Dr Crosby’s review of hunger strikes in Bahrain
This month, Dr Sondra Crosby, international expert on hunger strikes, joined the Bahrain Independent Commission of Inquiry (BICI) to review the state of the hunger strikes in Bahrain’s prisons. Motivated on humanitarian grounds, the BICI felt it important to evaluate the hunger strikers and their needs although this is not an integral part of the fact-finding mission underway.
As a result of Dr Crosby’s findings and due to the significant lack of awareness of hunger striking, the BICI highlights in the following information some key parameters and issues. A report has been issued to the Bahrain Ministry of Health including Dr Crosby’s recommendations and it is worthwhile noting that following her evaluations and recommendations, a number of hunger strikers have decided to end their strike.
Hunger strikes are a method for voicing grievances and alerting different publics to a cause, which is important to the individual hunger striker. Hunger strikes invariably occur when the individual in question feels that there are limited or no alternatives for the resolution of his/her grievances. As such, a hunger striker may be willing to place his health, and perhaps his life at risk, to bring grievances or injustices to the attention of authorities and to the world at large in order to produce change in a situation.
Hunger strikes encompass a broad array of situations, although all include some form of “food refusal” as a protest tool. It is important to note that hunger strikers are not suicidal, and do not strike with the intention of dying, although a minority of strikers may accept death as an outcome. For the most part, hunger strikers want to improve the state of the world for themselves and others and strike as a last resort – when it is felt that no other effective mechanism for protest is possible.
Hunger strikes take different forms of severity, but it is important to realize that any form of hunger strike can be detrimental to health. A “dry” hunger strike in which the striker refuses both food and water is rare because death would occur swiftly and this would not allow the hunger striker to achieve his goals. “Total fasting” generally means the striker is only consuming water, but this type of hunger strike may include the intake of minerals, sugar or vitamins and it is recommended that hunger strikers take in approximately 2 liters of water on a daily basis.
Other forms of hunger striking include the allowance for carbohydrates, minerals, vitamins, or other supplements in varying quantities. It is important for the supervising doctor to know the exact intake of each hunger striker so he can continuously monitor and assess the hunger striker’s health and provide him with relevant information for his wellbeing. In this regard, it is also important to realize that the ingestion of small amounts of calories by the hunger striker does not “negate” the hunger strike, and in fact may only prolong the course while resulting in the same serious health effects.
The health risks associated with hunger strikes vary as they depend on the individual’s age, pre-existing medical conditions, water and other intake, amount of weight lost, and the duration of the strike.
Any type of hunger strike can be detrimental to one’s health. Thus, it is important for hunger strikers to be receiving care and advice from an attending physician. Each hunger striker should have access to a trusted doctor, whose first priority is to care for the hunger striker. It is important for the doctor and patient to maintain a constant line of communication.
Sometimes hunger strikers may feel coerced or pressurized by other inmates to participate in a hunger strike, or to continue a strike even if they wish to stop. The physician must determine if the hungers striker is being coerced by any forces from either inside or outside the prison, and take measures to diffuse these pressures. Allowing access to family members may help ameliorate peer pressure and provide support.
The dignity of hunger strikers should be respected at all times; they should not be punished or coerced to end the strike.
Both a thorough physical and psychological evaluation at the beginning of the strike is important so that the physician can assess potential health risks to the individual hunger striker. Any underlying health problems are likely to be made worse by fasting, and some underlying conditions, such as diabetes, will make fasting very dangerous, even life threatening, early on in the strike.
It may be discovered that some people need treatment for psychological disorders such as depression, and the possibility that psychological disorders may be influencing the decision to hunger strike must be considered. If a hunger striker is suffering from depression or other illness possibly as a result of torture or inhumane treatment, they require immediate psychological evaluation and treatment.
It is important to understand the medical sequence of events that occur when someone fasts, including that if the hunger striker is ingesting only water, death will occur between 55 and 75 days into the strike. Young healthy people can usually do well for about 4 weeks before serious medical complications begin to take place. If other nutrients are ingested, this timeline can be extended, although not predicted with accuracy.
Medical monitoring should begin at a weight loss of 10% of initial body weight. Serious problems can occur at a weight loss of 18% of initial body weight, and the situation becomes life threatening when more than 30% of initial or ideal body weight is
In addition, an understanding of the expected sequence of symptoms that will develop when on a hunger strike is crucial:
a) Initially, for the first 3-7 days, the healthy adult hunger striker will feel reasonably normal, as long as adequate water (2 liters) is ingested. Feelings of hunger abate after the second or third day.
b) Shortly thereafter, the striker will begin to experience symptoms of dizziness, fatigue and weakness when it might even be difficult to stand.
c) After the first few weeks, the hunger striker will likely develop a sensation of feeling cold, and abdominal pain is common.
d) During the latter part of the first month, mental lethargy and irritability will develop.
e) By the 4th week, hospitalization may be necessary.
f) Between 4-5 weeks, if the hunger striker is not taking vitamins, double vision, severe vertigo, vomiting and difficulty swallowing will occur due to nerve damage. This phase of the hunger strike is described as extremely unpleasant by those who have survived prolonged fasting.
g) From about 40 days onward, progressive confusion, incoherence, loss of hearing, blindness, and bleeding may occur. Death eventually occurs from cardiovascular collapse and heart arrhythmias.
h) Other complications of malnutrition include kidney, liver, immune, and cardiac dysfunction. Wound healing is impaired and susceptibility to infection is increased throughout the duration of the hunger strike.
Children are especially vulnerable to the complications associated with fasting which are described above. In addition, malnutrition can interfere with growth and bone development and can irreversibly impair neurological development, which includes brain damage. Children should not be encouraged to hunger strike. They do not have the decision making ability to evaluate and process the consequences of a hunger strike, and thus cannot make an informed decision to strike. All young and teenage hunger strikers should be provided with additional psychological and medical support from clinicians trained to care for adolescents.
When starting to eat after fasting, food consumption must be done slowly to avoid what is termed the “re-feeding syndrome.” Re-feeding after a period of fasting can precipitate a number of potentially lethal metabolic and physiologic complications caused by electrolyte and fluid shifts resulting in cardiac, respiratory, and neuromuscular abnormalities. Thus, when the hunger striker begins to eat after a period of prolonged fasting, he should be under a physician’s supervision and monitoring.
The BICI is mandated to “investigate and report on the events occurring in Bahrain in February/March 2011, and any subsequent consequences arising out of the aforementioned events, and to make such recommendations as it may deem appropriate”. Its report is scheduled to be delivered on 30th October to HM King Hamad and will be made public in its entirety.