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.

Concern Raised For New Immigration Detention Centre

A new immigration detention centre (IDC) for women is planned to open at the former Secure Training Centre, in Medomsley, County Durham later this year. In her position as co-chair of the Forensic and Secure Environments Committee of the British Medical Association (BMA), our Medical Director, Dr Rachael Pickering, was one of hundreds of signatories to a letter sent to the Home Secretary yesterday detailing concerns about this IDC.

Coordinated by Women for Refugee Women with other campaign groups, this letter outlines concerns that this new detention centre would pose serious mental health risks to the women it would detain. It has been found that just under half of women in another IDC have self-harmed, and many of these women were already survivors of torture, rape and trafficking, with their detention only adding to the trauma they had previously experienced.

These women arrive in this country extremely vulnerable, often claiming they have had to flee persecution in their country of origin. Whether this claim is true is for the government to decide, but does this necessitate locking them up and treating them as criminals?

There are other ways to monitor and track these women in the community as they apply for asylum, so what is the point of this facility? How will it benefit their care? Why don’t we take this opportunity to extend compassion to them rather than imprisoning them?

For media enquiries, please phone our Medical Director or email our European office.

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…

Nil By Mouth

Miss Danielle Fung is a final year medical student with a keen interest in offender healthcare. She writes this personal opinion piece as part of her medical elective with Integritas Healthcare…

On strike

Hunger striking is an emotive, enduringly controversial topic. Exploring it in the context of a real life (or in this case, now dead) prisoner’s story sets it in context but makes it no more palatable. And that is what we’re going to do now as, 40 years ago today, a hunger striking Member of Parliament (MP) died in a British prison.

Who was this MP? Why did he hunger strike to death? Why do other prisoners do it? What do medical ethical codes and international humanitarian law (IHL) say about managing hunger strikes? And, boiling it all down to the main point of interest to someone like me who is working within a medical NGO with a heart for detainees, how should secure environment healthcare professionals treat their hunger striking patients?

Let’s find out…

BOBBY SANDS MP

Bobby Sands was a member of the IRA, a paramilitary group seeking independence for Northern Ireland. Following the bombing of the Balmoral Furniture Company in Dunmurry, in 1976 he was imprisoned for a second time and sent to the infamous Maze Prison.

He and his comrades started protesting against the fact that they had ceased to be regarded as political prisoners - a class of prisoner traditionally afforded certain privileges such as being permitted to wear their own clothes and not being obliged to do prison chores. So, rather than putting on prison uniforms, they went naked or wore just blankets - earning themselves the nickname ‘blanket men’. And rather than slopping out their cells every morning, they smeared their own faeces over their cell walls - a ‘dirty protest’.

Bobby Sands on hunger strike in HMP Maze, as re-created by Sarah-Louise Bedford from a photograph

They then upped the stakes with a phased hunger strike. Bobby was the first striker, commencing his hunger strike on 1st March 1981. During the following 66 days he managed to get elected as an MP before dying in the prison hospital on 5th May.

OTHER SUFFERERS

The following week the first two of nine other hunger striking comrades died. In total, including Bobby, ten men died between 5th May and 20th August, taking between 46 and 73 days to succumb to death. They were all under 30 years of age.

Thirteen additional men who had joined the hunger strike went on to survive, including one man who had refused food for 70 days. They lived due to medical emergencies (such as suspected perforation of a duodenal ulcer) necessitating urgent treatments or, as was legal then, their families making clear that they would act to authorise life-saving medical interventions.

Interacting with and caring for hunger strikers can take its toll. Over the following few years, alcoholism, absenteeism and suicide blighted the staff side of HMP Maze. These other sufferers included Dr David Ross, the prison doctor who had cared for the hunger strikers day-in, day-out throughout much of 1981: he died after shooting himself in the abdomen.

Methods & Motives

Not all hunger strikes are the same. ‘Dry strikes’ consist of the refusal of fluids as well as food. They are relatively rare, not least because death results far sooner than is desirable when trying to negotiate with one’s opponents. Other prisoners conduct limited food refusals - declining some but not all foods.  

Detainees have far less autonomy than free citizens. The decision as to whether or not to open one’s mouth - to speak, to eat, and to drink - is one of the few things within their control. Hunger striking is therefore a logical means of protesting behind bars.

