The Life Series: Nothing Less Will Suffice

We continue this series of a young doctor considering the health and justice interface as applied to long-term incarceration. In the first issue we considered IPP sentences. We now move on to the thorny issue of 'life means life' sentencing…

It has been almost a month now since I opened BBC News on my phone and saw the headline of former Police Constable Wayne Couzens being sentenced for the abduction, rape and murder of 33-year-old Sarah Everard. He received a whole life order. He will never be released. He will die in prison. 

I read various articles describing the tragic events of 3rd March 2021 - the violent, inexplicable acts against an innocent individual - and I wept. I wept for Sarah Everard and for what she had to suffer. She was a young woman living a life with many parallels to my own. I wept for her family, her friends and for all the other people caught up in this horrific crime. And I wept as I thought about all the other evil and injustice in our world. 

Then, out of my anger and sadness came a longing for justice. But what does justice really look like, in the face of such evil? Is a whole life prison sentence the answer? 

Whole life orders

Since the United Kingdom (UK) abolished capital punishment, a whole life order has been the most severe punishment available. It is reserved for only the most serious offences. The remarks from Mr Couzens’ sentencing hearing highlight the seriousness of whole life orders, stating they are rarely given out and should only be…

…for the few exceptionally serious offences in which, after reflecting on all the features of aggravation and mitigation, the judge is satisfied that the element of just punishment and retribution requires the imposition of a whole life order. Nothing less will suffice.

(Lord Justice Fulford)

Whilst Mr Couzens’ crimes fell outside the list of offences that would normally qualify for a whole life order, Lord Justice Fulford stated that it is not a closed list and subsequently expounded on his sentencing decision. All the elements of kidnap, rape and murder were taken into account but particular emphasis was placed on Mr Couzens’ abuse of his position as a police officer. Lord Justice Fulford concluded that alongside other aggravating features, his misuse of his position and his undermining of public trust were deserving of lifelong imprisonment. 

The easy option would be to not question locking away those who kidnap, rape and murder. Such sentencing seems the obvious solution. But it is important to consider the function of imprisonment and to ask whether it truly achieves what we expect it to - the creation of a safer and fairer society.  

Public Protection

One function of imprisonment is public protection. When a violent crime is committed, we naturally want to prevent it from happening again. We can lock away those who pose a risk to society through their violence. Mr Couzens will never again drive a hire car down a South London street. By imprisoning him until he dies, we can take some comfort in knowing that he will never do to anyone else what he did to Sarah. 

There is a risk of reoffending at any age, but the risk of recidivism drops in older age - for certain types of crime at least. How do we know that Mr Couzens’ risk of reoffending will remain unacceptably high once twenty-five, thirty or forty years have passed? It also raises the question of whether lifelong imprisonment truly makes our streets safer. Coming just a couple of weeks before Mr Couzens was sentenced, the murder of yet another young female Londoner - this time 28-year-old primary school teacher Sabina Nessa - reminded us that the problem of violence against women was never going to be solved by locking away one man for the rest of his life.

What more can be done to create a safer, more just society?

Punishment

My gut response to Mr Couzens’ actions was that he must be punished and punished severely. Directly and indirectly, he has caused unthinkable harm: he inflicted sadistic, fatal harm on Sarah; and he carved agonising wounds into the hearts of her family and friends. He also damaged British society’s trust in the police. He may have pleaded guilty but so far has neither displayed regret nor expressed remorse.

In the old days he would have been in line for physically brutal punishment; as a supposedly forward-thinking, civilised society today we shudder at the thought of those historic punishments, characterised by public displays of physical violence and humiliation. Our modern-day punishments - locking people away for decades or even life - seem far more palatable. Offenders are hidden away behind heavy doors, removed from our public conscience.

But lifelong imprisonment is an immensely heavy punishment. To be deprived of your liberty and enclosed in a cell for the majority of your waking hours (often 23 hours or more per day, as he is a prisoner of notoriety and so will likely need to be segregated for his own protection) with no hope of release is a desolate place in which to be. Whilst we may not be punishing his body directly, as was once the custom, such incarceration will take its physical toll indirectly. Certainly it will be punishing his mind. And the same punishment extends its reach beyond a sentenced individual. Often there is a family left behind. Children, wives and mothers can all become branded by the same hopelessness.

Clearly Mr Couzens’ actions were unacceptable and cannot be ignored. My own initial thirst for punishment came not from a longing for justice but out of a desire for vengeance. What do we seek from his punishment? What motivates us to punish any other human being who has erred? We must ask ourselves whether a just society is ever right to condemn an individual to an unending punishment. We must protect ourselves from the tyranny of becoming cruel and vindictive, whether as individuals or collectively as a society. Regardless of what someone has done, we must treat one another humanely. To repay darkness with darkness will in no way bring healing. 

Deterrent

In addition to public protection and punishment, many view heavy sentencing as an effective deterrent to reduce further incidences of violent crime.

The relationship between sentencing length and crime rates has been long studied and there is much detailed research on the topic that is beyond the scope of these ponderings. The United States of America has 2 million people locked up - that’s a 500% increase over the course of just one generation. Whilst crime rates have fallen, it is widely agreed that this cannot be solely attributed to mass incarceration and that the increase in imprisonment plays only a small part. Similarly, UK prisoner numbers are expected to rise by 25% (that’s approximately 20,000 people) over the next five years as the government looks to pass and implement the Police, Crime, Sentencing and Courts (PCSC) Bill, which will deploy more police officers and expand the prison system.

