Price of Pandemic on Prisoners

A startling report was published by HM Inspectorate of Prisons on February 11th 2021 about the effects of restrictions imposed on prisoners in England since the start of the COVID-19 pandemic. Prisoners have had to spend 22 hours in a cell every day and have been unable to attend work, education, rehabilitation interventions or gyms, in an attempt to stop the spread of the virus. Visits from relatives and friends have also been suspended or highly restricted.

Saving lives

When the first lockdown was implemented back in March 2020, radical changes had to be made within the prison system as it was estimated that 2,000 prisoners could die from COVID-19. To an extent the measures have worked: the numbers of deaths has remained low thanks to the precautions.

The prisoners, made aware of the restrictions in the community, not only understood the necessity of prison lockdowns but also felt largely safe from the virus. As time has stretched on though, their mental strength to endure their restrictions has worn thin. Many desire the resumption of activities to make their lives meaningful again.

Price paid

The lasting psychological, physical and emotional impacts are already starting to show, with prisoners reporting an increase in self-harming behaviours, drug misuse, and deterioration in physical and mental health.

HM Chief Inspector of Prisons, Charlie Taylor, commented

‘The cumulative effect of such prolonged and severe restrictions on prisoners’ mental health and well-being is profound. The lack of support to reduce reoffending and help prisoners address their risk of serious harm to the public does not fill me with hope for the longer term […] Locking prisoners up in prolonged isolation has never been a feature of a healthy prison.’

The conditions many are faced with are not those you would wish upon anyone: eating meals in the same room as an unlidded toilet, inadequate ventilation, and often sitting alongside a cellmate. Those housed in single cells may not have the difficulty of being cramped in with another, but instead suffer the psychological impact of isolation and loneliness. These descriptions sounds more like those found in the detention centres of a low or middle income country, not the United Kingdom.

When allowed out of their cells for the daily activities of showering and exercise, there is a strict time limit. Many are frustrated that they don’t have long enough to complete these tasks.

Although the report does state that inter-prisoner violence has decreased, due to the reduction in face-to-face contact between prisoners, bullying and intimidation have increased.

And many prisoners have remarked on how underprepared they are for release into the outside world; without access to rehabilitation programmes or meaningful work, their chance of re-offending is far higher.

The solution?

The introduction of video calling and in-cell telephones have allowed some prisoners to remain in contact with their support networks. This may even be a post-pandemic solution for many isolated prisoners of the future.

The end of January saw eligible prisoners in England being offered vaccines, in line with the community rollout. This sparked some public debate as elderly & certain ill offenders will now be receiving vaccination before their (perhaps younger or fitter) victims in the community. That said, prisoners are not the only ones at risk within the prison system: prison staff are at risk and their representative bodies feel that both they and their prisoners should be higher up the vaccination queue.

Whilst individuals may disagree as to who should go to the top of the queue, there is common ground in the knowledge that we cannot fight this virus whilst fighting each other. We must act as a team to stop the spread and save lives.

The future

The longer-term impact of the restrictions imposed on prisoners is yet to fully come to light. However, this report has shown that - unless we act soon - many offenders are at risk of serious mental and physical deterioration. It is too soon to lift the restrictions without putting thousands of lives at risk. So, in order to emerge from this pandemic safely, we must look to vaccination as the way forward - in prisons as in the community.

#NeverAgain in the time of pandemic

27th January was chosen as International Holocaust Remembrance Day because it is the anniversary of the Russian army’s liberation of Auschwitz concentration camp - now 76 years ago.

scapegoats

This year’s opportunity to remember the horrors of genocide falls almost a year after our world became engulfed in this seemingly endless COVID-19 pandemic. Almost every one of the 7.8 billion members of our global society are affected. Billions of our less privileged members are stoically suffering even more than usual. Millions of our more relatively privileged members are getting royally fed up of suffering. And a significant number of us are beginning to lash out in all directions - at ourselves, our families, communities & governments, at other communities & other governments.

When distressed, it’s human nature to look for a scapegoat. It’s just so easy to climb up onto the slippery slope that starts at upset, slips through blame & anger, and hurtles right along to hatred of the newly-identified scapegoat. The trouble is, once you hate someone, it’s only two small slips further onto condoning their suffering & even their death. That might seem to be a shocking, hyperbolic exaggeration of where lashing out could get us. But it’s not. It’s history.

