Professional Documents
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EDITORIAL
Deprivation of food is one of, if not the oldest objective measures. Food deprivation is
method of punishment. Hunger and famine defined as a food intake below the dietary
are described in the Bible as a way of retri- required minimum energy level. There
bution when God was offended. There are are different ways to measure it, reviewed
accounts of the use of forced imposition of below. Food deprivation is often combined
hunger or starvation in places of detention with Food manipulation, a term referred to
and concentration camps worldwide. Sur- the quality, aspect, taste or contamina-
prisingly, however, the quantity and quality of tion of the food provided to an individual
academic research on the subject is unusually (DIGNITY, 2016).
low. (Rubin, 2019). It is neither mentioned 3. Starvation. Refers to a deficiency in
as a torture method in source handbooks caloric intake severe enough to be below
(i.e. Rejali, 2009) nor in the Istanbul Pro- the level needed to maintain an organism’s
tocol, which mentions it marginally con- life. While the purpose of a reduction in
cerning conditions of detention without any food supply can be to temporarily debili-
other mention or guidance within its pages tate the individual physically and psycho-
(UNHCR, 1999). In this Editorial, we would logically, in starvation, the purpose is to
like to update the medical and psychologi- produce unbearable pain and eventually,
cal research on the impacts of starvation as as a consequence, slow death.
a torture method and suggest some tentative 4. Malnutrition is the specific effect
conclusions and avenues for further research. of having a deficiency of one or more
essential nutritional components (ie.
1. Definitions and conceptual map thiamine deficit, iron deficiency produc-
ing anemia) without necessarily receiv-
1. Hunger. Refers to the subjective sensation ing an insufficient daily energy intake.
of wanting or needing food. Hunger is an
evolutionary adaptive signal essential for
T OR TU RE Vol u me 30 , N um b er 3 , 20 2 0
*) Editor-in-Chief.
Correspondence to: pauperez@runbox.com
https://doi.org/10.7146/torture.v30i3.123318
International Rehabilitation Council for Torture Victims. All rights reserved.
4
EDITORIAL
United Nations1, for a moderately active 70 ensure daily food provision for all family
kg individual (1.75 × BMR) between the ages members. The idea of food insecurity has
of 30 and 60, the daily energy requirement also been applied to monitoring detention
(or approximate Total Energy Expenditure centers. For instance, in a country-wide study
(TEE)) is 3000 kcal/day (44 kcal/kg/day) for in Malawian prisons, 95% of inmates consid-
men and 2500 kcal/ day (36 kcal/kg/day) for ered themselves food insecure (i.e. uncertain
women. The recommended WHO baseline that they could get enough food the following
protein delivery to avoid starvation in humans day). 61% of the prisoners reported feelings of
is ~ 0.75 g/kg/day. (FAO & WHO, 2005). anxiety over availability of food. Approximately
Based on the Minnesota study (see 22% of the prisoners stated they slept hungry
below), Wischmeyer, (2017) has suggested at night, 12% reported staying a whole day
that food-deprivation produces starvation and night without eating and 62% of the pris-
when intake is below 30 kcal/kg/day and 0.9 g oners used, they themselves believed, shame-
protein/kg/day. For an average 70 Kg person ful means of obtaining food, such as begging
this is 2100 calories2 and 36 gr. of proteins. or stealing from other inmates (Moloko et al.,
In monitoring visits to detention centers 2017). There are excellent reviews and pro-
or in the context of analyzing the use of mass posals of food insecurity measurements, from
starvation as a war weapon, an alternative short scales to complex multidimensional
measure is to estimate the percentage of in- measures (Coates et al., 2003; A. D. Jones et
dividuals with protein-energy malnutrition al., 2013; Leroy et al., 2015; Pérez-Escamilla
and, ideally, to perform a follow up after some & Segall-Corrêa, 2008).
