34.1

Care of Enemy Prisoners of War/Internees

Chapter 34

Care of Enemy

Prisoners of War/Internees

Introduction

Healthcare personnel of the Armed Forces of the United States

have a responsibility to protect and treat, in the context of a

professional treatment relationship and universal principles of

medical ethics, all detainees in the custody of the Armed Forces.

This includes enemy prisoners of war, retained personnel,

civilian internees, and other detainees. For the purposes of this

chapter, all such personnel are referred to as internees.

It is the policy of the Department of Defense that healthcare

personnel of the Armed Forces and the Department of Defense

should make every effort to comply with “Principles of Medical

Ethics Relevant to the Role of Health Personnel, Particularly

Physicians, in the Protection of Prisoners and Detainees Against

Torture and Other Cruel, Inhuman or Degrading Treatment or

Punishment,” adopted by United Nations General Assembly

Resolution 37/194 of 18 December 1982 (and provided as

Appendix 1 to this book). This is in addition to compliance with

all applicable DoD issuances.

The Geneva Conventions

 Define medical personnel as those individuals “exclusively

engaged in the search for, or the collection, transport, or

treatment of the wounded or sick, or in the prevention of

disease; and staff exclusively engaged in the administration

of medical units and establishments” (Geneva Convention

for the Amelioration of the Wounded and Sick in Armed

Forces in the Field [GWS]).
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 Medical personnel of enemy forces are not considered

internees, but are classified as “retained” in order to treat

other EPWs. Internees are also entitled to the protections

afforded under the provisions of the Geneva Convention

Relative to the Treatment of Prisoners of War (GPW).

Detained persons who are not protected under GWS and

GPW, may be protected under the provisions of the Geneva

Convention Relative to the Protection of Civilian Persons in

Time of War (GC).

The GWS states that belligerents must care for the sick and

wounded without any adverse distinction founded on sex,

race, nationality, religion, political opinions, or any other

similar criteria. Only medical urgency can justify priority

in the order of treatment.

EPW/Retained/Detained Medical Care (Internees)

Workload

The number of internees and retained/detained personnel

requiring medical in-processing and/or medical care can be

staggering. The US captured approximately 425,000 prisoners

in WW II and 105,000 in the Korean conflict. Coalition forces

captured over 62,000 internees during Operation Desert Storm.

During the 1-week ground war, 308 internees were treated by

US military medical treatment facilities (MTFs). From the end

of the ground war (28 February 1991) until the end of March

1991, 8,979 internees were treated.

 Fragment wounds accounted for 44% of the surgical

admissions during the ground war.

 23% of surgical admissions required treatment for fractures.

 Surgical intervention was required in 28% of Iraqi casualties

admitted.

 Most common operative procedures included

ο Wound debridement.

ο Open reduction and internal fixation of fractures.

ο Exploratory laparotomies.

ο Incision and drainage of abscesses.
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Care of Enemy Prisoners of War/Internees

 The most common internee medical condition reported

during Operation Desert Storm was dental disease (24%) such

as periodontal infections, fractures, and extensive caries.

Other common medical illnesses were unexplained fever,

nephrolithiasis, peptic ulcer disease, and malaria.

Wounds in internees may be different than those seen in

friendly forces due to differences in personal protective

gear, preexisting diseases, malnutrition, and neglect.

Medical Care of Internees

 What healthcare providers should do.

ο No matter the setting, healthcare providers have a

responsibility to report information, the consequences of

which constitute a clear and imminent threat to the lives

and welfare of others. Information gained from patients

who are internees should be treated no differently.

ο As given below, healthcare providers have specific

responsibilities for the care and treatment of internees. The

overarching principle of this guideline, however, is that

internees of any status should whenever possible receive

medical care equal to that of our own troops.

♦ As one would expect for our own troops, physicians

should report any suspected abuse or maltreatment of

a detainee or prisoner.

♦ Just as one would write a profile or duty limitation for

one of his own service members, physicians have a

responsibility to inform the detention facility chain of

command of internees’ activity limitations. This

includes “clearing the prisoner for interrogation,” with

the expectation that interrogation will conform to the

standards of AR 190-8. Medical recommendations

concerning internee activities are exactly that—

recommendations. Decisions concerning internee

activities are made by the chain of command.

ο Healthcare providers should be trained in the tenets of the

Geneva Conventions of 1949 and other documents and

principles of internee care. They should also be trained to
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Emergency War Surgery

recognize the symptoms and signs of internee

maltreatment or abuse.

 What healthcare providers should not do.

ο Healthcare professionals charged with any form of

assistance with the interrogation process, to include

interpretation of medical records and information, should

not be involved in any aspect of internee healthcare.

ο Healthcare providers charged with the care of internees

should not engage in any activities that jeopardize their

protected status under the Geneva Conventions.