It is most telling that this bill’s own impact assessment reveals a lack of evidence for the measures deterring offenders or reduce crime rates. The threat of punishment is not an effective deterrent.

Rehabilitation

The final role of prison is rehabilitation, helping prisoners to process their actions and to receive support as they return to society. In the USA this is referred to as ‘correction’.

A whole life order implies that a prisoner is beyond redemption or rehabilitation. The sentence says, ‘You will never be fit to return to society’. At the time of his sentencing, Mr Couzens had offered no form of apology. Some people never reach a point of rehabilitation in which they seek repentance and genuinely wish for inner change. For others it does happen - but very slowly.  A whole life sentence removes any incentive for repentance and reconciliation. Moreover, there is nothing to lose so bad behaviour in prison cannot be sanctioned much beyond the removal of privileges and intermittent stays in segregation. After all, what is worse than a whole life order? Nothing that the UK’s criminal justice system offers, that’s for sure.

To leave someone in prison for the rest of their life with no expectation of any apology or positive change seems tragically futile. To me, the impossibility of rehabilitation implies that the main focus of a whole life order is pure and simple punishment. 

We must also wrestle with the question of whether there is ever a role for forgiveness in cases of abhorrent wrongdoing. To forgive is not to forget, condone or minimise what has been done. These actions have inflicted deep wounds on a family and, to a lesser extent, wider British society. These wounds will leave permanent, painful scars. Sarah’s loved ones, and society in general, may neither be able to forgive Mr Couzens nor feel that it is appropriate to consider doing so. Yet we must be wary of the destructive nature of resentment and bitterness. In order to bring more justice and peace to this world, we must each be the caretaker of our own heart.

Could anything else suffice?

The question of whole life imprisonment is a weighty one with no easy answers. The process of reflecting upon these issues has been somewhat distressing for me, and perhaps you have found this an upsetting read. Regardless of our society’s myriad opinions on these matters, surely we can all agree that even the severest sentence imposed upon an offender can never make up for the loss of his victim’s life. That equation just will not balance.

Yes, there must be a response to injustice. No, we should not tolerate violent crime in others. Still, for ourselves, let us seek to live justly and compassionately in our day-to-day thoughts, words and deeds.

Dr Elinor Webb is one of our Health & Justice Fellows

If you have appreciated this article and would like to support our anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.

London's hidden homelessness

London photographer, Anthony Dawton, has spent 18 months highlighting how the homeless have coped during the COVID-19 pandemic. He says the conditions in which London’s homeless live is worse than refugee camps he has travelled to.

Around 2,600 people are estimated to be sleeping rough on any single night in the UK, according to government figures.

an expensive cycle

One third of prisoners leaving a UK prison have nowhere to live once they are released so it comes as no surprise that approximately 41% of the British homeless population has served time in prison. Some prisoners being released from prison are known to re-commit crime to prevent themselves from being homeless. According to the Ministry of Justice national statistics the current overall reoffending rate is 26%, costing £18.1 billion annually. That’s an awful lot of money!

an example of desperation

Anthony Kemp, aged 59, confesses to a murder he committed 38 years ago (aged 21) to avoid sleeping on the streets. He was later found guilty and sentenced to 15 and a half years in jail.

Whilst you may be thinking you are glad that Mr Kemp has been brought to justice, this situation highlights the level of desperation homeless people experience and the lengths to which they would go to to avoid being homeless.

Cheaper, safe option

So why we are not improving the rehabilitation and aftercare of prisoners to ensure that they can leave prison and not have to re-offend just to have a roof over their head? If this was to be achieved then you could pretty much guarantee that the re-offending rate would decrease along with the annual re-offending cost!

Everyone deserves a warm, safe bed.

To read more about Anthony Kemp please follow: https://www.bbc.co.uk/news/uk-england-london-58912035

Fiona Woodhead is our IT & Social Media Assistant

The Life Series: IPP

Imprisonment of any duration has a significant impact on a detainee's wellbeing. And whilst incarceration per se is near universal around the world, length of sentencing varies massively. For example, except for whole life orders, a life sentence in the United Kingdom (UK) is typically twenty-five years with the potential for reduction; in the United States of America (USA) though, receiving a determinate life sentence means dying in prison.

In this new series we will be discussing various issues associated with long-term including life-long incarceration. We will cover physical wellbeing, psychological consequences especially within the context of solitary confinement, indeterminate sentencing, and the thorny issue of 'life means life' sentences.

Leading gently into that theme, this first article looks at indeterminate sentencing within the UK…

What are IPP sentences?

A former tool of the UK's criminal justice system, the sentence of Imprisonment for Public Protection (IPP) was implemented through the Criminal Justice Act 2003. It was intended for criminals who had committed violent or sexual crimes, posed a threat to society and yet were not deemed to require life sentencing. An individual sentenced to IPP was set a minimum term of imprisonment. Once this term was completed, their case was reviewed by the Parole Board, which decided whether they were safe and ready to return to society. Release was never guaranteed and, even once granted, carried conditions including a license for indefinite recall to prison if further transgressions were committed. Once back in prison, further sentencing was once again indeterminate. 