Slippery slope

A century ago, the Jew-blaming Nazis took the German nation for a ride on a monstrous slippery slope: it started in the despondent ashes of post-World War I Germany, and it ended in World War II & the Holocaust. Yet it wasn’t just a few extremists who rode that blame train: no, the ride took on board generally caring & compassionate people - politicians & intellectuals, lawyers & doctors, and the man & woman on the street.

During the raking of the ashes of the resulting World War II, the Council of Europe was created and the European Convention on Human Rights (ECHR) drawn up - in part to try to prevent a recurrence of the ethical degradation of such slippery slope thinking. The ECHR even went so far as to write down, in Articles 3 and 2 respectively, what should have been obvious all along - that ill-treating and killing fellow human beings is wrong.

New weapon

It’s taken us just over a century to get in three world wars though thankfully ‘World War III’ is ‘humans v virus’ rather than ‘humans v humans’. Yes COVID-19 is a new & dangerous enemy and it’s essential that we put up a strong fight against it. But there’s another new weapon in town - double-edged smart phones. Their oh-so-fabulous edge is that they are incredibly handy lockdown companions. Yet their dangerous edge is that they are Tardis-like portals to the powerful realm of social media. This means that a 21st Century version of a slippery slope into scapegoating and genocide could be a far faster ride.

Responsibility

Quite rightly, we’re all being asked to play our part in preventing virus transmission - through hand hygiene, social distancing and mask wearing. Yet it’s equally vital that each one of us takes responsibility for our own words and actions. Could our words be interpreted as blame gaming? And could our actions - either directly or indirectly - contribute to the escalation of conflicts with our near neighbours? We must not succumb to the temptation of looking for a particular nation or people group to criticise or scapegoat for this pandemic, which we - as one massive community of 7.8 billion souls - are all in together. We need to care for one another in our thoughts, words & deeds. Otherwise our fight against this pandemic could very easily morph into a ‘humans v humans’ war with the coronavirus cheerleading from the side lines.

If a kingdom is divided against itself, that kingdom cannot stand.
If a house is divided against itself, that house cannot stand.

Gospel of Mark 3:24-25

It’s #InternationalHolocaustMemorialDay. #NeverAgain.

Death to the Inequality of Justice Part 1: Letter to POTUS

On 12th January 2021 the US government plans to kill Lisa Montgomery by lethal injection; she will be the first woman since 1953 to receive the federal death penalty in the USA. She was arrested in 2004 after she strangled a pregnant woman, cut her unborn baby from her abdomen, and then kidnapped the child to pass it off as her own.

TRAUMATIC CHILDHOOD AND MENTAL HEALTH

However abhorrent her crime might be, it must be placed into the context of her tragic and traumatic life. Lisa’s parents were alcoholics and she was raised in a deprived and violent household. Reported to have suffered brain damage as a child, she was a victim of sex trafficking and physical abuse, has a genetic predisposition to mental health problems, and has since been diagnosed with bipolar disorder, complex post-traumatic stress disorder and dissociative personality disorder. Yet all this mental strain went unrecognised and her mental health un-investigated - until after she was arrested and detained.

Lisa has taken full responsibility for her crime. Since being in prison she has been able to receive the help she needed in the first place, to begin to stabilise her mental health. Yet psychological reports, which stated that she was psychotic when she committed the murder and that her childhood trauma could explain her behaviour as an adult, were ridiculed in court. Her legal team’s attempts to have these arguments weighed in her sentencing were dismissed as ‘abuse excuse’. Instead her poor personal hygiene and unkempt home were used to degrade her character - as a person and as a mother.

As for the ‘abuse excuse’ accusation: examining a suspect’s mental health history and unfortunate background is the very opposite of looking for an ‘excuse’. No, it is a search for a partial ‘explanation’ at least.

Capital punishment is a divisive subject. Lisa’s crime was abhorrent. But regardless of what one believes about capital punishment, surely it isn’t right to execute someone who committed their crime whilst seriously mentally ill?

With less than 24 hours to go until Lisa is executed, we appeal to President Trump:-

Mr President

Sir, your administration has permitted Lisa Montgomery - a woman who committed a heinous crime whilst chronically mentally ill after a lifetime of severe social injustice - to be put forward for execution during the closing, supposedly ‘lame duck days’ of your presidency.

