12 May 2014
Since the outbreak of pro-reform protests in Bahrain in early 2011 security forces have deployed an unprecedented amount of tear gas resulting in the deaths of numerous individuals.

This torrent has also revealed a genetic component to Bahrain’s political unrest through a record spike in sickle cell deaths – a condition that predominantly affects the marginalised Shia population.

The Bahrain Independent Commission of Inquiry (BICI), set up to consider human rights violations following the Government’s crackdown, concluded that Bahrain’s police used a disproportionate amount of CS gas in the urban spaces of this community. It found that private homes were targeted in an “unnecessary and indiscriminate” manner (video) citing examples of gassing in small villages where the authorities simultaneously blocked escape routes (p277). Physicians for Human Rights recently noted how this “extensive, persistent, and disproportionate” use of tear gas continues. It was against this backdrop that doctors observed nearly a three-fold rise in deaths from sickle cell disease compared to pre-2011 levels. While a definitive clinical link between tear gas and sickle cell deaths remains disputed the practices mobilised around the disease raise important questions from a human rights perspective.

Sickle cell anaemia is an inherited blood disorder whose prevalence is higher in African, Caribbean, Indian and Arab populations, primarily due to the adaptive advantage of carriers (sickle cell trait) in areas afflicted by malaria. The dominant symptoms are painful “crises” arising from blood vessels becoming blocked by sickle shaped red blood cells. Crises can be triggered by a number of causes, including dehydration, stress and a lack of oxygen (hypoxia). Untreated these episodes can cause organ failure, strokes and, in some cases, it can be fatal. Pain management through the administration of pain relief is seen as key to managing and controlling these sickle cell crises.

Bahrain’s authorities have frequently attributed custodial deaths of political activists as the result of sickle cell disease. Invariably these accounts are disputed by both families and human rights groups who alleged mistreatment or lack of adequate care. As Bahrain is off-limits to independent organisations capable of verifying sickle cell deaths the official reports can still be examined and compared with those from independent media and local civil society groups.

Many deaths the authorities have attributed to sickle cell disease involve detainees who have not been exposed to tear gas as was the case of Hasan Jassim Mohamed Maki (39). An investigation by the BICI in 2012 concluded his death was a consequence of torture (p242). In February 2014 another detainee Jaffar Al Durazi’s (23) died in hospital. Within 18 hours the public prosecutor announced his death was “natural away from any criminal suspicion”, a result of complications from sickle cell disease. At the same time the Bahrain Centre for Human Rights, while not disputing Mr. Al Durazi’s sickle cell status, alleged he died after being severely tortured over a prolonged period. Another sufferer of sickle cell disease, Mohamed Ibrahim Yaqoob, reportedly died of “natural causes” related to his condition at Salmaniya Medical Complex. The BBC later reported photographic evidence of cuts and bruises on his body.

The conflict between these reports suggest that sickle cell disease is deployed as a catch-all explanation disguising the mistreatment of detainees. In the case of Sayyed Jawad Ahmed (20) the Government attributed his death entirely to his sickle cell condition. This account failed to mention that his difficulties arose following his participation in a protest confronted by security forces. According to human rights groups he died from complications following the inhalation of tear gas. More importantly his family denied he even suffered from sickle cell disease. Likewise Human Rights Watch reported that torture victim Mr. Maki (see above) was merely a carrier of the disease and had never displayed symptoms.

The potential for disguising causes of deaths by reference to sickle cell disease would not be unique to Bahrain. Through migration and the legacy of slavery sickle cell disease is somewhat prevalent in the US and Europe. Dyson and Boswell’s study of unexplained deaths over a 30 year period in US and UK custody found sickle cell disease was frequently suggested as a cause of death despite overlapping with forceful restrains, beatings and pepper spraying all of which can induce hypoxia, a trigger for the disease. Attributing deaths to the disease, they suggested, helped to avoid the need to confront institutional racism and was a convenient way to deflect criticism.

Systematic triggers of the disease?

It has been suggested by a leading expert on sickle cell disease that exposure to tear gas could trigger severe problems for a sickle cell sufferer as it could cause hypoxia by restricting the supply of oxygen. The head of the Bahrain Society for Sickle Cell Anaemia Patient Care dismissed the role of tear gas as sickle cell victims “did not fall on the road and die” and put the increase in deaths down to patients not getting “the right care at the right time”. However suffers do not necessarily die instantly and the first 24 hours are considered critical in the treatment of the disease.

With this in mind it is worth noting new guidelines published last year by the Ministry of Health recommending an eight hour gap in seeing a specialist and receiving an initial dose of pain relief. This and other changes have been criticised for contributing to overall poor outcomes for patients. The Government rationale is they do not want “a section of population becoming addicts”. Other health officials have gone further, using language likely to stigmatise sufferers, by alleging that sickle cell patients have been “caught trafficking drugs and sleeping pills, inappropriately behaving with women and injecting themselves with illegally procured painkillers”.

Further delays in the delivery of pain relief and care is the continuing practice by security forces of interrogating and arresting patients who display tear gas symptoms. Doctor also face dilemmas as to how they treat and report injured protesters – in 2011 numerous doctors were imprisoned and tortured, for treating protesters. This includes Dr. Ali Al-Ekri who remains imprisoned after giving prominent interviews on civilian deaths and the effects of tear gas (video). Those doctors who remain employed have been compelled by orders of the health authorities to report potential protesters and risk losing their jobs if they deviate from official guidance.

Sickle cell deaths, it can be argued, provide a window into broader human rights issues impacting Bahrain’s medical and social fabric that also have implications for medical neutrality. What the conflict between various media reports point to is a convergence of multiple factors – legal, ethical and political which are creating system of hypoxia that is increasing sickle cell deaths. If this is the case sickle cell deaths are merely revealing a set of practices inflicting stress, breathing difficulties, delays, neglect and physical abuse. In other words tear gas is just one of many factors contributing to these fatalities. As Bahrain attempts to convince the international community about its commitment to reform it may have to focus attention on these systematic triggers of sickle cell crises. From an Irish perspective the suitability of Bahrain’s hospitals for the clinical training of students will soon be examined by the Irish Medical Council when they visit the Kingdom later this year. The Royal College of Surgeons in Ireland (RCSI) operate a satellite campus in Bahrain and concerns over the suitability of local facilities and the treatment of staff are being raised at national level.

Image by Lewa'a Alnasr (http://www.feb14mg.com/details.php?image_id=1915) [CC BY-SA 3.0], via Wikimedia Commons