Problems with IPPs

Whilst this may sound like an attractive proposition for dealing with a few prolific recidivists, the problem was that IPPs were too popular with judges. In total, a weighty 8711 IPP sentences were issued, many for low level crimes. Parole boards became over-stretched and many people languished far past their minimum terms with no indications of release dates. These and other problems with IPPs amassed, and eventually the legislation was repealed in 2012.

However, this change was purely prospective. So, despite the abolishment of IPPs, a year ago there were still 1895 IPP prisoners who had never been released and 1357 who had been recalled back to prison.

Thorough research by the Prison Reform Trust reveals the many and varied problems of IPPs:-

• One individual may face a longer sentence than another for committing the same offence.

• The psychological burden of an indeterminate sentence leads to despair and a lack of hope that in turn increases the likelihood of mental health problems and increased rates of deliberate self-harm.  

• Prisoners’ frustration can lead to disruptive behaviours, causing harm to themselves and others.

• The circumstances under which these prisoners find themselves make it very difficult for them to progress, for example by engaging with educational programs that would be viewed favourably by a Parole Board.

• It is impossible to predict accurately how someone will behave once released.

• Family and friends must live with the uncertainty of not knowing when their loved one will be returning to participate in daily family life.

Moving forwards?

It is truly troubling that there are so many IPP prisoners still behind bars.  It could be called unjust and inhumane.  Those outside of the UK often look upon its criminal justice system as a bastion of high standards. However, in this particular case the world should ponder and learn from the legislative disaster that was IPP sentencing.  

We call on those in positions of power to review each individual’s case as a matter of urgency. UK residents can help to bring about this change by writing to our MPs and voicing our concerns. And there is no better time to do this than now as the UK’s Justice Committee has recently launched an inquiry into IPP sentences with the aim of reducing the number of IPP prisoners:-

The large numbers of people being recalled to prison under IPP suggests there is no end in sight to the problems created by this flawed sentence. 

(Sir Robert Neill MP, Chair of the Justice Committee)

Whilst strictly speaking IPP sentences are not life sentences, their perpetual cycling between recall and indeterminate sentencing takes away prisoners’ hope of ever being able to return to normal life. Let’s be honest, they may as well be life sentences. So it’s time to kick them into the long grass once and for all. 

Do join me next time when we’ll be exploring the various health problems associated with long sentences, and also consider how we can work together to bring about change.

Dr Elinor Webb is one of our Health & Justice Fellows

If you have appreciated this article and would like to support our anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.

Home sweet home?

Almost a decade ago the Ministry of Justice published a harrowing report majoring on certain findings of Surveying Prisoner Crime Reduction.  Its take-home message is as true today as it was then: there’s no place like home.

Revolving doors

Three out of four ex-offenders who lack a place to call home get reconvicted within a year of finding freedom. That’s just one complete turn of the revolving door between cells and the streets. Countless people are going round and round and round and round.

Soggy tents

Say the word ‘tent’ and most of us think back to family holidays and school excursions. It didn’t matter that you got soaked because soon you would be back home for a warm bath, hot meal and dry bed.

Yet camping is not a happy prospect for the many NFA (No Fixed Abode) ex-offenders released across the United Kingdom (UK) every week. For many of them, camping is joyless at best yet the nearest experience they will have to setting up in a place of their own. Yet these unhappy campers are luckier than others. As over half the women released in recent years from prisons such as HMP Bronzefield know, alternatives to camping include wet benches, drafty doorways, or even worse.

tangled knots

Few people enter prison without a pre-existing tangled knot of personal problems. Rarely is it just one thing that prompts someone to commit a crime. It is more typically a series of unfortunate events: adverse childhood experiences, unhelpful adult relationships, homelessness, addiction, and health problems, to name just a few.

And it’s vital to remember that prison doesn’t miraculously undo knots. Sometimes it stops them enlarging - temporarily - but often it just makes them bigger and even more messy. And once released, how on earth can any ex-offender prioritise the unpicking of his soggy knot of personal problems whilst squatting precariously on a sodden park bench?!

A bit of Maslow

It’s impossible to over-estimate the vital role of holistic care for this particular vulnerable patient group.

Consider Maslow’s Hierarchy of Needs and it’s evident that we’re too often failing to meet the most basic of ex-offenders’ physiological needs – food, water and shelter. Without these stable foundations, how can we expect them to rehabilitate and reintegrate into society?

Caring holistically also helps to ensure that any positive work that may have been done in prison is not promptly undone shortly after release. And of course, gold standard healthcare is more likely to be achieved when patients have reliable contact addresses.

Making it personal

I’ll never forget one man I met earlier in my medical studies, when I was doing a placement in a homeless shelter…

He’d been released from prison just three days previously, straight back onto the streets. He could barely walk. He hadn’t eaten a proper meal for days. And he confessed to having relapsed into stealing already.

His leg ulcer dressings, which had been applied by his prison’s nurses, were soaked through. Yes, his nurses had tried to arrange for him to be seen in the community for follow-up dressings. But with no address and no phone, there was no way for his proposed follow-up team to get in touch with him.

