The Medical Council has reaccredited the medical programme at RCSI Bahrain following a virtual process, subject to a ‘confirmatory’ site visit. However, human rights activists are strongly critical of the process. Catherine Reilly reports
An Irish Medical Council (IMC) assessor team did “not consider it necessary” to speak with witnesses of alleged breaches of medical neutrality at training hospitals used by RCSI in Bahrain – a Gulf country with a poor human rights record.
Three witness statements were submitted by the Global Legal Action Network (GLAN) prior to the reaccreditation process at RCSI Bahrain. A virtual accreditation process took place in March 2021 and a “confirmatory” in-person visit occurred in October 2022.
GLAN, an organisation of human rights lawyers and activists, offered to facilitate the Council’s assessor team to speak directly to the witnesses, where possible. However, in June 2021 the Council’s accreditation manager responded that the statements had been considered by the assessor team and it did “not consider it necessary to interview the witnesses”. In late 2021, the Council granted unconditional approval to RCSI Bahrain and its medical programme for five years subject to the “confirmatory” inspection.
The training hospitals – Salmaniya Medical Complex, Bahrain Defence Force (BDF) Hospital, and King Hamad University Hospital – have been linked with alleged mistreatment of political activists and prisoners, and discrimination against Shia Muslims.
A Bahraini doctor, who was one of the witnesses, told the Medical Independent (MI) that medical students in Bahrain would be afraid to speak out about concerns due to the political climate (Bahrain is rated as “not free” in Freedom House’s 2022 study of political rights and civil liberties worldwide).
The doctor told MI: “[The students] will be afraid of interrogation by the ministry of interior or simply they would be afraid of being dismissed from continuing their study in university by the ministry of education, which is interfering in all sorts of higher education in the country, including medical studies.
“No-one would be able to speak openly and freely in Bahrain without these fears in the back of their minds. It is very unfair for the Council to listen just to the students in Bahrain and ignoring anyone who worked in Bahrain or witnessed what they have seen there in the hospitals.”
The doctor said they trained and worked at BDF Hospital and Salmaniya Medical Complex, respectively, for several years post-2011. They reported being forced to discontinue training at the BDF Hospital due to alleged discrimination based on their Shia Muslim religion.
The doctor described witnessing police interference in medical treatment while working at Salmaniya Medical Complex.
This interference included police attendance at patient exams, interrogating patients, instructing the withholding of treatment, mistreatment of political detainees and injured protestors, and hospital staff reporting suspected protestors to the authorities
According to the doctor, they were tortured and imprisoned by authorities for treating injured protesters outside of the hospital system and they applied for asylum abroad. They are now working as a doctor in a European country.
In March 2021, the Council assessor team met virtually with groups of students from RCSI Bahrain. The student engagement process is confidential with no names noted in order to encourage participation. However, the assessor team was concerned about the low numbers of students who engaged in the process, according to Council documents released to GLAN through Freedom of Information (this issue was referenced in the Council’s published virtual accreditation report).
According to sparse handwritten notes of the assessor team’s meetings with students, the team asked most groups about patient dignity and specifically referenced prisoners. In one group, a “fear factor” was cited about reporting potential ethical concerns at clinical sites. Responses from an intern group referred to communication issues and barriers to care “due to diversity” which were “systemic”. The Council’s accreditation report stated interns raised the issue of language barriers impacting on care. There was no reference in the accreditation report to remarks about a fear factor or reference to the impact of the political climate on clinical sites.
Background
Situated on the Persian Gulf, Bahrain has a population of 1.7 million people. The majority of citizens are Shia Muslims and yet the ruling monarchy, the House of Khalifa, profess Sunni Islam. The discrimination experienced by the Shia Muslim community and their under-representation in governmental and other state roles has been a key driver of political tensions. These tensions erupted into large pro-democracy and reform protests in early 2011.
