). If the detainee demands to speak to the doctor, the nurse will reply: "I will write a note in your chart for the doctor". (c). If the detainee attempts to slow the EF process by stating that the EF is infusing

too fast, the nurse will reply: "The doctor has ordered some medication which may help with nausea; would

you like me to administer it?" (d). If the detainee attempts to direct the nurse to place him in a particular location

during EF, the nurse will reply: "This is a decision for the guards to make."

D. Ensure personal safety during EF, refer to JOG SOP #33 for proper management of detainees

while restrained for enteral feeding. If the RN or HM feels as if they are in any danger of BFE or personal harm, withdraw from the situation and speak with the guards to inform them of their concerns.

E. It is appropriate for the nurse to direct guards to wash the hands of detainees who present for EF

with feces on their hands in accordance with the JOG SOP #85.

Enclosure (11)




F. If any detainee threatens the nurse with physical assault or exposure to body fluids, each

occurrence must be reported to the guard staff immediately.

G. For detainees admitted to the BHU and receiving enteral nutrition: If deemed appropriate and necessary, the BHU medical director may direct nursing staff to use weighted or non-weighted EF tube based upon individual assessments of the detainee's potential to bite the EFT. The decision to use a weighted versus non-weighted EFT will be made after consultation with the SMO and EF physician, and will be written as an order in the detainee's medical chart. Nursing staff may not change the size or type of tube without a written order.

H. The EF reservoir bag will be flushed with at least 300 mL of tap water or until clean. It may be

re-used for the same detainee on the same day, but is to be disposed of at the end of each day.

I. The number of calories which are received will be documented both in the nursing notes and on the Hunger Striker Medical Flow Sheet.

IV. APPLICABILITY

The tactical procedure delineated above is applicable to all the enteral feedings performed by JMG personnel.

Enclosure (11)




DETENTION HOSPITAL SOP NO: TACMEMO #02 GUANTANAMO BAY, CUBA Supplemental to JTF-JMG SOP

#001 Title: STRATEGY FOR DETAINEE BITING ENTERAL Effective Date: OSMar 13

FEED TUBE

SCOPE: JOINT TASK FORCE-DETENTION HOSPITAL

I. BACKGROUND

On occasion, a detainee undergoing enteral feeding (EF) will attempt to bite the tube in an attempt to swallow the feeding tube, necessitating serial exams and possible EGD removal of the tube. Identification of these detainees and management of the EF tube will assist the RN in reducing the incidence of this event. The detainee may attempt to bite the portion of the tube outside the nose by turning his head and snaring the tube with his mouth, or may attempt to regurgitate the tube partially into the oral cavity and attempt to sever the tube covertly without opening his mouth. This is especially difficult to assess in the non-compliant detainee when it is necessary to affix a "spit mask" over his mouth. The JMG staff may utilize the following strategy to manage the behavior

KEY CONCEPTS:

• Personal safety of JMG staff is paramount. • Detainee may try to bite the RN during the EF tube insertion. • Guard staff should be appropriately utilized for monitoring behavior and securing a

detainee for the safety of JMG staff. • Special care is to be taken whenever procedures are initiated near a detainee's mouth.

II. POLICY Biting tube OUTSIDE the mouth:

A. If a detainee is actively attempting to tum his head to bite the tube between the nose to the

EF bag, the RN will affix the tube with tape to the midline of the detainee's nose and extend it upwards, affixing it with tape to the detainee's forehead.

B. If a detainee is actively attempting to bite the nurse, the nurse will immediately withdraw

until the detainee is appropriately restrained.

C. If the behavior persists, and there is legitimate concern that the detainee may still be able to bite the tube. The RN shall direct a member of the guard staff to continually monitor the detainee during the EF session.

D. To reduce head and jaw motion during insertion ofthe EF tube if required:

I. While the detainee is seated and appropriately restrained in the feeding chair, one guard will position themselves behind the detainee and hold the detainee's head in the midline position.




2. When the Nurse is satisfied that the detainee is secured and a safe environment exists, they shall insert the EF tube iaw SOP NO: JTF-JMG #001 and secure it as described in (A). 3. The guard may then release their hold on the detainee's head

E. If a particular detainee displays repeated attempts to bite the tube, a weighted I Of tube shall

be used for all subsequent EF.

F. If the detainee is able to gain the tube between his teeth, the nurse will: I. Simultaneously turn off feed and, immediately stabilize the distal end of the tube and pull the tube from the detainee's nose. 2. Maintain traction on the proximal portion of the tube until the detainee releases the tube from between his teeth. This may take considerable time.

Biting the tube INSIDE the month:

A. If a detainee is noted to be attempting to chew the tube, the RN should ask the detainee to

open his mouth for a visual confirmation that the tube is intact. If the detainee refuses, the RN shall immediately remove the tube, inspect it for damage, and re-insert it to accomplish the EF.

B. The RN will direct guard staff to maintain continuous visualization of the detainee's jaw to

assess for chewing.

C. If detainee is able to get the EF tube between his teeth, the RN shall: I. Immediately stop the enteral feeding while simultaneously maintaining gentle

traction on the EF tube. 2. Direct the guard staff to stabilize detainee's head in the midline position. 3. Hold traction on the tube for as long as necessary for the detainee to relax his jaw; then continue safe removal of the tube. This may take considerable time.

