When Force-Feeding Is Torture

This story was produced with support from the Fund for Constitutional Government.

Mohammad Salameh isn’t going anywhere. Two straps crisscross his abdomen, pinning his shoulders to the chair. Each ankle has its own restraint, and another strap is buckled across his thighs. His handcuffed wrists rest in his lap. His body is limp. A week earlier, Salameh was so weak that when guards came to remove him from his cell, he couldn’t walk to the door. (He got a disciplinary ticket for this “offense.”) Still, as the force-feeding is about to begin, three men dressed in black riot gear encircle him. They grasp Salameh’s head and shoulders as the physician assistant inserts a nasogastric tube into his nostril. Then the PA puts a carton of nutritional supplement and some sterile water into a feeding bag. The fluid starts flowing into Salameh’s body.

“My stomach has shrunk a lot,” Salameh pleads. He has been on a hunger strike for 34 days and lost 31 pounds, about 18 percent of his body weight. The PA ignores him and adds more water, then appears to milk the bag to speed up the flow of the liquid. “I have pain in my stomach, man, I swear to God,” Salameh says. It feels “very, very painful.” His breathing grows heavier and faster until, suddenly, he vomits into a bin on his lap. A few seconds later he vomits again, and the bin, which his handcuffed hand can barely grasp, slips out of his fingers and clatters to the floor. He turns to the guard and apologizes.

“You need to control yourself, Salameh,” the PA says as he refills the bag. “This is for your own good.” Salameh shakes his head and denies the vomiting was intentional. “No, I swear I did not!” He again asks the PA to slow down the feed, and again the PA ignores him. After a few minutes, as the PA begins to take down the bag and remove the feeding tube, Salameh vomits until the tube is pulled out of his nose.

The video footage of this scene isn’t from a movie, or from Guantánamo Bay, but from a 2015 incident at ADX Florence, a federal prison in Colorado that houses one of the most restrictive units in the country. The government bars the prisoners in H Unit, the ADX’s highest-security wing, from communicating with almost anyone in the outside world, including the press. Guantánamo is transparent by comparison. At Gitmo, the public could almost always learn about hunger strikes and force-feedings as they occurred—but legal restrictions called special administrative measures, or SAMs, prohibit the prisoners in H Unit, as well as their families and attorneys, from telling others about the protests in real time. A person can face criminal prosecution for repeating something a SAMs prisoner has told them, even if it’s as trivial as what they had for breakfast.

According to the data gathered by CBS’s 60 Minutes team, there were as many as 900 force-feedings conducted in H Unit between 2001 and 2007. To my knowledge, the most coordinated hunger strike in H Unit occurred in 2009, when dozens if not hundreds of additional force-feedings took place. I asked the US Bureau of Prisons for data on the number of force-feedings conducted at the ADX from 2002 to 2022. It gave me data for the years 2010 to 2022. According to the Bureau of Prisons, only 84 force-feedings were conducted at the ADX in those 12 years. If true, that would indicate a sudden, unexplained drop in force-feeding at the ADX, but given the difficulty of obtaining information about what goes on inside H Unit, it’s impossible to know whether this data is accurate. If SAMs prisoners were undergoing force-feedings right now, we would have no way of knowing.

The men in H Unit don’t easily elicit sympathy. It has held individuals convicted of the highest-profile terrorism offenses, including Salameh, who was found guilty of participating in the 1993 World Trade Center bombing; Joaquín “El Chapo” Guzmán, a leader of the Sinaloa drug cartel; and Dzhokhar Tsarnaev, who was convicted for his role in the 2013 Boston Marathon bombing.

The federal government did not want the public to see these videos. In early 2023, after nearly three and a half years of litigation and with assistance from the Civil Rights Clinic at the Cardozo School of Law, the Department of Justice finally released them. The footage depicts two instances of medical treatment forced on Salameh: one rehydration by IV and one feeding by nasogastric tube. After receiving the videos, I shared them with medical and human rights experts as well as individuals with knowledge of the ADX. Human rights experts told me there is no doubt that the Bureau of Prisons violated medical ethics and international law in providing forced medical treatment to Salameh. Two physicians told me that the force-feeding by nasogastric tube was conducted in a manner far outside of medical norms, causing significant discomfort to Salameh and potentially endangering his life.