RCSI Bahrain was established in 2004. The university invested in a multi-million-euro campus in Manama, the capital, where it delivers medical and nursing programmes. Currently, almost 900 students are enrolled in the undergraduate medicine programme, which has published fees of US$39,500 per annum for Bahraini nationals and US$41,475 for non-Bahrainis. Seventy-five per cent of medical students come from outside Bahrain.
In the early 2000s, Bahrain seemed to be pursuing political reforms. It has long since changed course. In the last decade, the authorities have “infringed upon human rights, curtailed civil society, banned political opposition parties and shuttered independent media”, stated Amnesty International ahead of parliamentary elections in November.
The IMC’s first accreditation process at RCSI Bahrain was delayed due to political unrest. The state’s brutal crackdown on activists and healthcare professionals in early 2011 made global headlines.
A report by Physicians for Human Rights (PHR), published in April 2011, documented the beating, abuse, and threatening of physicians and the obstruction of medical care through the “militarisation” of hospitals.
The Bahrain Independent Commission of Inquiry was commissioned by the Bahrain government to examine the events of February/March 2011 on foot of international pressure. The commission’s report had a chapter on incidents at Salmaniya Medical Complex and stated that security services “executed unlawful arrests” on the hospital premises and “attacked and mistreated some individuals, including medical personnel”. It also stated that some medical personnel had ties with the political opposition and “moved in and out of their roles as political activists and medical personnel”.
The Council’s accreditation visit proceeded in 2014 and it granted unconditional approval to RCSI Bahrain for the maximum period of five years. Prior to the Council’s vote, some members expressed concern about “insufficient consideration during the accreditation process of ethical and human rights concerns in Bahrain”, according to meeting minutes. The accreditation report made no reference to abuses of medical neutrality and human rights at training sites or any recommendations on such matters.
Accreditation standards
Under statutory rules for accreditation, a medical programme must demonstrate that it incorporates the Council’s ‘eight domains of good professional practice’, the first of which is patient safety and quality of patient care.
The medical programme must also comply with the basic requirements of the World Federation of Medical Education (WFME) standards, which state that the medical school must facilitate “adequate clinical experience” and “organise clinical training with appropriate attention to patient safety”. The learning outcomes would include knowledge and understanding of human rights and medical ethics, according to the WFME standards.
The medical programme must also meet the requirements of an EU Directive on recognition of professional qualifications, which states that the programme must provide “suitable clinical experience in hospitals under appropriate supervision”.
In 2019, in advance of the reaccreditation process at RCSI Bahrain, GLAN Director Dr Gearóid Ó Cuinn (PhD) wrote to then Council President Dr Rita Doyle. He noted the WFME requirements adopted by the Council and the rules for accreditation under legislation. According to GLAN, the Council’s “failure” to consider submitted evidence on human rights abuses at clinical sites during the accreditation process in 2014, “amounted to a breach of the Council’s duty, as a public body, to have regard to relevant information prior to arriving at its decision.” The granting of unconditional approval was “inconsistent with the standards which the Council is bound in law to apply” during the accreditation process.
GLAN has noted a past example of the Council granting conditional (not full) approval to a medical school in Ireland due to deficits at a training site.
In his correspondence, Dr Ó Cuinn detailed that the human rights situation in Bahrain “remained a matter of serious concern”.
There is evidence of ongoing breaches of medical neutrality and denial of medical care in Bahrain. In 2018, the UN human rights committee noted “with concern” reports of an increase in use of violence by law enforcement officials during peaceful demonstrations and reports that injured demonstrators were questioned in medical facilities about their participation and denied medical assistance.
The most recent published communication from a UN Special Rapporteur to Bahrain authorities (July 2022) raised the alleged delayed access to medical care for political prisoners and alleged refusal of Salmaniya Medical Complex to release medical files to their families.