D. If any particular detainees continually attempt to bite the tube. The RN will direct guard staff to maintain I:I visual monitoring of detainee during EF sessions.

III APPLICABILITY

The tactical procedure outlined above is applicable to all JMG personnel who are involved in

the enteral feeding of detainees.




APPROVED BY: _ _ .

...

• • - l ' l - 7::41'/eJ-oIS -.... Signature/ Printed Name Date Commander, Joint Medical Group. RECOMMENDED BY:

I

Signature/ Printed Name Required: [g)Yes DNo Date Deputy Commander, Joint Medical Group

I Signature/ Printed Name Required: DYes DNo Date Senior Medical Officer

I Signature/ Printed Name Required: DYes 0 No Date Senior Nurse Executive

I

Signature/ Printed Name Required: DYes 0 No Date Director For Administration

I Signature/ Printed Name Required: DYes 0No Date Medical Planner

I

Signature/ Printed Name Required: OYes 0No Date Senior Enlisted Leader

I

Signature/ Printed Name Required: DYes 0No Date Director, Behavioral Health Services

REVIEW LOG: Directorate Reviewer: Sig: Date: Sig: Date: Sig: Date: SOP SUPERCEDED/ CANCELLED THIS DATE:

I

Signature/ Printed Name Date Commander, Joint Medical Group


Exhibit E


UNCLASSIFIED//FOR PUBLIC RELEASE

JOINT MEDICAL GROUP SOP NO: JMG 001 JOINT TASK FORCE GUANTANAMO BAY, CUBA

Effective Date: 16DEC2013 Title: MEDICAL MANAGEMENT OF DETAINEES

WITH WEIGHT LOSS

SCOPE: JOINT MEDICAL GROUP, JOINT TASK FORCE, GTMO

REFERENCES:

(a) DoD I 231 0.08E Medical Program Support for Detainee Operations, 2006.

ENCLOSURES:

(I) Refusal to Accept Food or Water/Fluids as Medical Treatment (2) Weight Loss Medical Evaluation Sheet (3) Weight Loss Medical Flow Sheet ( 4) Approval Authority for Initiation of Involuntary Enteral Feeding (5) Clinical Guidelines for the Evaluation, Resuscitation, and Feeding of Detainees on Long

Term Non Religious Fast (6) Nursing Staff Clinical Procedure Checklist for Intermittent Enteral Feeding of Detainees with

Weight Loss (7) Enteral Feeding Nursing Note (8) Medical Equations, Calculations and Weight Formulas

I. BACKGROUND

A. A proJonged period oftime without adequate food and water wiJI have adverse health effects on the individual detainee and potentially the greater detainee population. Weight loss may be an indicator of long standing malnutrition or of an underlying medical problem) such as malignancy or infectious disease. Identification and early medical management of detainees with weight loss may prevent adverse health effects and death.

B. Patients with weight loss can be expected in any detained population. Maintaining adequate nutrition and health within a detained population is challenging. The medical management of detainees with weight loss in GTMO has evolved over t ime. The current medical management of detainees with weight loss in GTMO has been developed using procedures adapted from the Federal Bureau of Prisons.

II. POLICY

A. The DoD and Joint Task Force Guantanamo (JTF-GTMO) policy is to protect detainees' physical and mental health and provide appropriate treatment for disease. This includes preventing

1J ~Cl · Hn lrU£0 '1'(}\ 1() • . .. rl a a • ... r '



UNCLASSIFIED//FOR PUBLIC RELEASE ('NCLASSIREB,'FOllO

STANDARD OPERATING PROCEDURE: SOP: JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 2 of24

any serious adverse health effects or death from weight loss, chronic underweight or malnutrition. The Joint Medical Group (JMG) staff will provide health care monitoring and medical assistance as clinically indicated for detainees with weight loss.

B. Weight is one of the central non-invasive indicators of the health of the detainee. Historically, it has been shown that simple visual monitoring of detainees may miss clinically significant weight loss. Therefore, all detainees will be weighed at least monthly. Detainees who are of concern to the medical staff will be weighed more frequently as clinically indicated. Every attempt will be made to obtain weights voluntarily; however, weights may be obtained involuntarily to ensure compliance with this policy.

C. In the event a detainee refrains from eating or drinking to the point where it is determined by medical assessment that continued fasting will result in a threat to his life or seriously jeopardize his health, JMG medical personnel will make reasonable efforts to obtain voluntary consent for medical treatment. If consent cannot be obtained from the detainee, medical procedures necessary to preserve health and life shall be implemented without his consent pursuant to reference (a). When involuntary feeding/fluid hydration is medically required, the JMG Senior Medical Officer (SMO) will inform the JMG Commander. When the SMO and JMG Commander reach concurrence, they will inform the JTF Commander and request written approval to administer involuntary feedingffluid hydration.

D. JMG will not initiate involuntary feedingffluid hydration without the JTF Commander' s knowledge and written approval. This approval authority does not preclude the Medical Officer from performing any emergent actions deemed medically necessary to preserve life and health.

E. Preventing is important to maintaining good order and discipline in the detention enviromnent, and in protecting detainee health. The procedures outlined in this SOP will be protected from release to detainees and other personnel, including JTF staff and visitors without a need to know, consistent with FOUO designation.