months. For instance, a study of nutritional
status in a women’s prison in Anatinomora Legal definition and jurisprudence
(Madagascar) found that the proportion of At an individual level, Rule 22 of The Nelson
undernourished female prisoners was 38.4%, Mandela Rules establishes the duty to provide
including those who were pregnant and lactat- ‘food of nutritional value adequate for health
ing. Undernutrition was related to the intake and strength, of wholesome quality’. The Prin-
of two meals a day instead of three (p = 0.003), ciples and Best Practices on the Protection
insufficient energy intake (p < 0.001), incar- of Persons Deprived of Liberty in the Ameri-
ceration duration of more than 10 months (p cas of the Inter-American Commission on
< 0.001), absence of family visits (p = 0.013) Human Rights states (Principle XI) that:
and lack of financial assistance from family (p “Persons deprived of liberty shall have the right
= 0.013) (Ravaoarisoa et al., 2019). to food in such a quantity, quality, and hygienic
An alternative and useful measure when condition so as to ensure adequate and sufficient
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the nutritional status cannot be assessed is nutrition, with due consideration to their cultural
Food Insecurity, usually defined as those and religious concerns, as well as to any special
households where living conditions cannot needs or diet determined by medical criteria.
Such food shall be provided at regular intervals,
and its suspension or restriction as a disciplinary
measure shall be prohibited by law” (ICHR,
1 http://www.fao.org/docrep/007/y5686e/y5686e00.
htm#Contents
2008). Neither definition contains clarity on
2 The Minnesota study only included men, but what would be considered “adequate and suf-
lacking specific data, the value can be assumed ficient nutrition”.
for men and women.
5
EDITORIAL
It is beyond the scope of this medical review of food4 as ill-treatment or torture, especially
to analyze the legal precedents of food-depri- when combined with other methods (see foot-
vation as amounting to torture. Taking as a note for details).
reference a recent comprehensive preparatory
document for the Special Rapporteur Against
Torture (IHRLC, 2018) it can be suggested
U.N. Doc CCPR/C/110/D/1890/2009 (Apr. 23,
that there is some, although limited legal pre- 2014) (holding that the deprivation of “food and
cedence, notably in the jurisprudence of the water” contributed to a finding of torture and ill-
Inter-American Court of Human Rights, for treatment); Abdulrahman Kabura v. Burundi, ¶
7.8, U.N. Doc. CAT/C/59/D/549/2013 (Nov. 11,
considering deprivation3, and manipulation
2016) (noting that the victim was denied “water .
. . [and] food,” which contributed to a finding of
ill-treatment). (IHRLC, 2018)
4 According to the same review, providing food
3 The review considers the following cases: which was in poor condition or contained
Sendic v. Uruguay, ¶¶ 2.3, 2.4, 20, U.N. Doc. inedible elements, like faeces, urine or dead
CCPR/C/14/D/63/1979 (Oct. 20, 1981) (holding animals, as amounting to ill-treatment or torture,
that subjecting the victim to a “lack of food” in the following cases: Cariboni v. Uruguay, ¶
while in detention was, in addition to other 4, U.N. Doc. CCPR/C/31/D/161/1983 (Oct.
factors, a form of torture and ill-treatment); 27, 1987), Juvenile Reeducation Institute v.
Polay Campos v. Peru, ¶¶ 2.1, 8.7, U.N. Doc. Paraguay, Preliminary Objections, Merits,
CCPR/C/61/D/577/1994 (Nov. 6, 1997) (noting Reparations and Costs, Judgment, Inter-Am.
while the victim was detained, “the food [was] Ct. H.R. (ser. C) No. 112, ¶ 16 (Sept. 2, 2004)
deficient” and that this contributed to a finding Miguel Castro Castro Prison v. Peru, Merits,
of torture and ill-treatment); Danilo Dimitrijevic Reparations, and Costs, Judgment, Inter-Am.
v. Serbia and Montenegro, ¶¶ 2.2, 7.1, U.N. Ct. H.R. (ser. C) No. 160, ¶ 37 (Nov. 25, 2006),
Doc. CAT/C/35/D/172/2000 (Nov. 16, 2005) Déogratias Niyonzima v. Burundi, ¶ 2.7, U.N.