We would suggest that the death penalty is unnecessarily politicised in the USA and we feel that this scheduling is suggestive of political manoeuvring. Yet, reaching far beyond mere suggestion, the last few days have demonstrated solidly that passions boil over, people over-reach themselves, and allegiances switch - in politics and in personal lives.

Compassion is not the weakened motions of a lame duck - rather it is the decisive stroke of a strong man. Our Lord Jesus Christ, the Saviour in who you profess faith, commanded us so: ‘Do not judge, and you will not be judged. Do not condemn, and you will not be condemned. Forgive, and you will be forgiven. Give, and it will be given to you’ (Luke 1:37-38).

For the next few hours Lisa is still alive and for the next few days you are still the most powerful man on Earth. When we stand up in God’s court room, we will all need forgiveness. I will. Lisa will. You will too.

So Sir, please do the strong thing.

Yours respectfully

Dr Rachael Pickering (Prison doctor) & her colleagues at Integritas Healthcare

The Long Arm of the Crime

23/12/2020

Twelve years ago today, a little girl called Francesca Bimpson died in an intensive care unit after losing a three week struggle against catastrophic burn injuries. She had been trapped in a house fire caused by arson and tragically, unlike the rest of her family, she hadn’t managed to escape in time.

The arsonist was jailed. And the rest of the family lived on without their home & possessions - and without their beloved Francesca. They raised awareness about the need to support other victims and even opened a victim support centre in memory of their little girl.

But her father, Kieron Bimpson, kept blaming himself. And the end result of his devastating grief was that, this summer, one of his surviving children discovered him taking his own life in a particularly brutal manner. More death. More trauma and grief for those left behind. But all reaching back to the same index crime.

We often hear the idiom ‘the long arm of the law’. Thanks to modern-day forensics, the criminal justice system has increasing power to grab offenders from incredible distances - including backwards through time to catch historical offenders.

But we hear far less about the long arm of the crime. Stretching in the opposite direction to the limb of the law, the criminal appendage reaches forwards through time, holding tightly onto survivors & loved ones. Simply catching a criminal - sometimes thanks to the aforementioned long legal arm - and imprisoning him doesn’t stop the effects of his crime rippling on through time and space, blighting and even ending the lives of those who are left behind after the court case has concluded and the press photographers have packed up their camera bags.

A wrong action can be the start of a chain reaction of devastation within the life of an individual, a family, a community or even a whole society. It’s not enough to hunt down and lock up the person who knocked over the first domino. The surrounding dominos need intensive and ongoing support too. Psychological support. Social support. Medical support. Financial support. Crime has consequences - many, very long term consequences.

A Scrooge for our time?

18/12/2020

In an attempt to deflect attention from the misery of the pandemic, millions of generally comfortably off Brits are trying to cheer themselves up by going through their usual pre-Christmas motions. ‘Have you ordered your turkey yet?’ ‘No but I have put marzipan on my Christmas cake.’

My family is no exception. Last night, after tucking into the first of not one but two homemade Christmas cakes, we did what we do every December - watched The Muppet Christmas Carol. This fabulous rendition of Charles Dickens’ timeless festive tale of the righting of social wrongs never fails to make me both laugh and cry at the same time.

And then this morning I caught up on the news…

stunt

For the first time since Unicef formed just before Christmas 74 years ago, its United Kingdom (UK) branch has donated money to help feed needy London children over the Christmas school break. But rather than thank the United Nations agency tasked with bringing humanitarian and developmental aid to children worldwide, Leader of the House of Commons Jacob Rees-Mogg attacked the donation as a ‘political stunt of the lowest order’ and said that ‘Unicef should be ashamed of itself’.

As of yet, we have not seen evidence to support Mr Rees-Mogg’s reference to Unicef having taken up festive stunt work. But regardless of any political machinations that may (or may not) be going on behind the scenes, let’s take a step back, consider who’s suffering, and ask ourselves how they might perceive this donation.