F. Definitions.

1. Clinically Significant Weight Loss. For the purposes of this instruction, clinically significant weight loss is defined as:

a. The detainee's weight is the calculated ideal body weight (IBW).

b. The detainee has experienced a weight loss from his usual body weight. For those detainees whose usual body weight is less than their ideal body weight, a weight loss is considered clinically significant.

c. Weight loss or underweight associated with evidence of deleterious health effects ......... "'v' of loss reflective of involvement or to but

2




ti?~ ( 'Lit ~:ui JFIE DfPO e 0 STANDARD OPERATING PROCEDURE: SOP: JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 3 of24

d. A pre-existing co-morbidity that might readily predispose the detainee to end organ damage (e.g. hypertension, coronary artery disease or any significant kidney disease).

e. A prolonged period of weight loss, usually defined

2. Enteral feeder. A detainee who the JTF Commander has authorized for involuntary feeding via an enteral feeding tube. lt is important to note that an enteral feeder may or may not actually receive an ent.eral feed via a nasogastric tube on any specific day. Enteral feeders may still elect to eat a mea] or to drink liquid nutrition despite being designated an enteral feeder

3. Adequate Caloric Intake. The nwnber of calories required by a detainee to support daily metabolic functions and to maintain weight. Although this number varies individual for the purposes of this instruction, adequate caioric intake is considered to be daily.

4. Formulas:

Usual Body Weight (UBW) = the greater of the following: i. The weight of the detainee at in-processing physical exam. ii. The average weight of the detainee for the past twelve months.

ldeaJ Body Weight (IBW) =[(Height in inches - 60) x 2.3 + 50] x 2.2

% IdeaJ Body Weight(% IBW) =[Current Weight (pounds) I Ideal Body Weight (pounds)] x l 00

% Weight Loss (% WL) = [Usual Body Weight (pounds)- Current Weight (pounds) I Usual Body Weight (pounds)] x 100

III. Medical Management of Detainees with Weight Loss

A. Effective management of detainees with weight loss requires a close partnership between the JMG medical staff and the Joint Detention Group (JDG) guard force.

B. JDG guard forces monitor each detainee's .... ~ ............. this infonnation dai

the JMG SMO daily.

The JMG SMO or his designee will review The SMO will review the clin

3



UNCLASSIFIED//FOR PUBLIC RELEASE UNCL;tS!51ft~Dff'Ot'O


The SMO may order a detainee weight at that time, or may order that the detainee be weighed more frequently than what is nonnalJy required for detainees in this instruction.

D. If the result of a detainee weight qualifies as a clinica11y significant weight loss, the SMO will direct the detainee's medical provider to conduct an assessment. The intent of the assessment is to consider any medica) and or behavioral cause of the weight loss.

nee of latent untreated tuberculosis in the detainee detainee who loses chest radiograph to rule out the possibility of active tuberculosis.

F. Using Enclosure (3), Weight Loss Medical Flow Sheet, a medical provider will perform a complete medical record review, an intake (food/fluids) history, and a general physical examination to include vital signs, weight, and Percent Ideal Body Weight(% IBW). The medical provider may order clinically indicated laboratory tests to assess the detainee's physical and metabolic status, including but not limited to EKG, urinalysis, serum basic metabolic profile, liver function tests (LFTs), Magnesiwn (Mg), phosphate (P04) and calcium (Ca). Once completed, Enclosure (2) will be signed by the medical provider and placed in the detainee's medical record.

G. The SMO will notifY the Officer-in-Charge of the Behavioral Hea.lth Services (BHS) of any detainees who are added or removed from the list of individuals participating in long term non-religious fasting. If indicated, the BHS will perform a mental status exam and psychological assessment of the detainee. Docwnentation of the results of this exam and follow-up treatment plan wiH be placed in the detainee's medical record.

H. A JMG medical provider will advise each detainee who displays clinically significant weight loss as to the need to maintain weight. The medical provider may offer a nutritional consult. The medical staff will explain to the detainee via a linguist the health risks faced by the detainee resulting from clinically significant weight loss and encourage the detainee to resume eating sufficient food and drinking water. Documentation of this counseling will be placed in the detainee's medical record.

I. After the initial medical evaluation, the medical providers will continue to assess the health of the detainee biweekly or as clinically indicated and document their findings using Enclosure (3), Weight Loss Medical Flow Sheet, available electronically on the network share drive.

J. The medical provider will discuss the medical care of the detainee with the SMO biweekly or as clinically indicated. The SMO will brief the chain of command of any serious medical issues concerning the detainees.

K. When a JMG medicaJ provider determines that the detainee's life or health is threatened due to weight loss, immediate medical intervention may be indicated. In such a case, the JMG medical provider will notifY the SMO. The medical provider shall attempt to obtain voluntary

4



UNCLASSIFIED//FOR PUBLIC RELEASE l~NCLASSIFfEB/F,Ot;o

STANDARD OPERATING PROCEDURE: SOP: .JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS PageS of24

consent for intervention. The medical provider shall document their counseling efforts and treatments in the detainee's medical record.