MI spoke to a former political detainee about an episode of inpatient treatment at Salmaniya Medical Complex in 2019. This individual, who has a serious chronic condition, described long periods of denial of medical care by prison authorities. Medical appointments at Salmaniya were granted by authorities following the advocacy of a family member. At the hospital he remained handcuffed and shackled throughout almost all his treatment, which included a theatre procedure, he told MI.
He described the healthcare team working under the close surveillance of police officers which restricted the standard of care they could provide. Doctors and nurses were “frightened” to ask the police officers to remove handcuffs and shackles. The doctor would “not even dare” ask the police to leave during consultations to offer privacy. “The nurses would not even come [due to] the way they were treated by the police as well. They will only see me once during the change of the shift… they wanted to avoid the police.”
This individual alleged they were “severely” beaten by police in front of healthcare staff, after attempting to flee the hospital in desperation. He stated he did not have access to the necessary post-surgical care when he was brought back to prison.
Changed process
The accreditation renewal process at RCSI Bahrain was meant to take place in early 2020, but was delayed due to the Covid-19 pandemic.
In July 2020, a Council accreditation manager corresponded with the WFME to ascertain whether undertaking a virtual process for accreditations (due to the pandemic) would be sufficient to meet the standards.
President of the WFME, Prof David Gordon, said if an accreditation was a routine cyclical re-accreditation of a school in good standing, and there was “no reason to suspect any serious issues”, a virtual accreditation “should be adequate… provided a confirmatory site-visit is arranged once it becomes possible”.
The Council proceeded with this process at RCSI Bahrain.
On 12 March 2021, the Council contacted RCSI Bahrain’s Head of the School of Medicine, Prof Alf Nicholson, in regard to submissions by GLAN relating to concerns about clinical sites.
The Council’s accreditation manager asked Prof Nicholson if he had observations on whether such material was relevant in the context of the WFME standards and on the substance of the information.
Prof Nicholson responded that “to our knowledge, there is no precedent for such discussions being included as part of a formal accreditation visit in Ireland or other countries”.
He added: “I have been Head of School for the past 18 months and I can definitively state that I have not witnessed nor have I received reports from either staff or students to support these allegations.”
The virtual accreditation process proceeded on 23-24 March 2021. The assessor team comprised Prof Mary O’Sullivan (Chair of the Visiting Team and Medical Council member), Dr Tom Crotty (Medical Council member) and medical assessors Dr Ailís Ní Ríain, Prof Barry Lewis, and Prof Hisham Khalil.
The assessor team held 14 virtual meetings across 14 hours during the two days. The team spoke to RCSI Bahrain management and staff, students, and clinical site representatives. Videos of the university and clinical training sites were also submitted.
The documents released to GLAN included handwritten notes of the assessor team’s meetings with these parties.
According to notes of the meeting with RCSI Bahrain management, whose names were listed, the assessor team asked questions “in relation to treatment of prisoners”. The notes indicated that Prof Nicholson considered the issues raised as unusual: “Unusual issues being raised during accred[itation] visit, no direct reports that would support third party reports.”
In the notes on the meeting with BDF Hospital representatives, whose names were listed, there was no reference to questions or responses on patient dignity. However, the Council’s published virtual accreditation report stated that when asked about their awareness of any mistreatment of patients, “no staff member had ever witnessed any form of mistreatment.”
In the notes of the meeting with representatives of King Hamad University Hospital, whose names were not listed, there was a question on “lack of respect and dignity”. One of the representatives said they “clinically worked here 10 years” and taught at BDF Hospital but had “never come across any incidents”. The “culture [was] very welcoming to all”, there was “no discrimination whatsoever” and “dignity always maintained”, according to responses.
Asked about a “formal policy to report”, there was reference to a “strict” policy on dignity, mission values, and the ethics committee and morbidity and mortality committee.
In the notes of the meeting with representatives of Salmaniya Medical Complex, whose names were not listed, there was a question on “lack of respect and dignity-patients”. A response stated, “a lot [of] help provided to prisoners, treated with extreme dignity, if couldn’t come to SMC consultant sent to prisoners.” Asked about a “clear process”, there was reference to a “process within hospital in higher authority”.