Who will be helped by this feeding programme and would otherwise have faced a pandemic-infested Christmas made extra miserable through rumbly tummies? Not me. Probably not most of you reading my musings. And certainly not multi-millionaire Mr Rees-Mogg. Instead let’s hear from someone who is far closer to those being helped - the founder of the programme to which Unicef UK has donated:-

The response to our summer Breakfast Boxes programme has shown us that families are really struggling and many were facing the grim reality of a two-week winter break without access to free school meals and the indignity of having to rely on food banks to feed their children. By providing our Breakfast Boxes, families know that their children will have a great start to the day with a healthy nutritious breakfast… We cannot continue to rely on civil society to fill the hunger gap as too many children will miss out on the nutrition they need to thrive [emphasis mine].

ScANDAL

Like all countries that have been hit severely by COVID-19, the UK is under huge financial strain. Its many pandemic-support measures - such as the incredibly expensive furlough scheme - mean that the UK’s Treasury will be paying back the cost of this crisis for many a year. So in the grand scheme of things, what’s a festive shopping bill or two to feed the very neediest British children during Christmas? Almost nothing at all! It would be a tiny virus-sized drop in the vast vat that is the UK government’s pandemic debt.

Mr Rees-Mogg said, ‘I think it is a real scandal that Unicef should be playing politics in this manner…’. Well, I beg to differ. What is truly scandalous is that the UK, which is one of the richest High-Income Countries (HICs) in the world, has not already scraped the very bottom of its cavernous pandemic money barrel to spare its hungriest little citizens the lifelong consequences of childhood malnutrition. And that such criticism should have come out of the mouth of one of the UK’s richest MPs adds glittering insult to this festive injury.

Perhaps Mr Rees-Mogg spoke so defensively in an attempt to avoid his government being shamed again, so soon after it was embarrassed during footballer Marcus Rashford’s brilliant campaign to tackle UK child hunger. But does the UK government’s desperation to avoid getting splinters under its fingernails mean that Unicef should have shied away from lending its own hands? Absolutely not! Furthermore, such a move is utterly in sympathy with the advice handed out by its Executive Director earlier in this crisis:-

We cannot allow children to be the overlooked victims of the COVID-19 pandemic… We must simultaneously think both short and long term, so that we not only address the challenges posed by the pandemic and its secondary impacts on children, but also chart a brighter future for children and young people [emphasis mine].

Unicef is absolutely correct. A vast volume of high quality medical research shows that malnourishment as a child has lifelong consequences. ‘But wait a moment’, you might say. ‘That kind of research has all taken place in really poor countries - like those Mr Rees-Mogg described in his speech criticising Unicef. After all, he said, “I think it’s a real scandal that Unicef should be playing politics in this way when it is meant to be looking after people in the poorest, the most deprived countries in the world, where people are starving, where there are famines and there are civil wars”’. If you’re wondering this then yes, you have a good point that needs addressing.

Yes, the UK is undoubtedly a top drawer HIC. Yet even pre-pandemic, it had a sizeable wealth gap. This social divide is likely to have widened further during the first year of this pandemic. And my own experience as a doctor who works with vulnerable patient groups both in the UK and overseas leaves me in absolutely no doubt of the following conclusion…

It is not exaggerating to say that a small proportion of Brits live in similar conditions to those experienced by some less well-off citizens of certain Low- and Middle-Income Countries (LMICs). Therefore, it is medically appropriate to quote a conclusion reached in a series of Lancet papers examining maternal and child undernutrition in five varied LMICs: ‘The prevention of maternal and child undernutrition is a long-term investment that will benefit the present generation and their children’ [emphasis mine].

Scrooge

Malnutrition comes in many varieties and grades. Unicef’s advice is wise and its criticised action is not only a short term Christmas present for highly needy young Londoners but also a longer term investment in their future adolescent & adult health. And for one of our multi-millionaire politicians to suggest otherwise seems to me both near sighted and - to deploy a seasonal term - decidedly Scroogish:-

Kindly gentleman: "Under the impression that they [Victorian prisons and workhouses] scarcely furnish Christian cheer of mind or body to the multitude, a few of us are endeavouring to raise a fund to buy the Poor some meat and drink, and means of warmth. We choose this time, because it is a time, of all others, when Want is keenly felt, and Abundance rejoices. What shall I put you down for?"

Scrooge: "Nothing!"

Kindly gentleman: "You wish to be anonymous?"