And so he was looking like becoming another statistic in a sea of ex-offenders’ missed community appointments and unravelled prison healthcare interventions - until the street outreach programme I was with happened to come across him.

Glimmers of hope

That said, at last some rays of hope are starting to come through the clouds.

Rochdale Boroughwide Housing, for example, has implemented strategies of early intervention and planning prior to release, to try to secure a stable transition from prison. And St Mungo’s, a homelessness charity, has worked with both local authorities and probation services to set up a London housing clinic, which runs alongside probation hearings as well as reaching directly into prisons.

The common goal of these initiatives is to promote a planned transition. 

Jamming the revolver

There is no doubt that our society needs to prioritise ex-offenders being released to places of safety and stability. This ever-revolving prison-street-prison door needs to be closed off, with clear alternative signposting towards routes that have at least a chance of leading to rehabilitation. 

Miss Florence Kinder with Dr Rachael Pickering

Florence is a final year medical student doing a virtual elective with us,
and Rachael is a UK prison doctor and our medical director.                                 

If you have appreciated this article, we welcome donations towards our pandemic work with offenders & ex-offenders.

International Day in Support of Victims of Torture

On June 26th we remembered the UN International Day in Support of Victims of Torture. This date was chosen as it marks the day when the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) was implemented as a legal instrument in 1987.

History of torture prevention

In 1948 the Universal Declaration of Human Rights was adopted by the United Nations General Assembly states in Article 5:-

No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.

Then in 1975 the General Assembly adopted the Declaration of the Protection of All Persons from Being Subjected to Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, condemning torture and providing methods to prevent it.

Progress was made in the following two decades and eventually in 1984 the CAT was published, coming into force in 1987. This prohibits torture in all its forms and declares it cannot be justified under any circumstances.

How we support victims of torture

Regardless of whether they are signatories to national and international humanitarian laws forbidding ill-treatment, interrogation methods are brutal in many parts of the world both rich and poor. Rule of law may not prevail. And cultures of inter-prisoner violence (IPV) are often ignored or even encouraged by the authorities.

I signed my confession because I knew I would be beaten until I did. It was an easy decision.
(Detainee with strike marks on torso)

We utilise our expertise & advocacy in the detection and prevention of torture & ill-treatment. Patients, clinicians, relatives and legal representatives contact us for expert advice and advocacy. We also cooperate with the embassies of countries concerned that their citizens detained overseas are being torture or ill-treated.

The Gerry Serrano Centre is an institution based at Integritas House Olongapo in the Philippines. It provides healthcare, expert witness, advocacy, research and training for and about detainees past and present, especially those who have been tortured or ill-treated within the Western Pacific and South-East Asia.

The Gerry Serrano Centre is named in honour of the late Mr Gerry Serrano who was a long-term detained patient we were proud to know, care, and advocate for. He spent more than two decades behind bars facing many challenges but eventually, after 22 years, he was found innocent and released. He was free but his body could not recover sufficiently and he sadly died a year or so after release. Before he died, Gerry agreed that his story should be used in our work - promoting offender healthcare and opposing ill-treatment. And so we decided to preserve his memory by naming this centre after him.

Our advocacy and expertise work are needed more than ever to oppose ill-treatment and torture. In Spring 2021 we highlighted the many forms that torture and ill-treatment may take and how, despite international legal standards, torture still continues to this day. If you have been moved to support victims of torture and you’d like to support our anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.

C. René Padilla and the birth of Integral Mission

As an organisation that bases its principles on that of Integral Mission we remember Carlos René Padilla, the ‘Father of Integral Mission’ who sadly passed away in April this year.

CARLOS RENÉ PADILLA, 1932-2021

René Padilla was born in Quito, Ecuador before moving to Columbia with his parents at the age of 6 years. His father was a tailor by trade, and a Church-planter by faith; a difficult calling in a Catholic dominated society. Schooling was difficult due to his evangelical background resulting in several expulsions and exclusions. He went to University in the United States of America (USA) studying at Wheaton College (1953) and Manchester University (1963-1965), returning to Wheaton College in 1992.

As an economic migrant and as a member of a religious minority community, Padilla was shaped by a context of violence, oppression, and exclusion. The relationship between suffering and theology was an organic one for Padilla. As a young person, he recalled ‘longing to understand the meaning of the Christian faith in relation to issues of justice and peace in a society deeply marked by oppression, exploitation, and abuse of power’. The question for Padilla was not whether the gospel spoke to a challenging Latin American context, but how.

NEW THEOLOGY

In 1959 Padilla was Secretary to the Latin American International Fellowship of Evangelical Students. This meant travelling between institutions, providing him with an ‘ear to the ground’. In the 1960s, South America was gripped by politics and political unrest. Students were powerful and could cause turmoil, and often did with strikes. Evangelism was dominated by the large movements of the richer nations, with a model of separating out evangelism from social action.  Renée Padilla and his colleagues could not reconcile this style of working as he surveyed the young people and their political struggles. Working with Samuel Escobar and Pedro Arana, they began to generate a theology that would respond holistically from the Gospels to the pressing realities evident around them: social justice with an evangelical theology.

LAUSANNE MOVEMENT

In 1974, over 2,400 evangelical leaders met in Lausanne, Switzerland. This conference, known as the International Congress on World Evangelization (ICOWE) or the Lausanne Congress, brought participants together from across the world to share ideas on global mission for the first time. It was at this meeting that Padilla presented his theology on combining social justice and evangelism.