(finding that the victim was “denied food and Doc. CAT/C/53/D/514/2012 (Nov. 21, 2014),
water” and that this omission was found, along Muteba v. Zaire, ¶¶ 2.1, 8.2, 10.2, U.N. Doc.
with other factors, to constitute torture; Miguel CCPR/C/22/D/124/1982 (July 24, 1984), (noting
Castro Castro Prison, No. 160, ¶¶ 37, 44, 103 that outside food also needed to be brought by
(Nov. 25, 2006) (finding that inmates “did not the victim’s family in response to the provision
receive food [or] . . . water” during an attack on of “insufficient” food, and the “withholding” of
the prison where they were detained, and that food while in detention, which contributed to a
this contributed to a finding of torture); Institute finding of torture and ill-treatment) (IHRLC,
for Human Rights and Development in Africa v. 2018). Also in some instances, the treatment
Angola, Communication 292/04, Afr. Comm’n amounted to torture by the manner that the food
H.P.R., ¶¶ 51, 53 (May 22, 2008) (holding was provided (Cariboni v. Uruguay, ¶ 4, U.N.
that as “food was not regularly provided” to Doc. CCPR/C/31/D/161/1983 (Oct. 27, 1987)
victims in detention, and was “insufficient,” this (having to eat with the fingers), Giri v. Nepal,
contributed to a finding of torture); Prosecutor v. ¶ 2.4, U.N. Doc. CCPR/C/101/D/1761/2008
T OR TU RE Vol u me 30 , N um b er 3 , 20 2 0
Popovic, Case No. IT-05-88-T, Judgment, ¶ 844 (Apr. 27, 2011) (eating blindfolded), Istratii
(Int’l Crim. Trib. for the Former Yugoslavia June and Others v. Moldova, Eur. Ct. H.R., App.
10, 2010) (finding that victims “were detained in No. 8721/05, 8705/05, 8742/05, ¶ 62 (2007)
intolerable conditions of overcrowded facilities (noting that “all detainees had to eat standing
with no food” and that this contributed to a up” because there were no chairs in their cells,
finding of ill-treatment); Abdel Hadi, Ali Radi & although the decisional body did not clarify
Others v. Republic of Sudan, Communication whether this factored into their finding of torture
368/09, Afr. Comm’n H.P.R., ¶ 74 (Nov. 5, and ill-treatment), Prosecutor v. Kvocka, Case
2013) (holding that the general conditions of No. IT-98-30/1-T, Judgment, ¶ 64 (Int’l Crim.
detention, which included the deprivation of Trib. for the Former Yugoslavia Nov. 2, 2001).
food, constituted ill- treatment); Franck Kitenge (Only having 3 minutes to eat and being beaten
Baruani v. Democratic Republic of Congo, ¶ 2.4, afterwards).
6
EDITORIAL
At a collective level, Conley & de Waal tional Criminal Court, although accountabil-
(2019) advocate the term mass starvation ity and prosecutions of perpetrators remain
and starvation crimes when famine is inten- a complex issue (Akande & Gillard, 2019;
tionally produced through actions that impede D’Alessandra & Gillett, 2019; Hutter, 2019;
the capacity of a targeted country or commu- Marcus, 2003; Sheldon, 2012; Ventura, 2019;
nity to access the minimum food requirements Wayne Jordash et al., 2019).
to sustain life. They suggest nine purposes: (i)
extermination or genocide; (ii) control through Two situations that deserve separate analysis.
weakening a population; (iii) gaining territo- Taking into account all the above, this medical
rial control; (iv) flushing out a population; (v) and psychiatric review will be divided accord-
punishment; (vi) material extraction or theft; ing two different phenomena: Food Depriva-
(vii) extreme exploitation; (viii) war provision- tion and Manipulation and Starvation and
ing; and (ix) comprehensive societal transfor- Famine (see table 1). Although both situa-
mation. tions can ultimately represent a danger to life,
For the interested reader, especially the medical and psychological processes and
thought-provoking are the historical works on consequences are entirely different.
the use of starvation in World War -II (Gerhard,
2015) and post-World War II (Autumn, 2009), Table 1. Conceptual domains
Kampuchea / Cambodia (DeFalco, 2014;
Tyner & Rice, 2015), Ireland (Nally, 2006), 1. Food deprivation and manipulation.
