Hunger strikes in UK detention centres: injustice provokes desperate protests
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2102 (Published 15 May 2018) Cite this as: BMJ 2018;361:k2102
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If one accepts that immigration requires some controls then there will be a need for immigration control centres. Likewise with prisons. Speaking disparagingly of the Drs who work in these centres makes it even more difficult to attract staff to work in them. If the care is as poor quality as Dr Arnold alleges, why have there not been more MPTS tribunals for high-profile disciplinary proceedings against healthcare professionals?
Anecdote is not data. Hunger strikes are an emotive subject - particularly in Northern Ireland. Many of the detained persons are protesting a particular issue and choose food refusal as a method to increase the emotional tone of the protest. If managed well it rarely results in hospitalisation. Good management is often more administrative as much as medical - establishing a rapport with the patient, listening to their story, clarifying that one will not be manipulated and pointing out alternative methods of settling the patient’s grievance.
Food refusal is often not complete food refusal. Part of the reason for establishing rapport early and that notes are incomplete is that some patients in these circumstances can regard all forms of authority as set against them and decline weighing, urinalysis or other objective markers that allow quantitative measurement of how ill they are
DOI - have previously worked in custody medicine , have more recently participated in prison inspections . LLM thesis on the conflict between the rights of patients to autonomy and the responsibility of custodial staff to provide care
Competing interests: No competing interests
Re: Hunger strikes in UK detention centres: injustice provokes desperate protests
Dr. MacDonagh says that during hunger strikes “part of the reason for establishing rapport early and that notes are incomplete is that some patients in these circumstances can regard all forms of authority as set against them and decline weighing, urinalysis or other objective markers that allow quantitative measurement of how ill they are.”
I agree entirely that this would constitute good medical practice.
However, in none of the 23 cases I reported was the detained hunger striker offered daily weighing or advice or opportunities to measure their fluid balance, let alone (usually) further relevant investigations. Sadly, that is medical fact, not an isolated anecdote. It is also deplorable medical practice.
We also agree about the crucial importance of “establishing a rapport with the patient, listening to their story, clarifying that one will not be manipulated and pointing out alternative methods of settling the patient’s grievance.”
Unfortunately in almost all of the 23 cases, doctor-patient relations had broken down to the point where no such rapport existed. The DoH Guidelines for managing hunger strikes in custodial settings specifically mandate a role for independent doctors to help to re-establish such rapport. This requires the participation of the custodial doctor. Despite strenuous efforts on my part, and willingness of the hunger strikers to engage in this dialogue, IRC doctors were explicitly opposed to and sometimes very hostile to any such discussion.
Doctor McDonagh and I also agree that it is “difficult to attract staff to work in” IRCs. That is not an argument for failing to publicise evidence about the very poor clinical care that is frequently reported by detainees, the Prisons Inspectorate and other investigators. On such logic, Semmelweiss, Lister and the Mid-Staffs enquiry should have been muzzled. Rather, a manifestly difficult and dysfunctional system should be audited and its quality improved to make the work more feasible and attractive.
In passing, the relative inaction by Medical Practitioners Tribunals Service with respect to IRC healthcare is not necessarily evidence that all is well. It could be, and is more likely to be, an example of an under-informed approach by regulators.
I am sure that as a prison doctor and inspector, Dr. MacDonagh is at pains to pursue the best possible care for patients. However, he seems to be unaware of how far short of those standards healthcare in IRCs too often falls.
I hope Dr. MacDonagh will accept an invitation to accompany me on a medical visit to an IRC in the near future to see for himself, or contact me to discuss the evidence as set out in numerous careful and objective studies some of which are cited in the letter to which he responded.
Competing interests: FWA examines asylum seekers during and after their detention and frequently writes medicolegal reports about them; he is sometimes paid for doing so. He is a trustee of Medact.