Many countries’ prison authorities recognise a food refuser as being on hunger strike once (s)he has completed 72 hours of voluntary, total food refusal for an intended purpose. Intention is key: although a food refuser may be willing to pursue their goal regardless of the risk to their life, if their actual goal is to end their own life, then their actions are usually deemed to be a suicide attempt rather than a hunger strike.

The main aim of the 1981 HMP Maze hunger strike was to reinstate ‘political prisoner’ status for detained IRA members. And this ‘I want something to change’ motivation is a common, though not universal, thread running through the majority of hunger strikes. Prisoners most often hunger strike as a means of trying to get better or less restrictive prison conditions or to try to have their court cases reheard or their sentences reviewed. A high profile contemporaneous case is that of the jailed Russian opposition leader, Alexei Navalny, who recently went on hunger strike in a bid to obtain better medical treatment within his prison.

A poster depicting a Suffragette being force fed by a prison doctor and his assistants.
(Image is the property of Museum of London.)

ForceD Feeding

Back in Britain though, another famous example of hunger strikers is the early 20th Century suffragettes - women (and not a few men) who campaigned for women to be granted the right to vote. Jailed for relatively petty crimes (such as smashing windows and other acts of criminal damage) committed as part of their campaign, they too were denied the status of political prisoners.

In response, they closed their mouths, going on hunger strike. The government of the day feared that at least one would die in custody with likely risk of increased public sympathy for their demands. So the prison doctors of the day complied with government directions to forcibly feed these mentally competent prisoners. The film Suffragette contains a graphically accurate depiction of this procedure as it was conducted at that time.

Later on in the campaign, a law (the so-called Cat and Mouse Act) was passed in order to temporarily release hunger strikers who were nearing death, so obliging them to recover in the community before bringing them back to prison where the vicious cycle would often re-start. It is poignant to note the use of the word ‘torture’ in the pro-suffragette depictions of their ill-treatment.

Medical ethics

Four well-respected pillars supporting the broad pavilion of international medical ethics are autonomy, beneficence, non-maleficence and justice. In a nutshell, this means that doctors should have respect for patients’ right to self-determination, consider what is most just for the society within which their patients live, act for their patients’ good, and definitely not set out to harm their patients. 

Therefore, it is a very serious decision to force feed a patient who has exercised his or her right to autonomy and made a capacitous decision to hunger strike. And in 1975 the World Medical Assembly (WMA), an organisation founded in the aftermath of World War II to provide international consensus on medical ethics and clarity about medical practice, condemned forced feeding within the Declaration of Tokyo:-

PREAMBLE

It is the privilege of the physician to practise medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, and to comfort and to ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use is to be made of any medical knowledge contrary to the laws of humanity.

For the purpose of this Declaration, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.

DECLARATION

1. The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives, and in all situations, including armed conflict and civil strife.

7. A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician’s fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose.

8. Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially, as stated in WMA Declaration of Malta on Hunger Strikers. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.

(Extracts of the Declaration of Tokyo (emphasis in bold added), as revised in 2016)

Reassuringly, this declaration cuts through all the convoluted arguments created by the various definitions of torture within International Humanitarian Law (IHL). Doctors who are members of any national medical association - including the British Medical Association (BMA) and American Medical Association (AMA) - signed up to the WMA are left in no doubt as to what the vast majority of their worldwide colleagues believe torture to be.

The above-mentioned Declaration of Malta on Hunger Strikers was adopted by the WMA in 1991. It combines medical ethics with practical advice on how best to manage hunger striking patients. Key points include:- 

• identify the hunger striker’s goal;

• offer regular medical examination including serial weight measurements;

• offer detailed information about the side-effects and risks of prolonged fasting;

• consider psychiatric assessment to confirm capacity to refuse life-saving treatment;

• offer ongoing treatment for other pre-existing or emerging health problems;

• keep checking that food refusal is voluntary, as peer-pressure may be a factor;

• offer medical intervention for potential medical emergencies including, if appropriate, the option of resuscitation;

• offer palliative care, as the hunger strike progresses.

And the declaration’s bottom line couldn’t be clearer:-

23. All kinds of interventions for enteral [food delivered by mouth or a tube to the stomach or small bowel] or parenteral feeding [nutrition delivered into a large vein] against the will of the mentally competent hunger striker are “to be considered as “forced feeding”. Forced feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting.

(Principle 23 of Declaration of Malta on Hunger Strikers (emphasis in bold and explanations in square brackets added), as revised in 2017)

Both the International Committee of the Red Cross and the BMA’s Medical Ethics Today have eminently useful summarisations of these ethical codes and principles.