ο Healthcare providers charged with the care of internees

should not be actively involved in interrogation, advise

interrogators how to conduct interrogations, or interpret

individual medical records/medical data for the purposes

of interrogation or intelligence gathering.

 Recusal. Healthcare providers who are asked to perform

duties they feel are unethical should ask to be recused.

Requests for recusal should first go to the healthcare

provider’s commander and chain of command. If the chain

of command is unable to resolve the situation, providers

should engage the technical chain by contacting the

Command Surgeon. If these avenues are unfruitful, healthcare

providers may contact their specialty consultants or the

Inspector General.

 Specific medical requirements. Medical requirements for

internee care are provided in AR 190-8/OPNAVINST 3461.6/

AFJI 31-40/MCO 3461.1. Internees are entitled to medical

treatment. Each must have an examination on arrival at the

detention facility, as well as a chest radiograph (tuberculin

skin test for children up to age 14 years). Sick call must be

available daily, and each internee must be weighed at least

once a month. Sanitation and hygiene must be maintained at

all times (AR 190-8, para 3-4 i.).

 Medical records.

o Internee medical records, like the medical records of all

Service members, retirees, and their dependents are

property of the US Government. Internees are entitled to

copies of their medical records upon their release. The

original records; however, remain the property of the
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Care of Enemy Prisoners of War/Internees

United States. Entries should be made into internee

medical records as they would for any other patients.

ο The Health Insurance Portability and Accountability Act

does not apply to the medical records of internees (DoD

6025 C5.1, C7.10, C7.11). However, the handling,

disposition, and release of all types of medical records is

governed by regulation. Commanders and other officials

who have an official need to know can access information

contained in internee medical records by following the

procedures given in AR 40-66, Chapter 2 using DA Form

4254. Patient consent is not required. Receiving MTFs file

and maintain all DA Form 4254s. The MTF commander or

commander’s designee, usually the patient administrator,

determines what information is appropriate for release.

Only that specific medical information or medical record

required to satisfy the terms of a legitimate request will be

authorized for disclosure. Healthcare providers should

expect that released medical information will be used by

the chain of command, to include interrogators, in

accordance with Medical Information, which follows.

 Medical information.

ο Because the chain of command is ultimately responsible

for the care and treatment of internees, the detention

facility chain of command requires some medical

information. For example, patients suspected of having

infectious diseases such as tuberculosis should be

separated from other internees. Guards and other

personnel who come into contact with such patients should

be informed about their health risks and how to mitigate

those risks.

ο Releasable medical information on internees includes that

which is necessary to supervise the general state of health,

nutrition, and cleanliness of internees, and to detect

contagious diseases. Such information should be used to

provide healthcare; to ensure health and safety of internees,

soldiers, employees, or others at the facility; to ensure law

enforcement on the premises; and ensure the

administration and maintenance of the safety, security, and

good order of the facility. Under these provisions,
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Emergency War Surgery

healthcare providers can confirm that an internee is healthy

enough to work or perform camp duties.

 Reporting.

ο The chain of command is the first and foremost channel

for information and reporting. Healthcare providers

should report routine medical information, clear and

imminent threats, suspicions of abuse or maltreatment, and

any other relevant information to their commanders or

their commanders’ designees. If the healthcare provider

is not assigned to the detention facility, mechanisms must

be in place to also inform the detention facility chain of

command.

ο Alternative means of reporting exist for healthcare

providers who are unable to resolve issues through the

chain of command. The technical chain is the first

alternative, and begins with the Command Surgeon

responsible for medical oversight of the provider’s

activities. Other alternatives include the provider’s

specialty consultant, the Inspector General, and Criminal

Investigations.

Setup/Planning

 Develop plans for prisoners on a hunger strike or who refuse

treatment.

 Prisoners from separate armies should be housed apart—this

is the responsibility of the internment camp commander.

 Care should be exercised in the selection of medical personnel

to serve in internee facilities.

 Enemy forces may do little or no medical screening prior to

conscription. Chronic medical problems will be more likely

in these forces. Enemy forces may have preexisting diseases

that are not present in the AO or US forces. Planning for

appropriate medications may be required.

 Maintain medical records for internees in the same manner

as for friendly forces.

 Ensure that any internee/retained/detained person

evacuated to the MTF for treatment is escorted by an armed

guard as designated by the nonmedical (echelon) commander.

The guard must remain with the patient while in the medical
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Care of Enemy Prisoners of War/Internees

evacuation and treatment chain. To the greatest extent

possible, keep all internees segregated from friendly forces’

patients; but treat all enemy patients with the same level

of care as provided to friendly forces’ patients.

 An internee identification number must be secured for any

internee evacuated through medical channels. This is

accomplished by reporting the patient to the theater

Prisoner of War Information System (PWIS). Medical

personnel do not search, guard, or interrogate internees

while in medical channels; this is the responsibility of the

echelon commander.