Armenia (Peterson, 2004) and Darfur (De Short-term or partial restrictions in food
Waal, 2005), as well as the ongoing system- quantity, including food insecurity, or
atic use of hunger and starvation as torture food of low quality or which is provided
and method of war in Yemen (Graham, 2020), in a denigrating manner.
Syria (Amnesty International, 2016; GRCI, 2. Starvation and famine. Prolonged
2019), Libya (United Nations High Commis- and sustained restriction in the access
sioner, 2018), Turkmenistan and other former to food that causes undernutrition
Soviet republics (Sharipzhan, 2015) among and, ultimately, compromises life.
many other contemporary contexts.
De Waal and Conley have extensively re- We aim to answer the following questions:
viewed accountability issues regarding mass (a) Is it possible to operationally define food
starvation in a seminal paper (Global Rights deprivation within the study of the methods
Compliance, 2019) that follows the elements of ill-treatment or torture? (b) What is the
of the definition of torture as applied to a col- medical and psychological evidence that exists
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lective situation. They specifically review how on the severity of the suffering and the sequels
to probe intentionality, purpose and lawful- of Food deprivation and manipulation and
ness. Especially useful is the 41-page annex Starvation and famine? (c) Are there medical
that includes analysis of starvation in com- or psychological criteria that may be relevant
missions, inquiries and fact-finding missions, to the legal world regarding the consideration
courts and tribunals around the world. There of these facts as amounting to torture?
has been enormous progress in the definition
of the crime of starvation especially after its
inclusion in the Rome Statute of the Interna-
7
EDITORIAL
Setting the baseline: psychophysiology of hunger 2014). So, there are strong neural interconnec-
emotions and the feeding circuit tions between physical needs, meanings, emo-
There is a homeostatic circuit that controls tions and drives. In this sense, the idea of “gut
feeding through sets of neurons in the hypo- decisions” or “gut feelings” might have more
thalamus that segregate two specific hunger meaning than it may seem.
hormones: ghrelin, which signals energy
scarcity and drives towards food intake and 2. Short-term deprivation of food: physical
leptin, which signals energy availability and and psychological effects
inhibits food-seeking behaviour. Both add
to the effects of insulin in regulating sensa- Almost all existing academic research is based
tions of hunger in humans. The level of these on experimental studies with students, com-
substances depends on on internal chemore- pleted in reward for academic credit or small
ceptors (i.e. glucose level) and environmental financial incentives where the motivational
stimulus. Furthermore, external cues may be and attitudinal elements are far from what is
more important than internal signals in arous- to be found in natural settings where torture
ing feelings of hunger (Chen & Knight, 2016). occurs. The results must, therefore, be ana-
There is evidence of individual differ- lysed with caution. Here, we will specifically
ences in the perception of gastric signals of review the impact of food deprivation on emo-
fullness or emptiness. The reason is unknown, tions, cognitive functions, moral judgment
although there seems to be coincidence with and altruistic and prosocial behavior.
human variability in perceiving cardiac signals, Hunger and emotions. There is an as-
pointing to a general element of differences sumption that hunger evokes negative emo-
in the individual perception of vagal signals tions (rage, anger, irritability, sadness).
(Chen & Knight, 2016). Nevertheless, short-term laboratory studies
How we become aware of and feel hunger do not seem to confirm this idea. There is
is still largely unknown. Complex sensory in- only indirect and inconsistent experimental
formation from the bodily organs (e.g., bowel, evidence suggesting that low glucose levels in-
bladder, stomach, heart), the skin senses (e.g., crease impulsivity, aggression and leads to un-
cool, warm, touch, itch), internal chemore- stable mood (Anderberg et al., 2016; Benton,
ceptors (e.g. oxygen concentration, hunger 2002; Bushman et al., 2014; DeWall et al.,
hormones), and muscles and tendons (e.g., 2011; Gailliot, 2013; Hermanns et al., 2007).