Although Salameh is no longer being held in H Unit, he is still in the custody of the Bureau of Prisons and was unable to review or provide detailed comments on the videos. Still, this footage is being released with his permission. “The whole effort in court is to get them in order to be published, not to keep them inside a closet or a locker,” he told me in a letter. “These videos are part of history.”

Reporters have obtained footage of prisoners and detainees in federal custody in the past, but the public has never seen how the Bureau of Prisons responds to hunger strikes. What’s depicted in these exclusive videos reveals how correction officers and Bureau of Prisons medical staff operate when they have no fear of public scrutiny.

People understand the relationship between government secrecy and government misconduct, especially in prisons, said Jeanne Theoharis, a political science professor at Brooklyn College who has visited the ADX and written about SAMs. For the public, she continued, learning how hard it was to obtain this footage should make clear how successful the Bureau of Prisons has been in walling off H Unit from the outside world. “We didn’t even know this was happening,” Theoharis said. “We couldn’t even know this was happening. And that should scare you.”

The release of the videos comes more than three years after I published a cover story in The Nation in collaboration with Type Investigations that examined the hunger strikes and force-feedings that took place in H Unit between 2005 and 2016. In 2017, 51 prisoners in the US were subject to SAMs. Given that there are about 150,000 people in federal prisons, this may seem like a small number. But for those living under the restrictions, the isolation can be excruciating. People can go months with almost no communication with anyone, even in writing. The rules and security requirements mean that it can take as long as six months for Salameh to write his mother a letter and receive one back. Reading material is also severely restricted. For years, Salameh could only receive newspapers 30 days after publication. The men in H Unit were refused books on security grounds for baffling reasons, including The 2008 CIA World Factbook and Barack Obama’s The Audacity of Hope. At times, they were not allowed even to speak to one another. Some grew so desperate that they’d shout to each other by putting their faces in the toilets. “Sometimes the unit feels like a graveyard,” one former prisoner wrote. “There is no sound and everyone is in his grave.”

In 2017, I started reaching out to people I knew who had served time at the ADX and asked them to connect me to someone who had been force-fed there and was willing to speak. If writing about what was currently happening in H Unit was impossible, I thought, at least I could write about what had happened in the past.

It wasn’t long before I heard from Salameh. He wrote to me that he had been under SAMs continuously from 2005 to 2016. During that time, Salameh said, he spent 428 days on hunger strike, sometimes in coordination with other H Unit prisoners. Typically, they would demand improvements in their living conditions—two phone calls per month instead of one, having their shackles removed during no-contact visits with family, more recreation time, fewer restrictions on news access and reading material. Over the course of his eight hunger strikes, Salameh said, he was force-fed more than 200 times. (One man was force-fed more than 400 times during his time in H Unit, according to two former residents.)

In 2018, I got Salameh’s written permission to obtain copies of his medical records and any existing footage of forced medical treatment. I received his medical records relatively quickly, but the Bureau of Prisons did not want to relinquish the handful of videos of Salameh that it had not yet destroyed. The agency’s protocols require it to keep use-of-force videos for two and a half years, so by the time I’d filed my records request, only the videos from 2015 remained.

Based on Salameh’s medical records and our extensive conversations, I already knew some details about the 2015 hunger strike. When Salameh stopped eating in the fall of that year, he did so alone. He said that several years earlier, in order to sustain a healthy weight, he’d been granted permission to have double-portion meals, and he’d become accustomed to the additional food. But in October 2015, the prison suddenly halted his double portions. To an outsider, it may have seemed like a trivial issue, but to Salameh it was another indignity after more than a decade of deprivation and isolation. On October 9, he began declining his meals. On November 4, a forced-extraction team took him out of his cell, and he was forcibly rehydrated by IV. A week later, he was again extracted from his cell and force-fed.