 Internees are housed in internment facilities that are

established, maintained, and guarded by forces designated

by the echelon commander. Medical personnel are not

involved in the daily operations of these facilities.

However, these facilities normally have a medical staff

embedded in the organization to accomplish medical

examinations and to conduct routine sick call and

preventive medicine activities. Control procedures (guards,

physical layout, and precautionary procedures) are regulated

by the facility commander. If a patient must be transferred to

an established MTF for specialized care, transfer procedures

and guards are governed by the facility commander.

 In a mature theater (such as during WW II and the Gulf War

of 1991 [Desert Storm]), there are often sufficient internee

patients to warrant the designation of a specific hospital for

their exclusive care. In this case, coordination between the

senior command and control headquarters, and the senior

medical command and control headquarters is required to

provide security, establish prisoner-control procedures, and

regulate other nonmedical matters involved in establishing

and administering a medical facility specifically for internees.

The standard of care for this facility is required to be the same

standard of care as practiced in other deployed hospitals.

It is critical that medical personnel not enter the general

EPW holding area, but have patients brought out to them

for sick call and any medical treatment.
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Interpreters—Always a Shortage

 Internees may not know any other language but their own.

 NATO STANAG 2131, Multinational Phrase Book for Use by

the NATO Medical Services - AMedP-5(B) provides basic

medical questions in a number of NATO languages,

published as DA Pam 40-3/NAVMED P-5104/AFP 160-28.

 Use other retained persons/internees (especially medical

personnel) as translators.

 Simulation of mental illness by EPWs is a potential technique

for evading interrogation, especially if combined with a

captured interpreter.

Screening

 Ensure internees are screened for hidden weapons and other

potentially dangerous materials. This is not a medical

function; it should be accomplished by the guards. Medical

personnel, however, must remain vigilant of these threats

and mentally prepared should a threat or attack occur.

 Each prisoner who comes into the facility must receive a

complete physical examination including a dental

examination. Vital statistics are recorded for each internee

treated. Essential care should be given at this point. Other

follow-up evaluations are dependent on the baseline health

of the combatant population.

 During internment, routine sick call is provided on a daily

basis; this includes medication dispensing, wound care, and

indicated minor procedures.

 During transfer, release, and/or repatriation, another medical

examination should be performed. Final documentation of

any ongoing medical, surgical, or wound care problem is

completed and forwarded to the gaining facility or to the

appropriate medical records repository.

Supply

 The internment facility must enforce field hygiene and

sanitation principles.

 Plan for personal hygiene requirements and protective

measures (insect netting, insect repellent, sunscreen).
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Care of Enemy Prisoners of War/Internees

 Coordinate with the supporting medical HQ for additional

Preventive Medicine support (pest management, potable

water, dining facility sanitation, and waste disposal) and

Veterinary Services support for food safety as required.

 For medicolegal purposes, a high-quality camera is

important.

Medical Staffing

 Dictated by the organizational structure of the facility. The

same standard of care as that provided to US forces must be

maintained.

 Retained medical personnel should be utilized for care of their

compatriots in conformity with the Geneva Conventions.

Legal

 If possible, signed permission should be obtained for all

surgical or invasive procedures.

 In contrast to civilian medical photography, the patient’s

identity should be absolutely clear in each photograph.

This is invaluable should there be a claim of unnecessary

surgery or amputation. With clearly identifiable

photographs, the state of the wound for that patient can

be demonstrated.

Any patient who requires amputation or major

debridement of tissue should be photographed (face as well

as wound images).

Internee Advocate

 The military physician is the commander’s advisor for

medical ethics. The physician should be alert for potential

and actual ethical conflicts, and exert all efforts to remedy

any perceived conflicts. As the patient’s advocate (in this

case, the captured enemy soldier), the military physician and

all military healthcare providers must maintain the patient’s

health. They must also strive to maintain a “moral distance”

from participating in any proceeding potentially adverse to

the patient’s interest.
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Security

 There is always an element of danger to the medical staff in

treating internees.

 Physical security will be provided by nonmedical personnel

as designated by the appropriate leadership.

 The security routine must be maintained at all times. Security

personnel must accompany all internees whenever they are

in a treatment area or holding area. In forward areas, it may

not be possible to have separate and secure medical

treatment/holding areas for internees. The limited size and

compact layout of Level I and II MTFs and the forward

surgical team normally necessitate that internees are treated

and held in close proximity. To the extent possible, internees

should be segregated from allied, coalition, and US forces.

 If possible, medical equipment should not be taken into the

patient wards for security reasons—ie, bring the patient to

the equipment.

 If an EPW is to be discharged back to the general EPW

population, the physician should alert internment medical

personnel of any special needs the internee may have.

Personal safety should never be taken for granted by the

medical team, regardless of familiarity with internees and

surroundings.