proprioceptive feedback, fatigue) is transmit- The idea behind this assumption is the
ted via spinothalamic and vagal afferents to well-known - even in folk culture - ego-depletion
the anterior insular, somatosensory and orbi- theory (Baumeister & Vohs, 2007) that accepts
T OR TU RE Vol u me 30 , N um b er 3 , 20 2 0
tofrontal cortices of the brain where it is inte- that a human being has a limited amount of
grated (Stevenson et al., 2015). This process physical and mental energy. Self-regulation
is mediated by awareness and consciousness and self-control, therefore, depend on having
that attach meaning to the afferent sensations, sufficient “ego energy”. Glucose deficit due to
including emotions and feelings linked to that food-deprivation would provoke ego depletion
meaning (Quadt et al., 2018).These same cor- and allow negative emotions to appear and
tical centres support the integration of all these render the person more vulnerable to emo-
inputs into drive states (e.g., pain, sex, hunger, tional cues. This has been linked to false con-
thirst) and to associated behaviours (Harshaw, fessions in the interrogation of suspects (Davis
8
EDITORIAL
& Leo, 2012). Recent research suggests that (Vicario et al., 2019). In a similar vein, nine
the theory may be too “mechanical” and not hours of food restriction enhances memory for
give sufficient consideration to other factors, food items but not for non-food items (Mon-
and specially that high motivation can over- tagrin et al., 2019).
come the effect of glucose depletion (Baumeis- When turning to non-food-related cogni-
ter & Vohs, 2007) suggesting that short-term tive functions, the experimental evidence is in-
hunger should be better studied as a con- conclusive. In a review of ten studies, Benau et
text-dependent emotion. al., (2014) found that in seven of these, short-
In a similar vein, in a series of experi- term fasting did not affect performance in any
ments with volunteers, MacCormack & Lind- cognitive task, while in the remaining three,
quist (2019) showed that subjects who felt there was a low to moderate impairment in
hunger reacted with negative emotions to a psychomotor speed and reaction times in ex-
neutral stimulus only when they were put in ecutive functions including problem-solving
a context that they interpreted as unfavor- and decision-making. Short- and long-term
able. Only then, the person reacted with ir- memory seemed unaffected in all experiments
ritability or anger. Furthermore, this effect (Benau et al., 2014). In summary, research
disappeared when the volunteers were asked with volunteers in lab conditions shows that food
to express the emotions they were feeling, in- deprivation increases attention and memory
cluding hunger. In most subjects, this led to related to food cues, but not to other elements
self-control. This is what probably reflects the and it does not support the idea that short-
popularly-coined expression “hangry”, indi- term food-deprivation produces a decline in
cating feelings of bad temper or irritability as cognitive functions per se.
a result of hunger. When the person is made Taking decisions. Initial experimen-
aware, he can easily regain control and manage tal data suggests that during short-term
the emotion. food-deprivation people tend to be less ra-
A particularly relevant negative emotion tional and are guided by intuitive decisions,
is disgust towards inedible or unpalatable perhaps due to the overall feeling of tiredness
food. Laboratory research with volunteers has or to the need to save cognitive resources
shown that disgust was significantly reduced (Brown et al., 2020). Also, some very prelim-
in subjects who had been food-deprived for 15 inary evidence suggests that hungry individu-
hours and that this attenuation occurred auto- als tend to take greater risk and do not assess
matically. In other words, subjects found food dangers properly (Vicario et al., 2019). No
palatable that they previously saw as disgust- data on naturalistic settings is available.
ing even if they were unaware of their previ- Moral judgment and punishment. In
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ous reaction (Hoefling et al., 2009). two laboratory studies with students deprived
Cognitive functions. Laboratory studies of a mealtime, subjective hunger was associ-
show that five hours of fasting significantly ated with a more lenient view of moral viola-
increases distraction (mind-wandering be- tions in different ethical dilemmas (Vicario et
haviour) and thinking in actions in the imme- al., 2018) and with more lenient punishments
diate future related to food-relevant stimuli, for transgressors (Kerry et al., 2019). Hungry
interfering with normal cognitive function individuals seem to be less strict in judging
(Gidlöf et al., 2020; Rummel & Nied, 2017). moral contexts, which might be linked to an
This effect seems to increase in obese subjects overall element of fatigue. This can poten-
9
EDITORIAL
tially have implications for explaining wrong tions but, in fact, they are less prone to share
decisions in interrogations in the context of what they have (Aarøe & Petersen, 2013).