Salameh had told me what it was like to be force-fed, but I wanted to see what it looked like and find out how it appeared to medical professionals and experts in international law. In July 2019, the Cardozo Civil Rights Clinic filed a lawsuit against the Department of Justice and the Bureau of Prisons on my behalf after the government denied my initial Freedom of Information Act request for the footage.

According to Betsy Ginsberg, a Cardozo law professor who founded and directs the clinic, it was the first time the Bureau of Prisons had been sued under FOIA to gain access to videos of force-feedings. The government argued that releasing the footage could reveal sensitive “law enforcement techniques and procedures” and could “reasonably be expected to endanger the life or safety of BOP staff.” In one declaration, a Bureau of Prisons official argued that there was no such thing as a peaceful hunger strike by a prisoner. These actions demand staff time and resources to address, he said, and they seek to “upend the system of authority and rules in the institution,” which means they “pose as much, if not more, of a security risk as do other types of inmate resistance.”

When it came to Salameh, the official said, hunger strikes constituted an even greater threat, since what he really wanted was to get his SAMs lifted, resume contact with international terrorists, and endanger American lives. Elsewhere, the federal government has argued that the hunger strikes in H Unit come “out of the al-Qaeda playbook”—that refusing to eat is “consistent with the actions of a committed jihadist.” Department of Justice officials later cited Salameh’s hunger strikes as evidence that he was dangerous and therefore a reason to renew his SAMs.

In March 2021, Judge Brian M. Cogan ruled that there was a legitimate reason to withhold the footage of Salameh being extracted from and returned to his cell, concurring with the government’s claim that it would undermine the security of the institution. Yet he disagreed with the government that a FOIA exemption should prevent the release of the videos of Salameh’s forced medical treatment. He ordered the Bureau of Prisons to turn over the footage after redacting the faces and voices of any guards or medical professionals.

After watching the videos, I passed them along to two physicians with expertise in forced medical treatment: Dr. Matthew Wynia, an internist and the director of the Center for Bioethics and Humanities at the University of Colorado, and Dr. Steven Miles, a professor emeritus of medicine and bioethics at the University of Minnesota. Both emphasized that providing medical treatment to a competent patient against their will—including IV rehydration and feeding by nasogastric tube—was a violation of medical ethics. (The American Medical Association and the World Medical Association have been unwavering in their condemnation of force-feeding.)

The two doctors expressed concern that the procedures were conducted in a way that caused unnecessary pain. Although the size of the tube isn’t noted in Salameh’s medical records, Wynia said it appears that instead of using a feeding tube, the PA used a nasogastric suction tube, which is larger and less flexible, and therefore more painful to insert. Despite Salameh’s pleas, the PA opted to feed him rapidly. Wynia and Miles say the feeding was obviously causing Salameh distress and discomfort, and since he vomited almost everything he was given, Wynia noted, it provided only marginal nutritional benefit. This was a “brutal procedure that was a violation of his right to express himself by refusing food,” Miles said.

Not only did the force-feeding cause Salameh needless suffering, the physicians said, it also endangered his life. If someone who’s been extremely malnourished suddenly increases their carbohydrate consumption, the shock can trigger “refeeding syndrome,” resulting in a drastic drop of potassium, phosphate, and magnesium in the bloodstream and potentially fatal cardiac arrhythmias.

Wynia described a patient he’d treated recently who had been admitted to the hospital for a parasite and failure to eat. After giving her nutrition by IV for a few days, Wynia started feeding her through a nasogastric tube at a rate of 15 milliliters per hour, which he gradually increased over a few days. In H Unit, by contrast, the PA appears to attempt to feed Salameh water and three cartons of nutritional supplement in about 20 minutes, or more than 1,400 calories and at least 700 milliliters of fluid. There is no indication in the records that Salameh’s electrolyte levels were tracked.

According to the medical literature, Wynia said, Salameh was at “high risk” of refeeding syndrome. “He survived… so they got away with it,” he told me. “But that is way outside of normal practice.”