International humanitarian Law

Today though, some doctors have to negotiate a professional minefield.

In certain countries, there is tension between what a piece of IHL actually states and how a signatory nation has interpreted and enshrined it into its own national legislation. Take, for example, aspects of the European Convention of Human Rights (ECHR):-

ARTICLE 2 Right to life

1. Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.

2. Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary: (a) in defence of any person from unlawful violence; (b) in order to effect a lawful arrest or to prevent the escape of a person lawfully detained; (c) in action lawfully taken for the purpose of quelling a riot or insurrection.

ARTICLE 3 Prohibition of torture

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

An extreme interpretation of Article 2 may cause a nation to legislate that, in addition to its citizens having a ‘right to life’, the state has a duty to preserve the life of each citizen over which it has a measure of control - for example, detainees. Yet when these life-sustaining measures are carried out regardless of a detainee’s wishes, they may be in contravention of Article 3 of the ECHR - the right not to be ill-treated at all, yet alone ill-treated in a manner that could be said to amount to torture. In other words, one legal right can become elevated to that of a duty trumping all other rights. And this tension is demonstrated quite clearly in the treatment of force-fed Spanish detainee Mr De Juana whose case the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) investigated and corresponded over with the Spanish Government in 2007.

The Road to Guantanamo

Elsewhere it gets far more worrying. Certain other countries’ governments issue far less benevolent edicts with some of their politicians and lawyers riding roughshod over IHL. They may not be signed up to the Council of Europe’s ECHR or the United Nations’ Optional Protocol to the Convention Against Torture (OP-CAT) or even its more basic Convention Against Torture (CAT). Perhaps even more seriously though, others are signatories yet choose to ignore or ‘reinterpret’ their legal obligations.

Secure environment healthcare professionals operating within such countries have it very tough indeed, most especially if they share the same authority structure as surrounding discipline teams…  

Recreation of forced feeding as alleged to be practised within Guantanamo Bay

The Guantanamo Bay hunger strikes came to light in 2005 when about a third of the prisoners started food refusals. The camp authorities responded by authorising the forced feeding of those who were deemed to be causing themselves harm. The strikes were reported again in 2013, following on from which the United States government refused to disclose any further information regarding hunger strikes at the camp.

An extract from the book Torture Team, by leading IHL authority Philippe Sands, gives convincing evidence of additional medical complicity in ill-treatment during interrogation at Guantanamo as far back as 2003. Quoting a commentated extract from the detention log of fluid-refusing prisoner Mr Al-Qahtani who was resisting interrogation:-

A couple of hours later, at 0645, the doctor ‘attempted to put in an IV and was unsuccessful’. At 0730 the doctor ‘ran an IV by putting in a temporary shunt to allow continuous IV’. At 0745 the detainee ‘bent over and bit the IV tube completely in two. The guard strapped him to a stretcher and the corpsman attached a new IV. The detainee struggled through the entire process, but could no longer reach the IV.’… Another example was on 1 December at 0745: ‘Corpsman administers IV. Detainee’s head is restrained by MP to prevent detainee from biting IV’.

(extract from page 206 of Torture Team by Philippe Sands)

Secure environment healthcare professionals often feel pressure to make small compromises in how they adhere to medical ethical gold standards. Yet just one small step onto a slippery slope can prompt a slide towards the gates of disaster.

Medical ethical codes exist for good reason. We break them, bend them to our will, or even just ignore them at our peril.

Miss Danielle Fung, with Dr Rachael Pickering

PS If you’d like to support Integritas’ anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.

Autism Awareness in April

Today, the last day of April, marks the end of Autism Awareness Month, raising awareness about a condition that is close to our hearts…

There are around 11 million detainees in the world. Autism affects around 1% of the population. So in theory that’s approximately 110,000 autistic people behind bars across the world. However, we know that autistic people are over-represented within some secure environments - for example, one English prison found that 4.5% of its population had an autistic spectrum condition. Outside of work I care for an autistic person so I am more aware of the condition than your average UK doctor, and I take this awareness to my job as a UK prison GP. Most weeks I spot patients who are quite obviously autistic yet who have got to an advanced stage of life without it being formally diagnosed or even recognised as such.