hunger. In the most comprehensive set of laboratory
Social attitudes and short-term food game studies with volunteers, in overall, acute
deprivation. From the point of view of evo- hunger did not affect pro-sociality, neither in
lutionary psychology, in early infancy human cooperative nor competitive games (Häusser
beings seem prone to share food. 19-month et al., 2019). Again, these are lab studies: the
old infants repeatedly and spontaneously games did not have any emotional nor practi-
transferred high-value, nutritious natural food cal implications for the participant, much less
to a stranger as a way of exchange and inter- that there was competition for survival or any
action, even after a feeding delay (Barragan et risk to life.
al., 2020). But this changes with age. Hungry Psychosocial background and early
4-9-year-old children were less likely to share experiences. Data provide strong support to
overall, but particularly when sharing food-rel- the idea that experiences of poverty and lack of
evant resources. Despite that, children still ex- resources frame the emotions and behaviours
pected that others behaved to the contrary and associated with food-deprivation. In a series
shared their food (Huppert et al., 2020). of experiments, Allen & Nettle (2019) showed
Anthropological data suggests that in cul- that adults with a personal history of child-
tures where families place value on being har- hood socioeconomic deprivation reacted with
monious and empathic toward others, pay more impulsivity and emotionality in a situa-
attention to reciprocity rules, and childrear- tion of hunger probably as it evoked past ex-
ing practices support the expression of al- periences and attached negative explanations
truistic behaviour, then food-sharing is the and meanings to it.
norm. In individualistic societies, food-shar- The symbolic value of food. All the
ing and cooperative skills become less rele- above suggest that beyond caloric intake, in
vant in family education patterns and must be any given context, food has a symbolic value
reinforced at school (Barragan et al., 2020). that is also extremely relevant to assess. By
The results strongly suggest that hunger per way of example, in in-depth qualitative in-
se cannot explain altruistic food-sharing be- terviews with 30 female inmates at a correc-
haviour in human adults and children and cul- tional facility in the US, food was found to
tural and educational elements are essential. be a significant determinant of the subjec-
In adults, there is a robust popular concep- tive impression of punishment carried out by
tion, supported by various surveys, that hunger the institution (Smoyer & Lopes, 2017). Al-
undermines prosocial attitudes and human though sufficient in quantity, the variety and
T OR TU RE Vol u me 30 , N um b er 3 , 20 2 0
beings become selfish and survival-oriented. presentation, the way the food was cooked and
But the data shows conflicting results. Short- served, and being rushed and watched while
term food-deprivation seems to increase pro- eating were seen as dehumanising experiences
social behaviour (for instance, hungry people of symbolic punishment that were deeply hu-
are more supportive of welfare programs), but miliating. Food was far more than a means for
only if it does not mean parting with their survival and instead was seen as a mechanism
resources (i.e. giving money to a charity). of degradation, surreptitiously showing control
Hungry individuals support more egalitar- on all aspects of their life.
ian positions when these are theoretical ques-
10
EDITORIAL
unclear, but the authors found fMRI images terranean) and the Middle East. In her study
suggesting common neural pathways that re- among Brazilian sugar cane cutters and their
inforce craving for social connectedness and families, she describes extensive communi-
food. ties chronically malnourished, in a generally
All these elements are only preliminary weakened and debilitated state, that become
data suggesting the complex interactions and “mad” when, due to agricultural cycles, they
consequences of short-term food deprivation have even fewer food supplies. She describes a
and hunger in the creation of torturing envi- victim shaky, dizzy and disoriented, emotion-
ronments. ally labile, sad and depressed, without an ap-
11
EDITORIAL
petite, and often alternating between periods highly motivated conscientious objectors. All
of passive withdrawal and unpredictable out- of them had academic degrees and an average
bursts of rage in what she considers that rep- IQ of 130. Furthermore, as one of the partic-
resents a psychiatrization of chronic cycles ipants said: “The difference between us and the
of starvation. Similar reasoning can likely be people we were trying to serve: they probably had
applied to such diverse “cultural-bound” syn- less food than we did.We were starving under the
dromes as Susto (Mexico), Mancharisqa (Peru), best possible medical conditions and we knew the
Wendigo (Inuit) or Nubila (Central Africa). exact day on which our torture was going to end.