Scrooge: "I wish to be left alone. Since you ask me what I wish, gentlemen, that is my answer. I don't make merry myself at Christmas, and I can't afford to make idle people merry. I help to support the establishments I have mentioned [prisons and workhouses] --they cost enough; and those who are badly off must go there."

shame

Taking off my medical hat for a moment and speaking purely as the holder of a British passport, I’m ashamed that the leader of my parliament should so criticise Unicef, which is a massive, highly respected international non-government organisation (INGO) with decades of experience in managing children’s nutrition during times of crisis.

At the other end of the INGO scale, I spend my days running Integritas Healthcare, a very small body that focuses on health & justice rather than food poverty & malnutrition per se. Yet there are complex though undeniable links between poverty & crime and so I feel that this news story is right & proper fodder for me to comment on. I’ve lost count of the number of detainees in English police stations and prisons who’ve told me that one of the few benefits of being incarcerated is the provision of three meals a day. Out in the community, both they and their families frequently went to bed hungry - and that was before the pandemic came along.

In closing I’d like to say ‘Thank you Unicef’ for stepping in to help some of my neediest fellow citizens at Christmas, despite what appears to me to be the incredible ingratitude of one of our national leaders. Surely that is what should be attracting shame. And I’ll leave the final words to the donor…

Unicef UK is responding to this unprecedented crisis and building on our 25 years’ experience of working on children’s rights in the UK with a one-off domestic response… We believe that every child is important and deserves to survive and thrive no matter where they are born [emphasis mine].

… and Tiny Tim (with a bit of light editing by yours truly):-

God bless Us, Every One [including you too of course, Mr Rees-Mogg].

The author of this opinion piece is writing in a personal capacity and her views are not necessarily those of Integritas Healthcare.

Diminished responsibility

09/12/2020

Back on Mothers Day, paranoid schizophrenic Eltiona Skana took a knife along to an English public park and cut the throat of seven-year-old Emily Jones as she scooted along, near to her parents. Now, after being found guilty of manslaughter on the grounds of diminished responsibility, Eltiona has been sentenced to serve at least eight years in a secure hospital; if her mental health improves, she will be transferred to prison.

As a mother who works with mentally ill offenders, I have been moved to tears each time I’ve seen this case in the news. One can only imagine how Emily’s parents may be feeling. It is a profound tragedy with never-ending pain.

Mental healthcare

Eltiona is now under the care of skilled healthcare professionals in a high secure forensic unit. Although caring for a patient of such notoriety is no easy task, the United Kingdom (UK) is blessed with a well-developed high secure forensic psychiatry service.

That said, Eltiona hailed from Albania; had she committed her crime in her homeland, she may well have experienced significantly different healthcare and criminal justice handling. Across the world there are vast differences in both general and forensic psychiatric services, ranging all the way down to total absence. Though I am based in the UK, I have the privilege of travelling widely in my capacity as Integritas Healthcare’ medical director: some of the psychiatric hospitals I have visited make the UK’s 19th Century Dickensian lunatic asylums look positively patient-centred. Some societies do not even recognise mental distress as being related to the concept of health.

Higher stakes

This tragic case is a catastrophic demonstration of the incredibly high stakes at play in the field of psychiatry. It is not a game and we undervalue mental health at our peril. Yet only now, as the COVID-19 pandemic’s psychological sequelae start to be noticed, are many people beginning to consider that caring for their minds may be every bit as important as maintaining their bodies.

The very worst thing that can happen in physical healthcare is the patient’s death. Whilst of course the loss of any life is regrettable, in psychiatry the stakes are sometimes even higher: yes the patient could die (through suicide), but on occasion other people - even vulnerable children such as Emily - also lose their lives.

Undiminished responsibility

Human life is valuable. It should not be undervalued and its safeguarding needs to be paramount. As the pandemic rumbles on, there is increasing financial strain on all public services including healthcare. Managers and politicians are facing tougher-than-ever funding decisions. Those in positions of power should remember this case as an example of the importance of mental integrity.

Locally, nationally and globally, mental healthcare must not remain in the shadows as the diminished understudy to physical healthcare. No, now more than ever, the care of our minds needs to be promoted, well-funded and even expanded. It’s time for our local health authorities, national politicians and world leaders to take responsibility for bringing psychiatry up to the top table. It needs to be recognised for what it is: the equal partner of physical healthcare.