Regardless of exactly how many autistic people are behind bars though, they are some of the most vulnerable detainees. It fills me with sadness that they live in stressful, unsuitable environments. I still remember with horror an incident from the earlier days of my career behind bars, when I attended the death scene of an autistic man. My colleagues and I had tried to help him, but his despair was too much for him to bear. He managed to kill himself despite our best efforts to prevent him from doing so. It was a tragedy.

Whilst the UK’s criminal justice system still struggles to know what to do with autistic people, it is encouraging that a small minority of the UK’s prisons have succeeded in the challenge of achieving accreditation with the Autism Accreditation Service, which is provided by the National Autistic Society (NAS). One of these accredited prisons is HMP Wakefield, a high secure estate; another is YOI Feltham, a notoriously busy young offenders institution. If these particularly challenging secure environments can do it, then surely all other UK detention settings could manage to follow suit.

As a medical organisation with a heart for detainees, we’ve spent April considering how to amplify our autism & disabilities advocacy. We welcome all suggestions. But for starters, we’ve decided to become NAS-accredited ourselves. Why not turn to organisations within your sphere of influence and draw their attention to this fabulous scheme?

Near Miss

The trial and conviction of ex-police officer Derek Chauvin for the killing of George Floyd is to be welcomed as evidence that no-one - not even a law enforcement officer - need be exempt from the rule of law.

This tragedy has highlighted the dangers of law enforcement officers deploying unsafe restraint mechanisms on detainees. What hasn’t been so much talked about, though was mentioned in the trial, is the fact that even the most professional person is only as good as his or her training. A rogue person at the centre of a major incident is rarely the perpetrator of a one-off error. Usually, they will have been committing ‘near misses’ for years…

A near miss is an event that had the potential to cause injury or ill health but did not actually do so.

A risky-behaving professional could behave in an unsafe manner - such as deploying an unsafe restraint technique - 100 consecutive times with the first 99 episodes being near misses. Finally though, the 100th episode results in harm. Sometimes that harm is serious or even fatal.

So often, long before the fateful event, the risk-taker is well-known within his or her workplace - for taking a cavalier approach to health & safety, for not following policies & procedures, or for being difficult to line manage.

And this is true for all kinds of professionals, not just law enforcement officers. Take healthcare professionals…

We’ve just had a near miss in the prison I work in. A drug-addicted prisoner nearly received a duplicate dose of methadone [a prescribed alternative to street heroin]. I prescribed a dose for her, ignorant of the fact that she had already received a dose earlier that day. I didn’t know about that first dose because it had been marked erroneously as declined - that is, not swallowed - in her medical record. It was only by sheer luck that the true situation came to light before she was given my prescribed dose. I insisted on submitting a ‘near miss’ report because, just like unsafe restraint positions, methadone in excess can cause fatal respiratory depression.

(Anonymous UK prison doctor)

Restraint is used in both law enforcement and health & social care settings, either by physically holding the person, mechanically using equipment such as handcuffs or velcro straps, or chemically using pepper spray or a sedative. It should never be used as punishment, but only if there is a risk of harm to the person being restrained or to others around them. However, if someone is restrained, there must be safeguards in place to ensure that the benefit outweighs the potential harm of the restraint itself.

The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) provides guidelines on the use of restraint on prisoners, including the training of prison staff in its use:-

Rule 76

Training referred to in paragraph 2 of rule 75 [All prison staff shall possess an adequate standard of education and shall be given the ability and means to carry out their duties in a professional manner] shall include, at a minimum, training on:

(c) Security and safety, including the concept of dynamic security, the use of force and instruments of restraint, and the management of violent offenders, with due consideration of preventive and defusing techniques, such as negotiation and mediation;

Turning then to the issue of detainees like George Floyd being restrained, we could extrapolate this guideline as applying to any professional who may have to use restraint in their work environment. All would-be restrainers should be optimally trained to ensure that they may carry out their duties safely, and employers should be accountable for the provision of high quality training.

Whether you are a healthcare professional, a law enforcement official or a member of the public, you should have confidence in the safe and appropriate use of restraint. And we all have an obligation to support these individuals in pushing for optimal training and corporate responsibility.

Have you seen someone repeatedly ‘get lucky’ with unsafe working practices - be it unsafe restraint, inadequate record keeping, or anything else? Then raise a concern. And every time you come across or are involved in a near miss, report it as such. Doing so helps managers and their organisations - to improve training for all their staff, to close down unsafe practices, and to discipline the small minority of personnel who refuse to abide by safe practices. The end result is a safer environment for everyone.

