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The Hunger Games – Corrections Style
By Jeffrey E. Keller MD
Published: 04/10/2017

Fasting



I have two patients in my jails right now who are not eating. When I was told about these patients, the term “Hunger Strike” was used, as in “We have a new patient on a hunger strike.” However, “Hunger Strike” does not seem to be the right term to me for these two patients. I prefer “Hunger Games” for the majority of the patients who stop eating for awhile. “Hunger Strike” evokes memories of people like Bobby Sands.

I am old enough to remember when Bobby Sands starved himself to death. Bobby was in the Irish Republican Army (IRA), which was the major terrorist group in the world before Al Qaida and ISIS. Bobby was incarcerated in a British Prison and announced on March 1, 1981, that he would no longer eat. He died 66 days later. His protest was that he considered himself to be a prisoner of war or a political prisoner but that he was instead being treated as a common criminal. Bobby Sands also wanted to generate international publicity for his cause, “the liberation of Northern Ireland from the British” (as he would phrase it). He was quite successful at generating publicity; newspapers all over the world breathlessly followed his “Hunger Strike.”

These, then, are the true historic roots of a Hunger Strike. The essential features are:
  1. The person is committing suicide.
  2. The suicide is done for a political or religious cause.
  3. The goal is to generate maximum publicity.
Seen in this way, the classic hunger strike is little different from the Buddhist monk who sets himself on fire in front of the cameras to protest totalitarian rule in Myanmar–or in the modern “suicide bombers” who kill themselves and others for ISIS. The main difference is that it is much more difficult to starve yourself to death over 2 months than to, say, push a button triggering your explosive vest. Instead of “Hunger Strike” to describe this phenomenon, I like the term “Suicide-by-Starvation.” It probably won’t catch on, though. In just doesn’t have that “Pop.”

This is very different from the majority of our correctional patients who refuse to eat. Consider for example, these various participants in The Hunger Games:
  1. Inmates pursuing a long fast for religious reasons. I had one patient who told me that she was going to drink only water for the first ten days of every month to get closer to God. I thought that this would be too hard for her to keep up for long, but she did this for several months before she finally quit. Obviously, this was not a Hunger Strike; it was, instead, an extreme religious fast.
  2. Inmates who eat only a little food and who lose a lot of weight. Some of these people are “extreme dieting,” some just say they don’t like jail food. But none of them are trying to commit suicide. This type of patient is not common, but I’ve had a couple of inmates like this. One lost over 100 pounds in eight months. He went from being obese to normal weight and remained healthy despite the quite rapid weight loss.
  3. Mentally ill inmates who refuse to eat for delusional reasons such as being convinced that the jail staff is trying to poison them. Of all the inmates who refuse to eat, these may be the most likely to adhere to a prolonged fast with bad medical consequences.
  4. Manipulative inmates who say that they are on a hunger strike but who, in fact, are secretly eating. These are often caught by the fact that they do not lose weight. I have seen several inmates who have said “I have not eaten anything for the last seven days,” but when weighed, have actually gained weight in that period of time. I have seen other inmates conspicuously display their uneaten trays but who were eating hidden commissary food or are were being fed surreptitiously by friends in their dorms.
  5. Inmates who are, in essence, throwing a tantrum. I had one inmate who actually said “If I can’t have a second mattress, I just won’t eat.” Most of these have no idea how hard it is to not eat and quickly succumb to temptation.
  6. Inmates who announce that they are not going to eat in protest of something, like charges they think are unfair or perhaps to protest certain jail or prison policies. These inmates are usually different from a true Hunger Striker like Bobby Sands for several reasons. Often, when asked, they are not attempting to commit suicide. One inmate told me “I’ll eat eventually. I just want to make a point to the judge.” Others may say at the beginning that they intend to starve to death, but most lack the true believer’s resolve to actually carry through.
  7. Finally, the true suicide-by-starvation Hunger Strikers. I (fortunately) have never had one of these in my jails. This article is not about these particular patients.
The approach to each of these should be different. This is definitely not a “one-size-fits-all” phenomenon. In order to craft an appropriate response, you must first gather appropriate information. Once it has come to your attention that an inmate is not eating, you should immediately interview the inmate and ask the following questions:
  1. Are you expecting to die as a result of this fast (in other words, are you intending to commit suicide by fasting)?
  2. Are you protesting something by not eating? What is it?
  3. Is this a total fast or are there certain foods you are willing to eat?
  4. How long do you intend for this fast to last?
Once you have the answer to these questions, there are four separate areas to consider in crafting an appropriate plan.
  1. Housing. Does this inmate need to be in special housing? Any inmate who needs to have their food consumption monitored will probably need to be in special housing. Placing an inmate in special housing also removes them from an appreciative and supportive audience back in the housing dorm.
  2. Mental health. If an inmate states that she is intending to commit suicide by starvation, she should be placed on suicidal status just as if she stated she intended to hang herself. If the patient is psychotic and delusional, of course, there needs to be an urgent psychiatric evaluation.
  3. Medical monitoring. Early on, the only medical monitoring most Hunger Game patients need are a food log, vital signs and weights. A patient who is eating nothing will lose on average one pound a day. Laboratory monitoring usually does not have to begin until the second week of a fast for those few who get that far.
  4. Legal. Most hunger games patients do not need legal involvement. The two exceptions are psychotic patients who may need to be involuntarily committed or a court ordered medical override so they cannot refuse needed anti-psychotic medication. Suicide-by-starvation patients eventually will need to come before the court to determine if involuntary feeding can be initiated. Fortunately, it takes a long time to starve to death (it took Bobby Sands 66 days). Very few patients have the self-discipline and devotion to a cause needed to sustain a prolonged fast.
Coming Soon: A Step by Step Approach to the Hunger Games

Have you had a true Hunger Striker at your facility? How did you handle it? Do you have a favored way to handle the other types of Hunger Games?

Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog

Other articles by Keller


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