That’s not all. Under current medical norms, Wynia and Miles said, an X-ray is used to check the nasogastric tube placement. The H Unit footage and medical records show no evidence of an X-ray. Instead, the PA relies on the outdated “whoosh test,” listening to Salameh’s abdomen with a stethoscope as he injects air into the tube. Without an X-ray, medical providers run a higher risk of directing nutritional supplement into the trachea or lungs—which can lead to aspiration, pneumonia, and death.

For Wynia, the footage raises the question of whether the Bureau of Prisons was acting to protect Salameh’s well-being. “The pretense that this is about health is a little hard to keep up,” Wynia said, adding that it seemed like the aim of this treatment was: “We want to make this hunger strike as uncomfortable as possible to break the strike.”

After asking medical experts to evaluate the videos, I turned to human rights experts, including Joanna Naples-Mitchell, an international human rights lawyer at Physicians for Human Rights. She told me, “What we’re seeing is an illegal act under international law, unequivocally.”

Force-feeding is considered banned by the United Nations Convention Against Torture. It’s also prohibited by law in several countries, including the United Kingdom, where it had been used on striking suffragists and Irish republican prisoners. In Israel, where Palestinians have used hunger strikes to protest detentions without a charge or trial, force-feeding is legal, but the national medical association forbids physicians from participating.

For an act to constitute cruel, inhuman, and degrading treatment under international law, it must cause serious pain or suffering and be conducted with the consent or acquiescence of a public official. Given Wynia’s and Miles’s analyses of the force-feeding, however, the incident may rise to the level of torture, which the UN defines as an act committed with the intent to coerce, punish, or intimidate.

Gerald Staberock, an attorney and the secretary general of the World Organization Against Torture, pointed out that whether or not an act of force-feeding legally constitutes torture, it still violates international law. “If you are a prisoner, you still have the right over your body; you have the right to take a decision not to eat, and that needs to be respected,” he said. But after reviewing footage of Salameh’s force-feeding, Staberock told me that he believed the video revealed an abusive intent: “If you look at the environment here, it’s coercive from A to zed. And it is torture.”

An official from the Bureau of Prisons’ Office of Public Affairs had little to say when I asked for a response to the opinion of medical and human rights experts that the procedure shown in the footage violated international law and threatened Salameh’s life: “We appreciate the opportunity to comment, however, we respectfully decline.”

Salameh may have been tortured as defined under international law, but that doesn’t mean much in the US, where courts have consistently found that the force-feeding of prisoners and detainees is legal. Unlike in Israel, at least two US courts have ruled that state medical and nursing boards cannot penalize providers—for example, by suspending their licenses—for engaging in clinical conduct that is sanctioned by the state.

Given that there are few avenues for holding the Bureau of Prisons accountable, I was baffled that the Department of Justice was investing so many resources to fight me in court. It could be that the footage forces prison officials themselves to see the abuse. “The importance of what you’re doing here is showing [the videos], because when you speak about ‘torture,’ it sounds very abstract,” Staberock said. “If you watch this and think that way, no matter who you are—no matter whether you are a prison [warden], whether you are a criminal defense lawyer, whether you are a prosecutor—you have to say, ‘This is inherently abusive.’”

For Staberock, the footage is evidence that the Bureau of Prisons is secretly torturing people on US soil. And what we see on camera is just a sliver of what happens in H Unit. SAMs make transparency and accountability all but impossible. The videos may not change the conditions in H Unit—and we likely wouldn’t know for years if they had. But the legal fight to release the videos has set important legal precedents: At least one other federal prisoner has been able to obtain footage of her force-feeding. A ruling was also cited in The Intercept’s successful litigation to obtain footage from an ICE detention center.

Laura Rovner, a professor at Sturm College of Law in Denver who has represented individuals in H Unit, told me that the videos are a window into a facility otherwise shrouded from public view. “I think we owe it to these men to bear witness to these force-feedings when they’re being conducted by our government, in our names,” Rovner said. “These videos, however painful they are to watch, make that possible.”