Correctional health: Hunger strikers


REASONS FOR HUNGER STRIKERS STRIKING

– Religious, ideological or political reasons
– Inmates dissatisfied with conditions in prisons
-Inmates striving to gain secondary gains such as early parole or transferral to other prisons or other cells
– Mental health conditions such as schizophrenia or acute paranoia
– Physical conditions such as oesophagus carcinoma

DIFFERENT TYPES OF HUNGER STRIKING
– Dry fasting: inmates takes no water; death within 4 to 10 days
– Total fasting; inmates takes clear water but no food or nutrients; death within approximately 75 days; permanent damage much earlier
– Fasting; inmate takes no food. The inmate takes water and vitamins. The inmate does not take any foods

NEGOTIATION WITH HUNGER STRIKER INMATE
Negotiate with the inmate
– to take water (explain the dangers of acute kidney failure, heart dysrhythmias, electrolyte disturbances)
– to at least take some vitamins (explain the complications such as scurvy, Wernicke encephalopthy and vitamin deficiencies)
– to take food (explain the irreversible complications of hypoglycemia, ketosis, risks of hypothermia)

Emaciation

CLINICAL CHANGES

  • Nasolabial sebaceous plug
  • Sores at angle of mouth, cheilosis
  • Vincent’s angina
  • Minimal changes to tongue colour or texture
  • Red swollen lingual papillae
  • Glossitis
  • Papillary atrophy of tongue
  • Stomatitis
  • Spongy bleeding gums
  • Muscle tenderness of extremities
  • Poor muscle tone
  • Loss of vibratory sensation
  • Increase and decrease of tendon reflexes
  • Hyperesthesia of skin
  • Purpura
  • Dermatitis; facial butterfly, perineal, scrotal, vulval
  • Thickening and pigmentation of skin over bony prominences
  • Nonspecific vaginitis
  • Follicular hyperkeratosis of extensor surfaces of extremities
  • Rachitic chest deformity
  • Aneamia not responding to iron
  • Fatigue of visual accomodation
  • Vascularisation of cornea
  • Conjunctival changes

ETHICAL CONCEPTS AFFECTING THE CMP

The Declaration of Malta on Hunger Strikers (1991) provides an ethical framework for dealing with hunger strikers. Other legislation that has bearing is the National Health Act 61 of 2003, the Correctional Services Act 111 of 1998, common law, and the Ethical Rules of the Health Professions Council of South Africa.
– The inmate should not be force-feeded if they refuse to take nourishment

– Doctors must respect their patient’s confidentiality

-Doctors must not be influenced by dual-loyalty situations and must work independently according to ethical principles
– If the inmate goes into hypoglycemic coma the CMP will have to decide whether to treat and resuscitate aggressively (depending on whether the inmate stated advance directives)
– The CMP should not coerce the hunger striker into eating
– The CMP must exclude mental and physical pathology of the hunger striker

PATHOLOGY RELATED TO HUNGER STRIKING

  • The rule of 3s applies: a person can live 3 minutes without oxygen, 3 days without water, 3 weeks without food
    – The inmate loses approximately 0,5 to 1 kg per day depending ambient temperature
    – The inmate can develop serious irreversible pathologies such as Wernicke encephalopathy, physical disabilities due to repetitive hypoglycemic events. Diminished intellect and neurologic sequelae is very common
    – Hunger strikers develop vitamin deficiencies such as Vitamin B12 shortages (as they don’t take in any meat), vitamin B, C and D deficiencies
  • From a custody perspective hunger strikers immediately loose some of their privileges the moment they start hunger striking. They are isolated in the prison hospital where there is capacity for 24 hour medical observation
  • As stipulated by law, the hunger strikers are visited by the prison doctor on a daily basis in order to confirm whether they wish to continue with the hunger strike and to monitor their condition. Regular medical examinations are absolutely crucial in order to have perfect outcomes
Hypoglycemia scurvy Wernicke’s encephalopathyhypovitaminosis