L. If medical intervention is required for a detainee who is losing weight, the SMO will notify the JMG Commander. The SMO or his designee will attempt to obtain voluntary consent for the intervention. lfthe detainee continues to refuse reasonable care necessary to safeguard the detainee's health, it may be necessary to intervene involuntary. lfthis occurs, the SMO will discuss the care plan with the JMG commander. lfthe SMO and the JMG Commander concur with the proposed care plan, the JMG Commander or SMO will make a specific involuntary intervention request to the JTF Commander. Upon approval from the JTF Commander, the SMO will order the treatment. Usual! the SMO/JMG Commander v.rill receive the JTF Commander's authorization via email.

M. If involuntary enteral feeding is clinically indicated and authorized, Enclosure ( 4), Approval Authority for Initiation of Involuntary Enteral Feeding, will be completed by the SMO and placed in the detainee's medical record. These detainee will then be designated as an enteral feeder.

N. The SMO or his/her detainees approved for enteral feeding via the JMG to leaders within the JTF with a

0. Enteral feeders will be fed according to a schedule approved by the SMO as coordinated with the guard staff. All enteral feeders will be offered standard detainee meals daily. If the detainees refuse meals, they will be offered to consume the enteral feed solution orally. If they refuse their meals and the opportunity to consume their enteral feed solution orally, they will be asked to accept enteral feeding voluntarily. Only after they refuse all of the above will involuntary enteral feeding be initiated.

P. C1inical protocols for enteral feeding using graduated, continuous, and intermittent enteral feed infusions are found in Enclosure (5), Clinical Guidelines for the Evaluation, Resuscitation, and Feeding of Detainees with Weight Loss, which also includes guidance for the management of common electrolyte deficiencies. If the SMO deems it medically safe (e.g. low risk of refeeding syndrome) based on the duration of the detainee's fast, involuntary enteral feeding may be initiated with graduated intermittent feeds as opposed to a continuous infusion.

Q. Enclosure (6)> Nursing Staff Clinical Procedure Checklist for Intermittent Enteral Feeding of Detainees with Weight Loss, establishes the steps to be used in performing enteral feedings, and Enclosure (8), Medical Equations, Calculations and Weight Formulas will be used to calculate caloric goals/needs.

R. Routine deviations from the above procedure for specific detainees must be approved by Commander, JTF-GTMO.

5



UNCLASSIFIED//FOR PUBLIC RELEASE u ?" C l/cSS 11"1 E 8/F() F ()

STANDARD OPERATING PROCEDURE: SOP: JMG # 001 MEDICAL lVIANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 6 of 24

S. Enteral Feeders will be weighed weekJy, or more frequently as clinically indicated. Any continued weight loss in these detainees will be reported to the Commander, JTF.

IV. Weighing of Detainees

A The JMG Weight Monitoring Nurse will review the - frequently throughout each month ensuring the current month.

B. The JMG Weight Monitoring Nurse will notify the JMG OICs and charge nurses of all detainee ISNs that need to be weighted for the month.

C. The JMG OICs will notify the JDG Watch Commander (WC) or Block NCO which detainee weights are still needed. Once the weights are obtained, the JMG Corpsman will report the detainee ISNs and weights to the charge nurse for documentation.

D. Detainee weights may be obtained on the cell blocks, during routine clinic and medical space visits, or while the detainee is an inpatient in the Detention Hospital or Behavioral Health Unit.

E. Scales will be zeroed prior to measurement.

F. Detainees should stand in the center of the scale without assistance and without touching walls or any nearby objects. If the detainee is unable to stand, he may be weighed while sitting in a feeding chair or wheelchair using a wheelchair scale, but the weight of the chair must be subtracted from the total weight obtained.

G. When detainees are weighed while on backboards or wearing shackles or other restrictive devices, the weight of those devices will be subtracted from the measured weight.

H. Once the guards have the detajnee on the scale, a JMG member, usually a Hospital Corpsman assigned to the area where the detainee is located, will note the weight and give the measurement to the JMG Charge Nurse, who will forward th~ the JMG Weight Monitoring Nurse. The JOG guard staff will enter the weight-

L The JMG Weight Monitoring Nurse will report to the JMG Commander via the SMO and the JMG Deputy Commander any detainee who is overdue on their weights.

6



UNCLASSIFIED//FOR PUBLIC RELEASE r · ·er • fH rrtEH 'fot·o I ... .... . \ .i .S- ;. I


V. Monitoring Detainee Weights

B. The SMO will receive daily information on missed meals and detainee weights from the

C. The Weight Monitoring Nurse and the SMO will review - for trends and analysis no .less than monthly to identify any detainee whose wdght loss has become clinically signiflcant as defined above and to obtain a long term overview of all detainee weigbts.

VI. Reporting Detainee Weights

Commander may request special analysis of the information from the SMO at any time.

Vll. Dietary Consultation

A JMG providers may request a dietary consult for the detainee with the NH GTMO dietician for detainee education and recommendations to achieve optimal · tential medical consequences of obesity, health benefits of maintaining a nonnal and strategies to reduce weight and limit caloric intake.

VIII. In-processing

A. Upon first arrival to JTF-GTMO, the hei determined and recorded -IX. Out-processing

A Each detainee scheduled for transfer from JTF-GTMO will be weighed during outprocessing. The detainee's in-processing and out-processing weights will be noted on the final narrative summary.