Ghetto studies and The Minnesota None of that was true of people in Belgium, the
Experiment. During the Holocaust, Jewish Netherlands, or whatever.” (Keys et al., 1950).
doctors monitored and recorded the starva- Animal studies replicating Holocaust
tion process in the Ghetto of Warsaw and the conditions. There was a plethora of animal
process of starving to death in Dachau in adult studies in the following decades (table 2).
and children. None of the authors survived. Most of them would be ethically unaccepta-
Their compelling observations were published ble nowadays. Table 2 also shows a summary
after the war (Magowska, 2020). of contemporary studies with animals.
In the Minnesota Starvation Experiment, Body adaptation and medical and
conducted during World War II (Keys et al., psychological consequences of chronic
1950), thirty-six volunteers were subjected to food-deprivation. During the initial hours
a regime of semi-starvation in which most par- of acute starvation, there is a carbohydrate
ticipants lost in as much as a 30% of body depletion that affects muscle and brain func-
mass, with severe medical and psychologi- tion in particular, both highly dependent on
cal consequences including anaemia, chronic glucose, producing fatigue and mild cogni-
fatigue and apathy, extreme weakness, irritabil- tive effects. After 24 hours the body begins
ity, neurological deficits, and lower extremity to resort to body proteins and fat to produce
oedema (Guetzkow & Bowman, 2012; Kalm glucose through glycogenesis procedures and
& Semba, 2005). The participants experienced the use of fat acids (ketosis metabolism). There
dizziness, extreme tiredness, muscle soreness, is a down regulation to save resources and after
hair loss, reduced coordination, and ringing two weeks brain glucose consumptions falls to
in their ears (Keys et al., 1950). As one of 50%. Although there is significant variability
the participants explained, years later: “Food among individuals and contexts (high versus
became the one central and only thing really in low levels of stress associated to hunger), this
one’s life”. Pre-and post-starvation personality compensatory mechanism allows for some-
tests showed a temporary and reversible in- what decreased but normal functioning during
T OR TU RE Vol u me 30 , N um b er 3 , 20 2 0
EDITORIAL
implies a deterioration in muscle mass and in irritability, fatal oedema and death in an es-
the production of new cells, including blood timated three to four months. This terminal
cells, leading to anaemia and lymphocyte de- stage corresponds to what survivors of the Ho-
pletion (see table 3). There is also an overall locaust labelled as the “Muselmann”: human
decrease in endocrine functioning, includ- beings that, through a combination of star-
ing hypothyroidism symptoms and amenor- vation and the oppressive conditions of cap-
rhea. Vitamins decrease sequentially. Thiamine tivity had lost all identity and consciousness,
(Vitamin B1) after two weeks, Vitamins C and who were apathetic and acting without con-
T O R T U R E Vo l um e 3 0 , N um be r 3 , 2 0 2 0
D after 4-5 months and Vitamins A and B12 sideration for their actions – virtually waiting
after 12 months. The deficit of thiamine, the for death:
most dangerous consequence of chronic food “Their life is short, but their number is endless:
deprivation, produces potentially irreversible they, the Muselmanner, the drowned form the
damage in the cardiovascular and neurological backbone of the camp, an anonymous mass, con-
systems, with ataxia and permanent impair- tinually renewed and always identical, of non-men
ment of memory (Wernicke's encephalopathy). who march and labour in silence, the divine spark
If still prolonged in time, extreme starva- dead within them, already too empty to really
tion will then lead to lethargy, neurological suffer. One hesitates to call them living: one hesi-
13
EDITORIAL
EDITORIAL
tates to call their death death, in the face of which detainee may be a powerful method
they have no fear, as they are too tired to under- to produce severe suffering and break
stand…" (Primo Levi, If This Is a Man) identity.
