Partners in Health civil society initiative explain to Ahram Online how deaths and injuries are counted after political violence in Egypt, and why the numbers so often fail to add up As debate continues over the exact death toll in recent violent clashes, Ahram Online speaks to Jane Fahmi and Sherif Samir of the Partners in Health initiative about what lies behind the conflicting reports of injuries and deaths that emerge after violent incidents, and why politics, though significant, is far from the only reason for such confusion. Partners in Health started seven years ago as an independent initiative aimed at helping Egyptians learn about their health rights, and has continued during the revolution to compile reports about victims of clashes. Ahram Online: Can you describe how exactly situations such as a mass disaster or political clashes are handled in terms of procedures? And how, therefore, accounting for injuries and deaths? Partners in Health: The standard procedure followed in cases of mass injuries and deaths isn't different whether it's demonstrations or, for example, the major train accident that took place in 2002. The first contact point in the case of a patient or a dead body would be the emergency service, which is a central Ministry of Health related service that gets directed to the place of the incident. The person in charge in the ambulance calls and indicates to the central emergency service the type of injuries they're carrying, or the corpses, and is directed to a certain hospital or morgue, depending on availability and distance. This is the first registration point. Upon arrival at hospital, the doctor in charge submits an initial assessment that is a legal document in case the death or injuries have criminal implications. If there's a felony involved, whether accident or demonstration, the police are called and a visual assessment is made, before the case is forwarded to the prosecutor who then addresses forensics for a post mortem and also presses charges if the coroner's report suspects a felony was committed. Forensic examination takes place on site or at a central morgue, such as the famous (or infamous) Zeinhom facility. This is the standard procedure, if everything goes well. Accounting for cases of deaths or injuries are thus registered in various spots: the central emergency service, the reports of doctors in charge, and also police reports, in addition to coroner reports. However, these rarely coincide. AO: Where do things go wrong leading to a mismatch in numbers? PIH: The procedure is far from foolproof. On the contrary, anywhere throughout this procedure mismatches happen. First of all, some families just take their family member's body and rush to bury it completely unrecorded and unnoticed. It's not unusual for families to be weary of procedures and forensic medicine, even considering it irreligious, imagining their loved ones' body will be manipulated inhumanely. They might therefore find it more honourable to just escape from the entire hassle. Then it's not unusual for an ambulance to get diverted to a different hospital if the first hospital is full, and many times they fail to report that diversion back, so cases end up in different locations and never accounted for. It's also possible in mass injuries and deaths that they don't register centrally the number of cases they carry, or details of names, age and national identity card numbers as required. Then there's also a family-vs.-doctor bargaining process that happens if the two aren't aligned: for example, a family insists on taking the body without forensic or police involvement for traditional or conservative religious reasons, and thus finds a negotiation point with the attending doctor to report that this particular case doesn't belong to the demonstration or accident. Or vice-versa, a doctor who doesn't like to be too involved with police and questioning would convince the family that they're better off without the hassle, and thus reports an unrelated cause of death. There's also the whole matter of incompetent, newly-graduated doctors and not-so-clear cases where the injury or cause of death aren't so easy to visually note, for example if someone received a hard blow and died before it even turned blue, or suffered from injuries then seemed to recover, but dies a day later. These would certainly go unrecorded in reference to the mass incident. We cannot also ignore the fact that relating direct cause of death to a certain injury or accident isn't always so straightforward, especially if cases are large in number and if extended time passes before the examination, which is one way to manipulate results, of course. But even disregarding all these logistical, traditional and incompetency matters, forensic medicine and this entire branch of the judicial medical field isn't so straightforward globally, not to mention in Egypt. Relating cause of death to a certain incident isn't only a science but requires an entire system around it, and unbiased collection of evidence to be able to give a full consistent account of what happened to whom and where. This gets much more complex in a country where records in general aren't well kept, and in particular in politically charged situations. Until today, over two years since the January 25 revolution started, the true account of deaths and injuries is impossible to conclude for all these reasons, and as time passes, the task simply becomes impossible. AO: How would you see this all applicable to a situation such as the results of clashes between police and Brotherhood supporters at the sit-in at Rabaa Al-Adawiya square on 27 July? PIH: The situation there is quite dramatic because the matter has turned into a political battle, leading to the death toll becoming a currency each trying to bargain through. The discussion is truly about whether a certain death or injury was caused by live ammunition and it is in itself a difficult question to resolve in absence of all the factors described above. Muslim Brotherhood field doctors report that every single death and injury was caused by live ammunition, and that would have to be proved through forensic reports. Yet, the long and sad stories from the famous martyr of the revolution, Khaled Said of Alexandria, and the consecutive incidents of Maspero, Mohamed Mahmoud and other later incidents, all testify to the politicization of forensic medicine, where coroners are either ‘asked to report certain figures' or simply allowed to manipulate information to prove certain things. This has led to significant mistrust in the system, such that it's difficult to depend solely on one part of the evidence to tell the whole story. AO: According to the Freedom and Justice Party Facebook page, the number of clinically dead cases is 66. Can you shed some perspective on this figure? PIH: If that means cases on life-support machines then this figure is simply impossible. The number of spare life support machines in the entire city of Cairo cannot by any means be that large. They're in huge deficiency and usually very difficult to spare. We could argue that 66 cases use life support in Cairo over a year maybe but certainly it's not possible to place such a number of clinically dead cases on these extremely rare machines, given a potentially much larger number of injured also in need. AO: What about the number of injuries, reported by Ministry of Health to be 299 and by FJP to exceed 4,000? PIH: It's much more difficult to account for injuries, but just to put such numbers in perspective: for a relevant number of doctors to attend to such number of injuries at field hospital in the amount of time described, some 400 doctors are required, and enough space to place all these people on the ground side by side to attend to their needs. Of course if one assumes every heat stroke and falling during running an injury this could be imagined, but if these were live ammunition injuries we would have definitely seen the ground of Rabaa Al-Adawiya square covered with injured bodies, which didn't seem to be the case. However, it is also difficult to also say that all those injured are accounted for in hospitals. There's a tendency to try to hide the fact that an injured person was brought from the demonstrations for fear they would be arrested by the police. So they prefer to claim they were involved in a street fight. In addition, of course, to the reporting bias in public hospitals to reduce the number of injuries associated with clashes or crackdown. The truth probably lies somewhere in between all these reported figures, but it's nearly impossible to imagine that all the described testimonials could be reconciled into one coherent report. We will attempt to collect the various pieces of the puzzle and place them for the public soon; however, it's not likely it will ever make a single clear picture. http://english.ahram.org.eg/News/77676.aspx