Dr Esme MacKrill with Dr Rachael Pickering

The Ms Maxwell Series: what's diet got to do with it?

We return to our series pegged around the topic of torture, which made British news headlines in 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: How small is too small?

After exploring the question of ‘What is torture?’, we looked at how to decide ‘How small is too small?’ for a jail cell. Ghislaine is in the United States of America (USA), which is not subject to inspections by the UN’s torture inspection committee, which anyway lacks published standards on living space. However, if she was transferred to a European jail, the Council of Europe (CoE) would be able to apply its own torture inspection committee’s living space standards and declare her solitary 4.9m² cell too small. Whether or not such environmental ill-treatment would be deemed to amount to torture would however be a matter of deliberation for judges at the European Court of Human Rights (ECtHR).

So what about her diet?

In his interview Ian Maxwell raised concern about Ghislaine’s food and water:-

The water that is provided through the prison is brown, and the food that she is given is very highly microwaved and basically inedible.

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

Rule 22:-

1. Every prisoner shall be provided by the prison administration at the usual hours with food of nutritional value adequate for health and strength, of wholesome quality and well prepared and served.

So is this true of Ghislaine’s food?

Her food is described as ‘highly microwaved’. But what does this mean? Mostly microwaved as opposed to boiled or grilled? Or microwaved for too long a period of time? Rather than speculating further as to the meaning behind this ambiguity, let’s inspect known facts.

Microwaving does not necessarily deplete food of its nutritional value. In fact, it can preserve certain vitamins and minerals better than boiling, which causes nutrients to leak into the cooking water. The very nature of a microwave is that it requires only a short period of time to heat food. However, over-cooking even by microwave does start to affect a meal’s nutritional value.

Still, there’s poor food and poorer food. Prisoners around the world have very different meals. Many have to consume unrecognisable soups and stews that are barely sufficient to sustain life, and others have reduced or even completely absent food rations as punishment.

And what about her drinking water?

Rule 22 of the Nelson Mandela Rules also states:-

2. Drinking water shall be available to every prisoner whenever he or she needs it.

But how much water does a human require? The International Committee of the Red Cross’ handbook Water, sanitation, hygiene and habitat in prisons states:-

The strict physiological needs of a human individual may be covered by 3 to 5 litres of drinking water per day. This minimum requirement increases in accordance with the climate and the amount of physical exercise taken.

The minimum amount of drinking water that must be available inside the cells and dormitories is in the order of 2 litres per person per day if the detainees are locked in for periods of up to 16 hours, and 3 to 5 litres per person per day if they are locked in for more than 16 hours or if the climate is hot.

Ghislaine does has ready access to drinking water though it is apparently brown, which of course doesn’t look appetising and may affect its taste. Such discolouration may be due to the corrosion of plumbing leaching lead into the water. However, running the water briefly before use should flush the system. Moreover, in New York City the water is monitored carefully, from delivery from upstate reservoirs to street-side sampling stations, to ensure the the risk of lead poisoning remains low.

Such safeguards do not protect many of our globe’s 11 million prisoners. Little data exists on how many have access to clean drinking water, but it definitely is a problem. In Brazil, for example, Human Rights Watch found that in some prisons water is available for only half an hour in the morning and half an hour in the evening.

What about her access to natural light?

According to her brother, Ghislaine has ‘no natural light’ in her cell. If true, this is a contravention of the Nelson Mandela Rules:-

Rule 13: 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.

Rule 14: In all places where prisoners are required to live or work:

(a) The windows shall be large enough to enable the prisoners to read or work by natural light and shall be so constructed that they can allow the entrance of fresh air whether or not there is artificial ventilation;

Of course, there are greater and lesser degrees to which thousands of prisoners around the world are deprived of their right to natural light. Some, apparently like Ghislaine, are kept in cells lacking natural light but are allowed outside daily for exercise in the fresh air. This latter fact complies with another Nelson Mandela Rule:-

Rule 23:-

1. Every prisoner who is not employed in outdoor work shall have at least one hour of suitable exercise in the open air daily if the weather permits.

A prisoner, found in a dark solitary confinement block where we assessed his dental hygiene and general health

Many others though are kept without natural, or indeed any, light 24/7:-

It’s been my sad duty to visit solitary confinements in many countries across the world. And I can confirm that many regimes still subject human being to darkened solitude. If they weren’t mentally distressed upon entering such environments, then the environment itself soon rectifies this. Why is this still going on in the 21st century?!