During his presentation, Padilla castigated American evangelists for exporting the American way of life, bringing solutions to local problems, devoid of any social responsibility. Mainstream protestant evangelism considered social action as implicit and not inherent with evangelism. Padilla argued that social action and evangelism were essential and indivisible components (opposite sides of a coin) or in Padilla’s words, ‘two wings of a plane’. And that belief in Jesus not only brought salvation but a demand to look after the immigrant, poor, needy, vulnerable, and widowed; a new societal way of thinking that remains valid today. The Christian faith was a way of life, not an added extra.

From this meeting the Lausanne Covenant was drafted, a document detailing the goals of evangelism, including Integral Mission. This eventually led to the Lausanne Movement, a way to connect ‘influencers and ideas for global mission’.

RADICAL DISCIPLESHIP

Seizing the momentum generated by Escobar and his plenary papers, Padilla, alongside John Howard Yoder, rallied an ad hoc group of 500 attendees they called the ‘Radical Discipleship’. This gathering sought to further sharpen the social elements in the drafted Lausanne Covenant. After the congress, Padilla recalled their radical discipleship document as ‘the strongest statement on the basis for holistic mission ever formulated by an evangelical conference up to that date’. He also declared the death of the dichotomy between social action and evangelism in Christian mission.

The proclamation of the gospel (kerygma) and the demonstration of the gospel that gives itself in service (diakonía) form an indivisible (indisoluble) whole. One without the other is an incomplete, mutilated (mutilado) gospel and, consequently, contrary to the will of God. From this perspective, it is foolish to ask about the relative importance of evangelism and social responsibility. This would be equivalent to asking about the relative importance of the right wing and the left wing of a plane.

It may have been ‘radical discipleship’, but Padilla did not invent integral mission. Integral mission is the core teaching of God’s word. Throughout the Old and New Testaments, God calls His people to be aware of the undervalued (poor, refugee, foreigner) and vulnerable (old, widowed, sick). He frequently laments that His people are not doing this and constantly exhorts and reminds us of our duty and responsibilities.

Wash and make yourselves clean. Take your evil deeds out of my sight; stop doing wrong. Learn to do right; seek justice. Defend the oppressed. Take up the cause of the fatherless; plead the case of the widow.

Isaiah 1:16-17

HOW CAN WE DO INTEGRAL MISSION IN HEALTHCARE?

The UK’s National Health Service (NHS) is one of the largest employers in the world, employing 1,093,638 whole-time-equivalent people who work alongside many ancillary staff employed by partner organisations. The NHS budget in 2018/19 was £130.3 billion, 9.8% of gross domestic budget.

The NHS has employed chaplaincy staff (formal and informal) to look after the spiritual needs of patients and staff for many years, but overt expressions of faith by Christian staff are discouraged and often obstructed. The law in the UK and many other countries reinforce this.

For too long the Christian Church has colluded with society, encouraging ordinary folk to keep their faith private, to take it off like a coat when they arrive at work or - better still - leave it at home. Yet the Gospels tell a different story. Christians are encouraged to share their faith (Matthew 28:16-20), not to hide their light under a basket (Luke 11:33-36) and to be the salt in society (Matthew 5:13). The Manila Manifesto (a 1984 elaboration of the Lausanne Covenant) states that the ‘Gospel must become visible in the transformed lives of men and women’.

We are never promised an easy life, rather one of hard toil and persecution. The Christian life requires total dedication, not attention just one day in seven.  The work place is the largest mission in field in the world. How often have we seen churches commission pastors, overseas workers, schools workers and Sunday school teams whilst overlooking those who toil in the secular world? We are called to witness to our friends, colleagues and families - to plant that small seed (Luke 13:18-21).

How can we be witnesses in the work place? Why, simply by demonstrating the love of God to our patients and our colleagues. We can be a beacon for God, a mirror that reflects His love and glory (Isaiah 43:10). We are His ambassadors to a troubled world.

Intercede for your work place. Pray for your colleagues and patients. Be prepared to be open and vulnerable, to share your story. This may come at a cost. It may be uncomfortable and difficult initially but rewards will follow. People will come to know God. Talk to your colleagues. Have a coffee or meal with them. Listen and share. Deliver a loving service to your patients, respecting their intrinsic value as beings made in the image of God. Demand justice and peace for them. Take any opportunity that is offered - the Bible on the bedside table, a throwaway statement or a direct question.

Tomorrow may be too late, so seize the day: ‘Carpe Diem!’

Dr David Smithard is a consultant physician for older age adults at a South East London hospital
and is a current participant on the Health & Justice Track.

The Ms Maxwell Series: Is it torture?

This week we finish our series pegged around the topic of torture, which made British news headlines in early Spring 2021 when Ghislaine Maxwell’s brother, Ian, spoke out against what he felt were torturous conditions in her New York jail. She is apparently being continually observed in a 6x9ft (1.8x2.7m) cell with no natural light and terrible food & water rations.

Previously: is sleep deprivation torture?