b. It is especially relevant to assess the
4. Summary, conclusions and proposals. combination of short-term deprivation
and manipulation of food with
1. Measuring hunger and food other methods as part of a torturing
deprivation. environment, with preliminary
None of the different international stand- evidences showing an interaction with
ards for the treatment of prisoners es- fear, sleep deprivation, hypoxia and
tablishes criteria for deciding when a pain producing methods including
population is being starved. They adhere exhaustion exercises. It is also relevant
to the criteria of the person receiving food to explore actions that foster forced
in such a quantity, quality, and hygienic con- absorption in hunger feelings5.
dition so as to ensure adequate and sufficient c. A change in an interoceptive state – such
nutrition. This criteria can be problematic, as hunger – has implications, through
as lack of enough food will only be de- neural connections, with affective and
tected when there is already severe and cognitive functions. This has potential
detectable malnutrition. Based on UN implications in the susceptibility to
bodies recommendations, the minimum cognitive and emotional manipulation
nutritional requirements for a healthy techniques.
adult with low activity level can be esti- d. Specific physical and psychological
mated around 3000 kcal/day (44 kcal/kg/ impacts must be assessed on a case
day) for men and 2500 kcal/ day (36 kcal/ by case basis taking into account
kg/day) for women. Any food supply under specific vulnerability criteria of each
2000 Kcal/day (30 Kcal/Kg/day) should victim including age, gender, past
be considered as starvation (Wischmeyer, experiences of deprivation or trauma,
2017). Al alternative for monitoring visits physical state and psychological status.
is analyzing Food security, for which there
are different measures available in the lit- 3. Prolonged starvation and famine as
erature. a torture method.
a. In chronic food-deprivation, the
2. Short-term food-deprivation and human body may adapt and resorts
manipulation as a torture method. to systems of downward regulation
T O R T U R E Vo l um e 3 0 , N um be r 3 , 2 0 2 0
a. Hunger is a subjective sensation of during the first two weeks. After that
wanting and needing food. Context,
purpose, motivation and meaning are
essential for understanding the impact
of short-term food-deprivation. Food 5 The Kubark Manual (CIA, 1963) defined forced
manipulation and even mild food absorption as the practice of preventing distraction
from the pain of hunger; from escaping into
deprivation in caloric terms, when mental disconnect, thus making hunger one
used as a form of dehumanisation, of the central elements of the experience of
humiliation and denigration of the the detainee to create cognitive and emotional
tension and break the self.
15
EDITORIAL
Laura Pizer Gueron and MaryAnn de Ruiter present a study on the narratives of rehabilita-
present the results of a survey conducted tion and the importance of mutual support in
among professionals worldwide regarding the Congolese refugee population in Athens.
the availability and use of physiotherapy ser- This work is co-authored by Gianfranco di
vices with torture survivors. The same team Maio, who unfortunately passed away recently.
presents the development and gives initial A person who has been linked for more than
assessment data of the Group physiotherapy 15 years to the work with torture survivors
model with torture survivors that has been de- and who left a deep impression for his com-
veloped by the Center for Victims of Torture mitment and humanity.
16
EDITORIAL
9004.2007.00001.x
All in all, an important group of studies to Benau, E. M., Orloff, N. C., Janke, E. A., Serpell, L.,
close a year marked by the COVID pandemic & Timko, C. A. (2014). A systematic review of
as an element of distortion. We are confident the effects of experimental fasting on cognition.
Appetite, 77, 52–61. https://doi.org/10.1016/j.
that in 2021 there will be new challenges and
appet.2014.02.014
we will strive to keep on being the Journal of Benton, D. (2002). Carbohydrate ingestion, blood
reference in the field of prevention and reha- glucose and mood. Neuroscience and Biobehavioral
bilitation of torture victims if you, our authors Reviews, 26(3), 293–308. https://doi.org/10.1016/
S0149-7634(02)00004-0
and readers, decide so. Brown, H., Proulx, M. J., & Stanton Fraser, D.
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