(Dr Rachael Pickering,
one of our medical experts)

And what are the likely health consequences?

A diet lacking in fibre can cause constipation, which may be linked to bowel inflammation and even perforation.

A diet with inadequate intake of key vitamins and minerals, can lead to malnutrition. Vitamin deficiencies can cause lethargy, breathlessness, palpitations, reduced vision, gum disease, and muscle wasting to name a few. Vitamin D deficiency, which is caused by dietary deficiency and lack of access to sunlight, may cause various symptoms including bone and muscle pain, difficulty walking, muscle weakness, and increased risk of fractures. It may also impact mental wellbeing, being linked to depression and schizophrenia.

Even without associated vitamin D deficiency, lack of exposure to sunlight may contribute to low mood and fatigue, due to the brain’s reduced production of serotonin and increased production of melatonin.

So is Ghislaine Maxwell being tortured?

Next week we will reflect on the findings within this series and consider…

If these allegations are true, is Ghislaine being ill-treated?

And if so, is it ill-treatment which could be said to amount to torture?

Until next week…

Dr Esme MacKrill

PS If you’d like to support our anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.

Please Sir, I want some more

Many of my fondest childhood memories involve food: the delight of a chocolate birthday cake, eating eggs for breakfast on the weekend, or walking home from school ravenous but knowing that my mum would be waiting for me with a warm, nourishing meal.

These heart warming recollections are far from universal. Many children here in the United Kingdom (UK) face serious chronic hunger. This is a hunger that is never treated appropriately with regular meals. Rather, it is only ever palliated. What must it be like to live each day not knowing where your next decent meal is going to come from?

Growing hunger

The last year put new questions into our minds as we traversed the daily hardships of the COVID-19 pandemic. Many more parents started to ask, ‘How am I going to feed the kids this week?’ Though this terrible dilemma existed long before the pandemic, it’s now being asked in more UK homes than we could ever have imagined.

The UK’s pre-pandemic wealth gap has left our most vulnerable citizens exposed to the devastating social and economic impacts of the pandemic. Parents have faced job insecurity, loss of social support from friends and relatives, and a daily risk to health for those who have been unable to work from home. And these challenges piled in on top of their pre-pandemic difficulties in providing for their children. The end result has been higher rates of food poverty.

Invisible hunger

When our schools first closed, many of our most vulnerable children sat behind locked doors, unseen and unheard. We look back with disdain to the neglect of children by our Victorian ancestors, when Dickens gave voice to their pleas through the immortal Oliver Twist. Yet so many modern-day hungry children have gone unheard during the pandemic. Even if they have been heard though, who in a position of authority has really listened? We must speak up for these precious young lives.

Chronic hunger

The issue of childhood food poverty goes far beyond the daily misery and anxiety that comes from being chronically hungry. Children with growling bellies do not concentrate well on their lessons. They do not exercise well.  They do not invite their friends round for tea. Malnutrition at a young age impedes healthy development and it leads to a multitude of both short-term and long-term health problems, including the current obesity epidemic. Our poorest families are unable to access and prepare enough healthy food.

Even now, as the pandemic in the UK starts to ease, there are no clear solutions for these families. The economic consequences of the pandemic will be long-lasting. There is ongoing debate between the government and local authorities about who should provide free school meals going forwards. Will they continue during future school holidays and, if so, in what form? Should meal packages contain one potato or two carrots? Whilst some provision is better than no provision, we can and must do better.

Ending hunger

Today in the UK there are children who will be going to bed hungry, as they do every night. We need to swallow our pride, stop blaming their parents, and accept that childhood food poverty is not limited to so-called ‘under-developed countries’. The way that we (do not) provide for the youngest members of our society is far from ‘developed’. We must not content ourselves with the promises and supposed quick fixes rushed out at the height of the pandemic. Instead we must push for committed action to bring about long-term societal change. Every child in the UK should have enough food to grow up happily into a healthy adult. 

Dr Elinor Webb is a junior doctor working in the NHS and studying on the Health & Justice Track delivered by Integritas Healthcare for Christian Medical Fellowship

Jamming the Wheel: Remembering Dietrich Bonhoeffer

Who was Dietrich Bonhoeffer?

Pastor Dietrich Bonhoeffer

Image provided by Encyclopædia Britannica

76 years ago today theologian and dissenting minister of religion Dietrich Bonhoeffer was executed at Flossenbürg concentration camp. German born and raised, he opposed Nazi dictatorship and championed Christian discipleship despite the cost.