The assessor team asked a group of student representatives, “have any of you heard lack [of] respect in terms patients or prisoners.” The response was “all treated well and other vulnerable populations”.
A second student group was asked about “lack [of] respect to patient ie prisoners or are all treated equally respect and dignity”. A response stated, “early in careers not full experience in clinical setting,” but from what was known and/or experienced “respect heavily focused on” and “not seen or heard anything like that”.
Another group was asked about “interacting with patients” and whether prisoners were treated with a lack of dignity. A response referred to having “never picked up on particular group of people”. Some general examples of ethical concerns in regard to patient care were outlined in responses. A question was asked on whether students would know where to report potential ethical concerns. The responses stated, “don’t know who to go to” and “fear factor, don’t want to say anything”.
Interns were asked about “any incidents [involving] lack of respect for patients”. The responses were noted as follows: “Incidents – may have seen, miscommunication…”, “lack [of] communication” and “steps if issues arise”. There was “not intended malice – population diverse”. Another noted response was “barriers to care – due to diversity. Systemic not from anything taught by med sch[ool].”
According to draft notes of a close-out meeting with RCSI Bahrain management (and noted in the virtual accreditation report), it was “both unfortunate and unusual for us as assessor team that of the eight meetings arranged with students and interns we had to cancel three of them across the two days because either one or no students attended”.
The students who it met were “very enthusiastic” and had provided “a very positive view” of the medical programme.
‘Serious reprisals’
Mr Sayed Ahmed AlWadaei is Director of Advocacy at the Bahrain Institute for Rights and Democracy (BIRD) in London. He was granted political asylum in the UK after participating in the pro-democracy protests in 2011.
Commenting on the Council’s process, Mr AlWadaei underlined that students and clinical staff would feel inhibited from raising concerns due to the oppressive political climate.
“No-one would dare to speak about any wrongdoing because they will face serious implications, serious reprisals, if they dare to do so,” according to Mr AlWadaei, who spoke to MI on 17 November.
“So the only way for this Council to really conduct proper due diligence and to really examine the places properly is they have to speak to political prisoners and hear from them directly about their experiences, what sort of treatment they are getting.”
Ordinarily, non-imprisoned human rights defenders and political activists can access medical services if they do not cause suspicion during their presentation.
“The problem is if someone is protesting against the government and gets an injury because the police shot them or used gunshot pellets or tear gas or anything that resulted in injury linked to protest. Then they would not be able to go to the hospital because they will end up being in prison themselves. And interrogated as well.”
People in Bahrain who challenged “the dictatorship” and called for democracy were routinely “thrown in prison after being tortured”, many serving life sentences and some on death row. Some were facing a “slow assassination through denial of medical treatment” in prison, including political prisoner Mr Hassan Mushaima, aged 74. Mr Mushaima is Secretary General of the Haq Movement, a banned oppositional party.
Mr AlWadaei said he spoke to Mr Mushaima on 7 November – “and he detailed how harrowing his situation is…. He is in remission from cancer and a man of this age with really serious medical issues would require proper treatment, and unfortunately he is not getting that.”
He noted that Bahrain had the highest rate of imprisoned people in the Middle East.
“And most of those prisoners in the country are political prisoners – we estimate 1,400 political prisoners; 500 of them are serving more than 20 years’ imprisonment. Many of them are in prison since 2011, simply because they took part in what we call the Arab spring revolution…. It is a situation where human rights defenders, peaceful opposition figures, are behind bars simply because they wanted to challenge the dictatorship in the country.” Human rights defenders and activists were considered by the authorities as a “threat”.
“I am currently a stateless individual. Simply because I am a human rights defender working from exile. You would imagine what it would mean for those individuals who are human rights defenders who are in the country. Regrettably, one of the biggest names is Abdulhadi al-Khawaja – he is a dual Danish-Bahraini national and he is also serving life imprisonment. Recently they are just propping up new charges against him, some of them are because he protested the conditions in the prison and one of the key issues is obviously access to medical care.