During this series we have asked ‘What is torture?’, ‘How small is too small?’ for a jail cell, and ‘What’s diet got to with it?’. And most recently we asked, ‘Is sleep deprivation torture?’ Over in Europe, a landmark case in the European Court of Human Rights (ECtHR) concluded that sleep deprivation, used as part of five techniques used in interrogation, amounted to inhuman and degrading treatment, but not torture. For Ghislaine over in the United States of America (USA) though, sleep deprivation as a consequence of suicide monitoring during the night could be an over-reaction and indeed counter-productive, unless that monitoring matched her level of risk. Whether sleep deprivation is inflicted for the purposes of interrogation, suicide surveillance or it is a result of other biopsychosocial factors from living in prison, it can have lasting health consequences that no human deserves.

Conclusions

Is it ill-treatment?

If Ghislaine is indeed being held in a 6x9ft (1.8x2.7m) cell with no natural light, under constant surveillance, and with terrible food and water rations as her brother reports, then could this amount to ill-treatment? According to the Nelson Mandela Rules (NMR), which the USA (as a member of the United Nations (UN) General Assembly) has to abide by, it could well be the case:-

• Has she been held for 22 hours a day, for more than 15 consecutive days as defined as solitary confinement, so breaching rules 44 and 45?

• Has her microwaved food lost its nutritional value to the extent that it is inadequate for health and strength, so breaching rule 22?

• Has there been insufficient attention to minimum floor space and lighting in her cell, so breaching rule 13?

If the answer to any of these question is an objective yes, then it may fairly be said that she has been subjected to cruel, inhuman or degrading treatment.

But is it torture?

Moving on from an objective yes to the above ill-treatment questions, then - as torture is a subset of ill-treatment - it may be that Ghislaine is being tortured. Let’s see…

We can’t use the European Convention on Human Rights (ECHR) or its more detailed Convention on the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), as she is not being held in Europe. Even if we could use these conventions, they do not actually define the torture that they ban. Instead, ECtHR judges sometimes rule on whether a particular case of alleged ill-treatment could be said to amount to torture.

We can’t utilise the UN’s Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT) and monitoring by its mandated Subcommittee for the Prevention of Torture and Cruel, Inhuman or Degrading Treatment or Punishment (SPT) to inspect her jail and look for evidence of torture, as the USA is not signed up to OPCAT. And even if USA jails did qualify for SPT inspections, this monitoring body does not have publicly available standards by which to judge cell size, nutrition, lighting and sleeping conditions.

However, the USA is signed up to the UN’s more basic Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). And according to CAT, torture requires a particular action to have:-

• caused severe pain or suffering, whether physical or mental;

  and

• been intentionally inflicted for such purposes as:-

  • obtaining information or a confession from the victim or another person,

  • punishment for a suspected or actual deed committed by the victim or another person,

  • intimidation or coercion of the victim or another person,

  • or discrimination of any kind;

  and

• been inflicted by a public official or other person acting in an official capacity.

Pain or suffering arising only from, inherent in or incidental to lawful sanctions such as corporal or capital punishment is specifically excluded.

So, to consider whether Ghislaine’s conditions are torturous according to the letter (as opposed to the spirit) of the USA’s legal obligations under the international humanitarian law it has chosen to sign up to, we must establish affirmative answers to all of the following questions:-

1. Is it causing severe mental or physical pain or suffering?

   • Severity is a completely subjective concept. In healthcare, we use a scale from 0 (no pain) to 10 (agony) for people to rate their pain. The major downside to this though is that one person’s 10 is another person’s 5. So this severity stipulation within CAT is the major sticking point for our conclusion.

2. Is its purpose to get information or a confession, or else to punish, intimidate, coerce or discriminate?

   • It’s difficult for third parties like us to establish the exact purpose or purposes.

3. Is it not a lawful sanction of corporal or capital punishment?

   • This is easy to answer. Yes, it is most definitely not a lawful act of corporal punishment.

4. Is it authorised or conducted by a state official?

   • Again, this is fairly easy to answer. Yes, it will be being authorised by her state prison managers and it will be being carried out by state prison officials (eg guards and cooks), although it’s possible that some of the poor cooking is being done by fellow prisoners.

Letter of the law

So, the long and the short of it is that no, according to the letter of the law, Ghislaine is not being tortured.

Spirit of the law

But really, is it right that a certain action may be judged torturous in one country yet non-torturous in another? Why is it that nations including ‘leaders of the free world’ such as the USA may belong to Club UN without ratifying OPCAT? Even signing up to the more basic CAT is optional. After all, Council of Europe member states are obliged to sign up to the CPT on top of the ECHR.

And as an aside, considering that information obtained under duress is often inaccurate, it is surely concerning that the majority (the USA along with China and Russia) of the five permanent members of the UN Security Council (the UN body charged with maintaining international peace and security) are OPCAT signatories.

But let’s return to the fact that what is deemed torture in one state is deemed non-torturous in another. Where is the equivalence? Where is the justice? So many of the world’s 11 million prisoners eat terrible food and live 24/7 in cramped, dark cells - with the full knowledge of their country’s officials. Others are kept alone for months and years at a time. At the very least, this is discrimination against people who are deprived of their liberty. It is surely perverse that we need to argue about semantics in order to decide if these poor people are being tortured! Just how malnourished, lonely, cramped and light deprived does a human being have to be before the law will consider protecting him or her?!