7




l"'\CLAS!iril PI Ell/FOt'Q, STANDARD OPERATING PROCEDURE: SOP: JMG # OOl MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 8 of24

X. Cessation of Enteral Feeding

A. Most detainees will commence ora! feeding on their own at some point. they will no longer be designated enteral feeders. These nitored for their wei fluid consum ·on and caloric intake.

ical monitoring. the SMO will notify the JMG

Commander. If the SMO and JMG Commander concur, they will request from the JTF Commander permission to resume enteral feeding.

B. For evidence of malabsorption or other select cases, the SMO, with the approval of the JMG Commander, wi!J determine an individualized care plan for transitioning an enteral feeder back to an oral diet. Generally, a three- to five-day period is sufficient for the transition to an oral diet. If the detainee has been intenninently consuming food by mouth during a period of weight loss, the transition to an oral diet may be achieved sooner.

8




t 7~CLAS8IFIEtl/fi'Ot~ () STANDARD OPERATING PROCEDURE: SOP~ JTF-JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 9 of 24

Refusal to Accept Food or Water/Fluids as Medical Treatment

Detainee Number ------- Age __ _ Date _______ _

The above detainee has refused food and/or water as medically recommended by the Medical Officer.

The grave risks of not following the medical advice directing him to eat life-sustaining food and to drink water/fluids have been explained to the detainee. He states he understands that as a direct result of his refusal to eat and/or drink, he may experience hunger, nausea, tiredness, feeling ill, headaches, swelling of his extremities, muscle wasting, abdominal pain, chest pain, irregular heart rhythms, altered level of consciousness, organ failure and/or coma. He states he understands that his refusal to eat life-sustaining food or drink water/fluids and to follow medical advice may cause irreparable hann to himself or lead to his death. He states he understands that this is not a complete list of the risks involved with the refusal to follow medical advice.

The detainee states he understands the alternatives available to him including oral food and fluid oral rehydration solutions, oral nutritional supplements, and intravenous fluid hydration.

The detainee states he fu lly understands the risks to his health if he does not accept food and water as advised above.

Translator/ Witness Signature _____________________ _

Medical Provider Signature-----------------------

t l ~'CL~\SNI PIE B/rO 1:10 Enclosure (1)




l 'NC.LA!'Sglflfi::f')/"f?Ot 0 STANDARD OPERA TlNG PROCEDURE: SOP: JTF-JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 10 of 24

Detainee Number: Date of Evaluation: -------- - - ----

Date of Onset: ------- Drinking Fluids: Yes No

HPI:

MEDS:

ALLERGLES: NKDA or -------- FOODALLERGIES: ______ _

PMH:

J:'hvsical Assessment:

In processing Wt: ___ lbs Usual Wt: ___ lbs/date: ___ _ IBW ___ _

Current Wt: __ lbs % IBW %Wt Loss: ----Heart Rate: ____ BP: / __ RR: __ _ T: __ _ LOC: Yes No

Other Pertinent Physical Exam and Laboratory findings:

Assessment: Detainee with Weight Loss

1. Explained risks of inadequate intake of food and/or water to detainee. See Refusal to Accept Food or Water/Fluids As Medical Treatment, Enclosure (I).

2. Document and execute follow up plan . J. Other:

Medical Provider: -------------------

UNCLASSIFIED//FOR PUBLIC RELEASE Enclosure (2)



trr<CLAB~fflf:Dff'ObO STANDARD OPERATING PROCEDURE: SOP: JTF-JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 1J of24

Detainee ISN ###

Comments

(lbs} dizzy. nausea. constipation. diarmea. abd pain.

unable to pass tube

coherent. alert oriented, verbal.

Sign~ture At1eoding Physician

U"'\CL~=\SSIFIEB/FOUO Enclosure (3)




l r"" 'FL " "'' I fl EB 'FOFO :\ :--t .. j ._ i - ) ST A.i~DARD OPERATING PROCEDURE: SOP: JTf-JMG # 001 MEDICAL MANAGEMENT Of DETAINEES WITH WEIGHT LOSS Page 12 of24

DETAlNEE 'S IDENTIFICATION NUMBER: CHRONOLOGICAL RECORD OF MEDICAL CARE

MEDICAL RECORD STANDARD FORM 600 (rev. 9/0.5)

UNCLA:5SI fff:B/P(lt 0 Enclosure (4)




U~~ C LAS~IF It! FJfFO F~O STANDARD OPERATING PROCEDURE: SOP: JTF-JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS Page 13 of24

Clinical Guidelines for the Evaluation, Resuscitation, and Feeding of Detainees with Weight Loss

***Note: These are only Guidelines. Clinical presentation of the patient will determine the individualized patient plan of care prescribed by the Credentialed

Medical Provider! ***

Once a detainee with weight loss meets the criteria for enteral feeding, the following protocol may be initiated. If clinically indicated, after initial IV fluid resuscitation, the SMO may initiate intennittent or continuous enteral feedin of the detainee. In the event of multi detainees with

I.

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Management of Common Electrolyte Deficiencies

Hypokalemia - Replace potassium with KCL elixir/tablets, I 0 milliequivalents for every 0.1 mEq/L below the normal value of 4.0 in the detainee's serum. for example, if a detainee has a senun potassium of 3.4 mEq!L, 60 milliequivalents of KCL elixir/tablets should be ordered.