“A lot of the problems that Abdulhadi suffers today are because he suffered serious torture back in 2011 and he has to deal with the consequences of that torture.” (On 28 November, BIRD reported that a court had upheld “reprisal charges” against Mr Al-Khawaja following his protests).
In granting accreditation to RCSI Bahrain, which depended on allegedly compromised training sites, the IMC was “legitimising” the actions of the Bahrain government, he believed.
“They are legitimising the denial of the medical treatment to hundreds of political prisoners in the country.”
He said discrimination against the Shia majority was also “a huge problem in the entire country”, including in healthcare employment.
Mr Alwadaei said BIRD receives core funding from the Sigrid Rausing Trust and Joseph Rowntree Fund. It also receives funding from the European Commission to support its work on death penalty abolition in Bahrain.
‘Final approval’
The Council’s education and training committee approved the virtual accreditation report at its meeting on 17 November 2021 and “final approval” was received from the Irish Minister for Further Education on 21 December 2021. In line with WFME requirements, the approval was subject to a “confirmatory site inspection”.
This site visit took place in October 2022. “The report of this visit is still in the deliberative phase and will be put before the education and training committee for approval when finalised,” the Council informed MI. The site visit included in-person inspections “of all clinical training sites associated with RCSI Bahrain”.
The spokesperson confirmed a “lower than normal” attendance of students during the virtual accreditation. The assessor team was, however, “satisfied” with the information gathered. At the two virtual accreditations carried out during the pandemic, student attendance was “significantly lower” than in-person accreditations.
The Council “followed all accreditation procedures in relation to third-party submissions”. It did “not direct the questions to WFME in this instance”.
A spokesperson for RCSI said the accreditation report provided feedback and recommendations for the university “to maintain the high-quality medical education it offers to its students”.
“The Council commended the university for the strong presence of professionalism throughout the undergraduate medicine programme, the quality of facilities on campus and at teaching sites, the support provided by the research office to medical students and staff across the spectrum of research activities and the enthusiasm and commitment of RCSI Bahrain medical students to their education.”
They added: “Our primary responsibility is to contribute to our students’ high-quality education in a safe, supportive, and non-sectarian environment.
“To this end we are committed to ensuring we provide our students with access to clinical training in the affiliated teaching hospitals in a safe and non-sectarian environment where the principle of medical neutrality is absolutely respected.”
Bahrain authorities
MI contacted the communications directorate of Bahrain’s ministry of health and awaited a response at press time.
Commenting on 25 November, Bahrain ombudsman’s office (which receives complaints about the interior ministry) said it had received “some complaints about the delay in obtaining medical care by some inmates”.
The office’s spokesperson maintained there was “no intentional deprivation of any inmate of medical services”. Where necessary, “the ill inmate is immediately transferred through ambulance to an external hospital.”
In regard to the aforementioned cases of Mr Mushaima and Mr Al-Khawaja, “we are already following up on any complaints or assistance requests. We provide those who submit official complaints on their behalf (such as their families) with the necessary and updated information about their condition adhering to the principle of preserving the privacy of personal information.”
GLAN response
Ms Siobhan Allen, Senior Lawyer, GLAN, told MI: “In its assessment of whether to reaccredit RCSI Bahrain, the IMC appears to have given inadequate consideration to the human rights situation in Bahrain or the specific (and numerous) allegations of violations in the training hospitals used by RCSI Bahrain.
“These procedural breaches make the assessment process, and the IMC’s resulting decision to grant unqualified reaccreditation, unsound.” In the context of the “long running and severe situation involving the medical mistreatment and neglect of prisoners, protesters and pro-reform advocates it is unimaginable that these training environments could live up to Irish standards as they are required to do pursuant to the relevant standards the IMC purports to apply”.
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