A higher law

As we are a Christian faith-inspired NGO, we also look to an additional set of rules to guide our work - God’s Laws as set out in the Bible.

The Bible has much to say about how to live in just societies. In a nutshell, it rests on how we treat one another. In the New Testament, Jesus teaches his followers ‘The Golden Rule’ as well as ‘The Greatest Commandment’:-

“So whatever you wish that others would do to you, do also to them, for this is the Law and the Prophets.”

Matthew 7:12

Jesus replied: “‘Love the Lord your God with all your heart and with all your soul and with all your mind.’ This is the first and greatest commandment. And the second is like it: ‘Love your neighbour as yourself.’ All the Law and the Prophets hang on these two commandments.”

Matthew 22: 36-40

Loving our neighbours - that is, others living within our culture - as ourselves is a wonderful principle, regardless of one’s faith. Let’s ask ourselves, ‘Would I wish to live day in, day out in a tiny, dark cell? Would I want to eat bland, unhealthy food for breakfast, lunch, and dinner? And would I want to live my life under constant scrutiny?’ If our answers are ‘No, No and No’ then consider: ‘How can I not speak up whilst this is happening to my neighbours?’

At Integritas Healthcare, we advocate for those who are tortured or otherwise ill-treated because we believe that every human being is made equal with innate worth and dignity. We are called to treat everyone with the kindness and compassion we ourselves would want. Taking inspiration from Matthew 25:37-39, whatever we do in the service of others, we do in love of our fellow man and in our love for God:-

“For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.”… “Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.”

A glimmer of hope

We end this series with some recent good news that provides a glimmer of hope for prisoners in solitary confinement in the USA.

From next year, the State of New York has agreed to ban solitary confinement exceeding 15 days, so as to ensure compliance with the Nelson Mandela Rules. This new law will include screening for suicide risk and the development of rehabilitation units for those who would otherwise have been sent to solitary confinement.

It may only be one law, but it could be the start of a nationwide change in how detainees are treated within the USA’s penal system. It is also the beginning of being able to hold certain USA detention centres accountable for any discrimination against vulnerable patient groups who are disproportionately sent to solitary confinement and who are generally more poorly treated within many of the world’s penal institutions. So watch this space!

If you have been moved by this series on torture and you’d like to support our anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.

A Day in The Life of a Clinical Fellow

I’m Esme, an honorary clinical fellow with Integritas Healthcare. I’m a junior doctor based in the UK, currently taking time out of formal medical training.

I have been a clinical fellow with Integritas since January 2021, having been a participant on the new Health & Justice course run by Integritas in partnership with Christian Medical Fellowship (CMF) since Autumn 2020. Through this track I was inspired and encouraged to pursue my interest of working with vulnerable patient groups by joining the team!

Being a clinical fellow is really flexible to fit around my other commitments. I work in a part-time manner, doing two and a half days a week. Here is a breakdown of what a typical day might look like for me:

7:15am: I wake up and get myself ready for the day.

8am: I log on to zoom for telemedicine clinic, it is 3pm in the Philippines and our Integridad team are ready to show us the patients for the day. They have sent us a pre-filled clinic record with the patient’s details, observations and the presenting complaint before we begin. I accompany one of the more senior clinicians and complete the online electronic medical record as we go along. We see a variety of complaints from foot ulcers and diabetes management, to communicable diseases and ENT problems!

9am: Clinic finishes promptly at 4pm Philippines time, when the detainees must go back to their cells. Our European and Philippines team now meet online for devotions - a time of bible study and prayer. This is a wonderful time of fellowship and helps me get ready for the day ahead.

9:15am: I make a cup of tea before I check my emails and come up with a list of tasks for the day.

9:30am: I log on to our website editing suite and start a new opinion piece for our current blog series on torture and ill-treatment. A large part of my work is advocating for vulnerable patient groups, which I do through writing blog posts and raising awareness on social media. Through this I have been able to stretch my writing skills and develop my knowledge of the difficulties faced by those in secure environments.

12:30pm: My lunch break is pretty flexible, and I usually use it as a chance to stretch my legs and get come fresh air after sitting at my desk all morning!

1:30pm: I log on to zoom for a meeting with a colleague I am creating training videos with. We prepare in advance an interview script to record, and once we are done I edit it to ensure it looks professional. I upload this to dropbox for later use.

4:00pm: And that’s me done for the day!  

Every day can be very different - sometimes I attend board meetings, sometimes I get involved in other projects, and sometimes I work outside my normal hours to write a statement for a breaking news story. It can be challenging but I have certainly learned a lot and would recommend this position to anyone!

If you are thinking about taking a gap year either as a student or junior healthcare professional and you’d like to be involved in advocacy work, you can apply to join us here! We welcome all enthusiastic Christian healthcare professionals who want to learn and grow with us as an organisation. If you have any questions please get in touch.

Mental Health Awareness Week

To mark Mental Health Awareness Week 2021, we are releasing a short audio edit taken from a mental health training video series currently in production. This training is aimed at christian healthcare professionals and will be delivered during our formal training courses. However we feel that whether you’re a healthcare professional or not, you might benefit from learning about today’s chosen topic - dissociative disorders - which are a less widely known and often misunderstood mental health problem.

Listen below as one of our volunteers kindly shares her experience of living with dissociative disorders:

Warning: this content contains the discussion of sensitive topics, including self-harm.