His participation in rescuing Jews, his refusal to cooperate with the Nazification of the German Church, and his links to plots to overthrow Hitler eventually led to his downfall.

After being arrested in April 1943, he spent the next two years in detention. Firstly, in Tegel Prison, Berlin awaiting trial. Then he was sent to Buchenwald concentration camp. And finally he was transferred to Flossenbürg for a quick show trial. He was hanged the very next day, on 9th April 1945, just one month before Germany surrendered. During his detention he suffered both physically and psychologically; the manner of his death was also possibly more cruel than some biographies state.

During his time in prison he lived a life devoted to Christ, sharing God’s offer of salvation with fellow prisoners and prison officers. He also wrote fervently to friends, family, and his fiancée. Posthumously his letters and some of their replies were compiled into a well-known book, Letter and Papers From Prison. Reading these letters is both encouraging and humbling.

CONSIDERING the suffering

Memorial plaque to Bonhoeffer and others at the site of his execution

Bonhoeffer understood suffering more than most. His faith in Christ led to his own suffering and death. He was a righteous man who knew what it was to take up his cross and follow his Lord Jesus, who was tortured and executed for us on Good Friday, just as the first disciples were taught:-

Then he [Jesus] said to them all: “Whoever wants to be my disciple must deny themselves and take up their cross daily and follow me.” 
(Luke 9:23)

Blessed are those who are persecuted because of righteousness, for theirs is the kingdom of heaven.
(Matthew 5:10)

Bonhoeffer had lived experience of these gospel passages. And during his imprisonment, Bonhoeffer reflected on the suffering of others that he was witnessing:-

We must learn to regard people less in the light of what they do or omit to do, and more in the light of what they suffer.
(Letters and Papers from Prison)

How true. Yet how often do we fail to evaluate people in light of their past, their trauma and their suffering, rather than reacting directly to their words and behaviour?

Behaviour of mentally unwell detainees is often misunderstood, resulting in them being restrained and even fixated unnecessarily

In medicine we are privileged to see people at the very beginning and end of their lives. We bear witness to heart-breaking moments and life-changing situations. Human beings are fragile. In times of tension, emotions run high. Unpleasant outbursts happen, filled with anger and blame. Some patients turn repeatedly to vices we wish they would stop for the sakes of their health and family.

Yet despite all this they are still children of God, valued and respected by Him. A good healthcare professional will see beyond what their patient is doing or saying, choosing instead to view the behaviour or words through the lens of their troubles.

And outside of the healthcare arena also, we should be challenged by this piece of wisdom. We need to look for the inestimable worth and dignity of our fellow human beings. Let’s give one another the respect each one of us deserves, whether we are free or behind bars.

JamMING The Wheel

Also whilst behind bars, Bonhoeffer wrote what may be his most famous quotation:-

We are not to simply bandage the wounds of victims beneath the wheels of injustice, we are to drive a spoke into the wheel itself.
(Letters and Papers from Prison)

Medieval torture wheel

This sentence encapsulated all that he lived for. He did not simply write and teach on the morals and ethics of the Christian life. He lived it too. His firm belief was not just in helping those crushed by the weight of this world’s injustices, but in radically intervening for the oppressed and averting the course of injustice so as to stop ‘the wheel of injustice’ from moving on to crush others in the future. And it cost him his life.

Detainees are one of the world’s most vulnerable patient groups. Without their freedom, they have very little power to express their rights. And in many countries detainees who are unwell, disabled, poor or from a minority background are especially vulnerable.

JAMMING WHEELS TODAY

Logo of our expertise and advocacy services

As a medical organisation with a heart for detainees, we are all too familiar with wounds in need of literal or metaphorical bandaging. Whilst performing holistic healthcare, we also see the overwhelming need to advocate for our patients and to take a stand against the injustices many of them are facing. So in our own way we are trying to ‘drive a spoke into the wheel’ of injustice towards detainees, through our expertise and advocacy services.

As a Christian faith-inspired organisation, we will be forever encouraged in our work by the great example of Pastor Dietrich Bonhoeffer. Yet it is not a choice. God commands all of His followers to advocate for the disempowered:-

Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy.
(Proverbs 31:8-9)

Dr Esme MacKrill with Dr Rachael Pickering

PS If you’d like to support our anti-torture & ill-treatment work, we welcome donations towards the Gerry Serrano Centre.