Hypomagnesaemia- Replace with magnesium oxide. Crush four 400 mg tablets (approximately 960 mg of bioavailable magnesium) and mix in water before adding to entera.l solution. Continue daily until normal serum Mg++ level is cont1rrned by lab draw. Oral magnesium may cause diarrhea. Alternatively for severe hypomagnesaemia, 1-2 grams of magnesium sulfate may be infused intravenously over 30 minutes.

Hypopllospllatemia -Replace with 4 packets of K -phos daily (total of 1000 mg of phosphorus, 1112 mg of potassium, and 656 mg of sodium daily) until normal serum phosphorus level is confirmed by lab draw. Alternatively, for severe hypophosphatemia, 15 mmol of sodium phosphate mixed in 250 ml of Y2 NS may be given over 4-6 hours. Usually, this is repeated for a total of 4-8 doses.

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Nursing Staff Clinical Procedure Checklist for Intermittent Enteral Feeding of Detainees with Weight Loss

NOTE: IF THE RN OR HM FEELS THEY ARE IN ANY DANGER OF PERSONAL HARM DURING AN ENTERAL FEED, THEY ARE TO WITHDRAW FROM THE SITUATION AND IMMEDIATELY INFORM THE GUARDS OF THEIR CONCERNS.

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UNCLASSIFIED//FOR PUBLIC RELEASE E. , EL t '"("' I Fl ~ B 'F'Ot 0 N Jt .. i.:i ~ I

STANDARD OPERATING PROCEDURE: SOP: JTF-JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WITH WEIGHT LOSS p 21 f24 age 0

ENTERAL FEED NURSING NOTE

ISN: I I AM/PM I I Date: I Detainee placed in restraints/restraint chair by guard staff for enteral feeding procedure.

INITIAL ASSESSMENTNITAL SIGNS

n Detainee required Forced Cell Extraction to restraint chair/gurney or 0 Detainee ambulated to feed chair/gumey. Detainee placed in cbair/gurney at

n Detainee refused vital signs (For long~tenn fasters Qnly) 0 Vital Signs: T HR RR BP 02 sat % Weight 0 Pulses WNL x 4 0 Detainee denies nausea/vomiting 0 Detainee denies pain ~- J Other

PROCEDURE NOTE: INSERTION OF FEEDING TUBE

Ci Enteral Feeding Time Out performed with two Feed Team members. Using: 0 olive oil D2% viscous lidocaine 0 sterile lubricant, an 08Fr CJ IOFr enteral feeding tube was inserted in the

0 Right 0 Left nostril using standard nursing procedure. r Placement in stomach was confirmed by air auscultation by 2 JMG staff(at least I RN) and test dose with IOml water. Type of Nutritional solution: :=J Pulmocare C Ensure 0 other amount: ml -Additives: OWater ml O MgO __ mg dfhiamine __ mg OK-Phos __ mg cMultivitamin X --tab Other:

ASSESSMENT DURING ENTERAL FEEDING

Enteral feeding initiated at Circulation assessed using at least one of the following every 15 minutes while r~straioed: 0 No skin discoloration noted C iNo edema noted C Pulse Rate/Rhythm WNL ::JCapillary Refill Time <3 seconds Complaints/ Complications during feed: ::::1 None 0 Otber

POST ENTERAL FEEDING ASSESSMENT

Enteral Feeding completed and Enteral Feeding Tube removed at Detainee's condition post enteral feed: C Detainee denies pain :J Detainee denies nausea/vomiting =:! No Injury/complaint noted. c Injury/complaint noted. Describe:

Physician notified (if applicable): Name: Time:

Restraints released at and detainee released Co guard staff

=.! Detainee required Forced Cell Extraction back to cell OR 0 Detainee ambulated back to ceiL HM/RN note:

HM signature: Dateffime:

RN signature: Dateffime:

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r l~CL/t~SIFIEU/ttQt ' f) STANDARD OPERATING PROCEDURE: SOP: JTF-JMG # 001 MEDlCAL MANAGEMENT OF DET ArNEES WITH WEIGHT LOSS Page 22 of 24

MEDICAL EQUATIONS, CALCULATIONS AND WEIGHT FORMULAS

Determination of Energy Requirements: TOTAL CALORlE PER KILOGRAM METHOD

Classification Kcal/kg Morbid obesity 20 Starvation, Ventilated, Intensive Care Unit 25 Ambulatory Maintenance 25-35 Malnutrition/ Moderate Stress 30-35 Severe Injuries/ Stress 35-45

HARRIS -BENEDICT EQUATION:

Men (kcal/day) = [66.47 + ( 13.75 x weight (kg))+ (5 x height (em))- (6.76 x age)) x activity factor x stress factor

ActMIJ o.m,titl Chair or bed bound Seated work with little movement Seated work with little strenuous leisure activity Standing work Strenuous work or highly active leisure activity 30 - 60 minutes strenuous leisure activity 4 - 5 times/week

"* 1.2 x AEE 1.4 - l.5x BEE 1.6 - 1.7 X BEE

1.8- 1.9 x BEE 2-2.4 x BEE

2.3-2.7 x BEE

~ Elective surgery Multiple trauma Severe infection

Peritonitis Multiple/long bone fractures Infection ll'.itlt trauma

Sepsis Closed bead injury Cancer Bums Fever

Determination of Protein Requirements:

Condition Grams/kg/day Renal Failure/Dysfunction 0.6 - 0.8 l40gram min}_

Dialysis Patients (moderate stress) 1 -1.2 Dialysis Patients (high stress) Sepsis 1.2-1 .5 Liver Failure/Cirrhosis Re-feeding Syndrome

i Multiple trauma 1.3-1 .7

Catabolism 12-2 Post-op 1- 1.5

...... 1-l.lxBEE 1.4 x BEE 1.2- 1.6 X BEE

1.05- l.25x BEE 1.1 - 1.3 X Bt::E

1.3 - 1.55 x BEE

1.2 - 1.4 X BEE 1.3 xBEE 1.1-1.45 x BEE 1.5-2.1 x BEE 1.2 x BEt (per I"C >37"C)



UNCLASSIFIED//FOR PUBLIC RELEASE l ~ ( t . '~" lf'lt:IJ 'f70l'() \ A .. 9 ~'5 3 I - I

STANDARD OPERATfNG PROCEDURE: SOP: JTF-JMG # 001 MEDICAL MANAGEMENT OF DETAINEES WlTH WEIGHT LOSS Page 23 of24 Determination of Fluid Requirements:

111 10 kg 211<1 10 kg Each kg >20 kg

Method 2 -Age

Frwe Water RequiNntent 100 mUkg 50 mUkg 20 mUkg (.550 years} 15 mUkg (>50 years)

Young Athletic Adult 40 mUkg Most Adults 35 mUkg Elderly Adults 30 mUkg Method 3 -Energy Expenditure 1 mUkcal energy expenditure

Sources: I. Gouschlich, M, et al. The Science and Practice of Nulrition Support: A Case-Based Core Curriculum. Iowa: Kendall/Hun! Publishing Company: 2001. 2. Grant A and DeHoag S. Nutrition Assessment and Support. 4th ed., Seante: Northgatc Station: 1991. 3. Klein S el al; Nutrition Support in Clinical Practice: Review o_{Published Data and Recommendations for Fulure Research Direction. JPEN. 21:133-155, 1997. 4. Shikora S, et al. Nulritiona/ Considerations in the Intensive Care Unit. Iowa: KendaH/Hunt Publishing Company: 2002. 5. Shronts EP ed. Nun·(tjon Supporl Dietetics Core Curriculum, 2nd ed. Rocl<:ville, MD: American Society of P~nteral and Enteral Nutrition: I 993. 6. Skipper A; Nutrition Support Policies. Procedures. Forms, and Formulas. Aspen Publishers, Inc. 1995. 7. The American Dieteti~ Association. Manual of Clinical Dietetics.ftflh edition. American Dietetic Association, Chicago., 1996. 8. Zaloga, GP. Nutrilion in Crilical Care. St. Louis: Mosby: 1999



UNCLASSIFIED//FOR PUBLIC RELEASE t PcCL .. 't9LJifiEfJ/ft)r,o

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{£ 1)-.c i 5

Date

arne Required: Yes 0No Deputy Commander, Joint Medical Group Date

I ----------------~----~~--~~--Signature/ Printed Name Required: D Yes 0No Senior Medical Officer Date

----------------~~------==---==------Signature/ Printed Name Required: D Yes 0 No Senior Nurse Executive Date

----------------~~------==---==------Signature/ Printed Name Required: D Yes 0 No Director For Administration Date

-------------------~------==---==------Signature/ Printed Name Required: OY es 0No Medical Planner Date

----------------~~------==---==------Signature/ Printed Name Required: DYes 0No Senior Enlisted Leader Date

------~----~--~~------==---==------SignattUe/ Printed Name Required: DYes 0No Director, Behavioral Health Services Date

REVIEW LOG: Directorate Reviewer: Sig :. _________________________________ Date :. ________ _ Sig: Date: ________ _ Si : Date: P SUPERCEDED/ CANCELLED THIS DATE:

----------------~~-------------------Signature/ Printed Name Commander, Joint Medical Grou Date



Exhibit F


1

DECLARATION OF CORI CRIDER

I, CORI CRIDER, DECLARE UNDER 28 U.S.C. §1746:

1. I am a member of the bar of the State of New York. I am Strategic Director of

the London-based charity Reprieve and have been visiting clients in Guantánamo since June

2007. Petitioner Imad Abdullah Hassan (ISN 680) is my client. I also represent Ahmed

Belbacha (ISN 290), Shaker Aamer (ISN 239), and Nabil Hadjarab (ISN 238) who were

petitioners in a motion for an injunction in Aamer v. Obama, ___ F.3d ___, 2014 WL

519238 (D.C. Cir. Feb. 11, 2014).

Reason for declaration from counsel

2. I make this Declaration because hunger-striking detainees have in the past

been deprived of the ability to participate in communal prayer during the Islamic holy month

of Ramadan. This happened in 2013. Unless the Court intervenes to prevent this surely will

happen again this year, when Ramadan begins around June 28.

3. In 2013 multiple Reprieve clients (some who were hunger-striking, and some

who were not) reported that hunger-striking prisoners were not allowed to pray communally..