If you or someone you know may be struggling with symptoms of a dissociative disorder there is more support and information on the NHS website and also on the website for mental health charity Mind.

The Ms Maxwell Series: Is sleep deprivation torture?

We return to our series pegged around the topic of torture, which made British news headlines in early Spring 2021 when Ghislaine Maxwell’s brother, Ian, spoke out against what he felt were torturous conditions in her New York jail. She is apparently being continually observed in a 6x9ft (1.8x2.7m) cell with no natural light and terrible food & water rations.

Previously: What’s diet got to do with it?

After exploring the questions of ‘What is torture?’ and ‘How small is too small?’ for a jail cell, we discussed ‘What’s diet got to with it?’. The UN’s Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) stipulate food must be nutritious and a detainee must have ready access to drinking water. However, whether or not allegedly inedible food could be considered ill-treatment amounting to torture as defined by the UN’s Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) is doubtful. Either way though, it’s neither necessary nor proportionate punishment for detainees to be without access to nutritious food and reasonable quality water.

Now: sleep deprivation

More recent news reports have shone light on new bruising around Ghislaine’s eyes, suggesting she is now suffering from sleep deprivation as a result of being woken by torchlight repeatedly throughout the night as part of her suicide watch.

The suicide prevention in jails and prisons guidance written by the World Health Organisation (WHO) recognises that adequate monitoring of suicidal prisoners is important to prevent deaths, especially during the night:-

Adequate monitoring of suicidal inmates is crucial, particularly during the night shift (when staffing is low) and in facilities where staff may not be permanently assigned to an area (such as police lockups).

The guidance also understands that the ‘level of monitoring should match the level of risk’. If Ghislaine’s New York jailors have conducted risk assessments that clearly identify her being high risk of suicide, then constant surveillance may be necessary for her own safety. However, if Ian Maxwell’s claims are true and her jailors are acting purely out of an excessive fear for their own reputation, then her level of monitoring is truly excessive and could even be counter-productive. And, as the Judge presiding over Ms Maxwell’s case has already suggested, she could have an eye covering to help her sleep despite frequent nightly checks. So why didn’t someone think of it before?

The Nelson Mandela Rules, which are designed to maintain a prisoner’s human rights and dignity, include guidance on sleeping arrangements:-

All accommodation provided for the use of prisoners and in particular all sleeping accommodation shall meet all requirements of health, due regard being paid to climatic conditions and particularly to cubic content of air, minimum floor space, lighting, heating and ventilation.

Darkness is essential for good quality sleep. As levels of light decrease at the end of the day our body produces the hormone melatonin, which causes muscle relaxation and the feeling of tiredness, which in turn initiates sleep. Light exposure during the night may impede this natural rhythm, provoking periods of wakefulness. Therefore, appropriate lighting, or lack of it, at night time is an important right for prisoners.

Sleep deprivation and interrogation

Historically, the technique of depriving a prisoner of sleep has been used for the for purpose of obtaining a confession or other information. Sleep deprivation was one of five techniques employed by the British Military as an interrogation method during the 1970s. In the European Court of Human Right’s trial Ireland v. the United Kingdom, it was concluded:-

... Although the five techniques, as applied in combination, undoubtedly amounted to inhuman and degrading treatment, although their object was the extraction of confessions, the naming of others and/or information and although they were used systematically, they did not occasion suffering of the particular intensity and cruelty implied by the word torture as so understood. ...

The Court concludes that recourse to the five techniques amounted to a practice of inhuman and degrading treatment, which practice was in breach of [the European Convention on Human Rights] Article 3.

Whether sleep deprivation is inflicted for the purposes of interrogation or it is a result of other biopsychosocial factors, what might be the health consequences?

The importance of sleep

It is common knowledge that a lack of sleep can impact health and wellbeing. In the short term, it reduces concentration and increases irritability. Ongoing sleep deprivation decrease the immune system’s defence against infectious diseases - not a welcome thought during a worldwide pandemic! It also increases the risk of heart disease and diabetes with serious consequences for life quality and expectancy.

How can prisoners achieve better sleep?

Achieving good sleep in prison is a challenge. The stress and chaos of prison life, sometimes compounded by drug and alcohol use, or a mental health problem, often lead to sleepless nights.

Many of the environmental factors in prison cannot be changed, but it is both easy and important to empower prisoners to choose small things that can have a positive impact on their quality of sleep. This is called ‘sleep hygiene’. Making these small changes also increases their sense of control, which is a rare and precious sensation for most of the world’s detainees.

PILs

Our picture-heavy, word-light Insomnia Patient Information Leaflet (PIL) has been designed especially to help prisoners with sleep hygiene. We are in the early stages of an ongoing project to translate our detainee-friendly PILs into multiple languages and make them freely available on our website. This will make them readily accessible to individuals and organisations involved in supporting many of the world’s 11 million detainees. If you have a heart for helping detainees improve their own health and wellbeing, you could donate to our work or (if you’re suitably skilled) join us as a translator.

So Is Ghislaine Maxwell being tortured?

Next time we will reflect on this series’ findings and decide…

If Ian Maxwell’s allegations are true, is Ghislaine being ill-treated in a manner that could be said to amount to torture?

Until then…