Personal View: Diagnosing Pinochet syndrome
Authors: Mary E Black
Journal: BMJ (2006)

It is time that Pinochet syndrome entered the medical lexicon. The triad of defining features is (1) ill health, which is (2) cited as a reason to delay or stop extradition and judicial investigations into crimes against humanity by (3) a deposed or former national leader. All reported cases so far have been in men, mostly elderly.

Pinochet syndrome was originally coined by the New York Times in 1999 to describe a new malady stalking the presidential palaces and bunkers of the world. In the international human rights lexicon it has mutated into the “Pinochet precedent,” after a Spanish judge was able to have Augusto Pinochet, the Chilean dictator from 1973 to 1990, arrested while in London for medical care. Since then an increasing number of successful legal actions against former dictators has occurred. The charity Human Rights Watch notes that this shows how far we have come from the days when despots could terrorise their own populations, secure in the knowledge that at worst they would face a tranquil exile.


Improvement in the patient usually signals that his political clout is finally weakening


Pinochet demonstrated all the syndrome's symptoms perfectly. He had used the defence of mental illness and dementia successfully for seven years since the age of 82 to avoid standing trial in Chile to face allegations of human rights violations committed during his 17 year dictatorship. He was regularly hospitalised just before important court decisions concerning him. Pinochet had successfully used the mental illness argument to avoid extradition after his arrest for human rights violations while in London in 1999. Chile's judiciary has struggled for years to deal with Pinochet's appalling human rights legacy, and judicial rulings on his fitness to stand trial had flipflopped to either side. In July 2005 the Santiago Court of Appeal finally ruled that Pinochet was mentally competent to stand trial and ordered a criminal investigation into his role in the 1973 disappearance of two brothers in southern Chile, one of several cases pending against him.

The Serbian variant of the syndrome seems to be less virulent. Slobodan Milosevic was deposed in October 2000 after a NATO bombardment and an uprising of the country's citizens. Complaining of heart problems, he was transferred in early 2001 from prison to Belgrade's Military Hospital. His stay in hospital of a few days received close media attention, and on discharge he was sent back to jail. Milosevic was rapidly transported to the Hague in July 2001 to face the UN's International Criminal Tribunal of the Former Yugoslavia. “The trial,” he protested, “is bad for my blood pressure. My health situation has deteriorated, and it is the direct result of your refusal to enable me to get my health back.” Although his continuing health problems have led to delays, the wheels of justice are grinding on.

The deposed Iraqi leader Saddam Hussein exhibited Pinochet syndrome immediately on his arrest on 13 December 2003, eight months after the fall of his regime. Reports of cancer exacerbated by torture and abuse circulated but were not substantiated. He faced the challenge inherent in the Pinochet syndrome: turn up too obviously sick and you dilute the global media opportunities to shore up political support during a highly publicised trial.

The syndrome's differential diagnosis lies between genuine ill health and straight prevarication—which, confusingly, may coexist. The prognosis is deemed gloomy by the defence side and cautiously optimistic by the prosecution. Second medical opinions, usually international, are invariably sought. The elite clinics and hospitals of more than one country are engaged; former strongmen tolerate inferior health care for everyone but themselves. The delays to justice and the expense the process involves incense the dictators' victims, when they themselves live with the health and other consequences of abuse and oppression. The most effective contribution to resolving a case can be made by an independent medical and legal team that is immune to political or other influences. The team will usually face harassment and obstruction and may need police protection.

The outcome of Pinochet syndrome depends on the awfulness of the alleged crimes, the strength of the patient's remaining international and national influence, and media interest in the case. Improvement in the patient usually signals that his political clout is finally weakening. Confirmation of health sufficient for the patient to stand trial is an important indicator of the return to independence of a country's medical and legal professions.

Given the state of the world, advances in international mechanisms for pursuing human rights, and the decrease in summary executions of deposed presidents, the trend in cases of Pinochet syndrome is numerically upwards. If the medical and legal professions can develop more effective tools for managing it, the duration of symptoms in a case will, we hope, shorten.