4. One of my clients, Younous Chekkouri, ISN 197, a Moroccan who, like the

Petitioner, is cleared for release informed me in a conversation on July 18, 2013, that he had

been hunger-striking, but indicated that because of the threats to move him into isolation he

had dropped out.

5. He stated that on the previous Thursday [this would have been July 11, 2013]

the AOIC had come to the block and called his ISN and 5 others and said: ‘either you stop

your strike or we will put you back in isolation.’ “There was no third option. I thought about

it…My sickness, my morale, Ramadan, it was all very low…They were threatening to move


2

us to a punishment block for hunger strikers. And if you are on ‘punishment’, it takes months

for your ‘level’ to get back up to compliant. It was like blackmail: nobody would want to be

isolated, especially during Ramadan. Communal prayers are our tradition in Ramadan.”

6. He also stated, “We are tired, you know? I’m tired, I’m really sick. I can’t

bear my sickness anymore. Spending Ramadan alone on top of this was too much to take.”

7. Finally, he stated, “My feeling is that they blackmailed me into taking food.”

Done in London, England, this 7th day of March, 2014.

______________________________________ Cori Crider


1



Civ. No. 05-1607 (RCL)

[PROPOSED] ORDER

The Court, having fully considered Petitioner Mohammad Ahmad Ghulam Rabbani’s

Application for Preliminary Injunction and all supporting documents and the record in this matter,

hereby ORDERS that Petitioner’s Application for Preliminary Injunction is GRANTED.

IT IS FURTHER ORDERED THAT

1. Respondents are enjoined from performing wrongful and gratuitously painful

practices in the force-feeding of any detainee at Guantánamo Bay, including but not limited to (a)

unnecessary forcible and violent removal of detainees to the force-feeding location, (b)

unnecessary and degrading genital searches, (c) unnecessary use of restraint chairs, (d)

unnecessary insistence on force-feedings twice per day, (e) insertion and withdrawal of feeding

tubes twice each day, (f) use of unnecessarily thick feeding tubes, (g) use of a dangerous and

unreliable method to determine placement of feeding tubes, (h) unnecessarily rapid force-

feeding, including any form of force-feeding that resembles the “Water Cure” form of torture,


2

and (i) the use of over-feeding and anti-constipation medication to induce defecation during

force-feeding;

2. Respondents are enjoined from force-feeding any detainee at Guantánamo Bay unless

a physician determines that, as a result of hunger-striking, the detainee is actually facing an imminent

risk of death or great bodily injury;

3. The current Guantánamo Bay force-feeding protocols are declared invalid.

Respondents are directed to promulgate new protocols that conform to standards exemplified by the

U.S. Board of Prisons regulations;

4. Respondents shall allow all hunger-striking detainees at Guantánamo Bay, including

Petitioner, to perform the Islamic tarawih prayers communally during Ramadan in 2014; and,

5. Respondents shall disclose to Petitioner’s counsel the current standard operating procedure

that governs the use of restraint chairs in the force-feeding of Guantánamo Bay detainees, as well as

any other as-yet-undisclosed standard operating procedure on force-feeding.

IT IS SO ORDERED, this _____ day of _______, 2014.

________________________________ United States District Judge




Civ. No. 05-1607 (RCL)

NOTICE OF FILING

Please take notice that on March 27, 2014, counsel for Petitioner Mohammad Ahmad

Ghulam Rabbani (known as Ahmad Rabbani) filed a Supplemental Memorandum In Support of

Motion For Preliminary Injunction with Exhibits G and H pursuant to the terms of the September

11, 2008 Protective Order and Procedures for Counsel Access to Detainees at the United States

Naval Base in Guantánamo Bay. The Supplemental Memorandum and attached exhibits contain

material that the Government has purported to designate as Protected Information pursuant to the

Protective Order. Petitioner objects to that designation and thus anticipates that Government

counsel will file a motion with this Court, as required by the Protective Order, for designation as

protected information.

Respectfully submitted,

/s/ Jon B. Eisenberg



2

/s/ Alka Pradhan REPRIEVE Clive Stafford Smith (LA Bar #14444) Cori Crider (NY Bar #4525721) Alka Pradhan (D.C. Bar #1004387) P.O. Box 72054 London EC3P 3BZ United Kingdom 011 44 207 553 8140 [email protected] [email protected] [email protected]






Civ. No. 05-1607 (RCL)

NOTICE OF ERRATA

On March, 27, 2014, Petitioner Mohammad Ahmad Ghulam Rabbani filed an

Application for Preliminary Injunction with a Statement of Points and Authorities in Support of

Petitioner’s Application for Preliminary Injunction (Dkt. # 306-1).

Minor typographical errors have been discovered in the Statement of Points and

authorities, which counsel wish to correct. Accordingly, counsel for Petitioner hereby submit a

corrected version of the Statement of Points and Authorities In Support of Petitioner’s

Application for Preliminary Injunction.




2

/s/ Cori Crider REPRIEVE Clive Stafford Smith (LA Bar #14444) Cori Crider (NY Bar #4525721) Alka Pradhan (D.C. Bar #1004387) P.O. Box 72054 London EC3P 3BZ United Kingdom 011 44 207 553 8140 [email protected] [email protected] [email protected]




Documents

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT …...Petitioner Mohammad Ahmad Ghulam Rabbani (known as Ahmad Rabbani), by and through undersigned counsel, and pursuant to Fed