Hunger strike renews concerns over health in UK detention centresBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1446 (Published 29 March 2018) Cite this as: BMJ 2018;360:k1446
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Dexter and Katona illustrate, strikingly, intersection between migration, health and health care in the multiplicity of challenges. arising. We have a great deal to reconsider. The post-second world war consensus condemning racism, xenophobia and religious prejudice (1) is being undermined. International conventions requiring nations to offer the persecuted a fair hearing and compassion, and where appropriate, settled, refugee status are being flouted. Problems that have escalated recently include the overt persecution of ethnic and religious minorities, deportation of people even from their country of birth, the erection of border fences and walls, inhumane conditions for detention including of children, and increasingly strident, widely reported political statements proclaiming racist viewpoints.
Paradoxically, these trends are occurring at a time when international and national legislation and policy in favour of equality, and compassion towards the persecuted, has never been stronger. Furthermore, some of the greatest cities in the world e.g. London, New York, San Francisco, Vancouver, and Sydney - to mention a few - have demonstrated the creativity, strength, harmony and sheer excitement of living in a multi-ethnic, multicultural, diverse environments where prejudice and discrimination are condemned. They are not immune from problems but these are acknowledged and confronted. It is also paradoxical that there is unparalleled travel abroad and rarely mentioned large-scale emigration from well-off industrialised countries.
Our knowledge of the health status and health care challenges of societies accepting recent refugees and other kinds of migrants has increased greatly recently. The health of ethnic minorities is sometimes better than that of the recipient, majority population. Overall, the unfair perception of migrant and ethnic minorities being a burden or a threat to the health status of the recipient population, sometimes from contagious and other property related diseases, has been demonstrated to be a superficial, stereotyped view and sometimes incorrect.
Global dialogue is required urgently. Scholars, researchers, policymakers, practitioners and civic society need to think together about how we manage the challenges and opportunities of our modern migratory world, including the public health emergency in handling refugees from war zones.
The first World Congress on Migration, Ethnicity, Race and Health will take place in Edinburgh, Scotland on the 17th-19th of May 2018. It will focus on health and well-being, and the social determinants of these, and consider the response by policymakers, and public health and health care services. In addition to recent migrants and settled racial/ethnic minorities the Congress will focus on other minorities including the Roma and Indigenous populations. The health of detainees will certainly be on the agenda.
Well over 600 people from more than 50 countries will be meeting. The aims and general content of the Congress have recently been published.(2) This is a unique opportunity for those wishing to advance, through careful dialogue, the health and health-care of all populations within the framework of equality and equity. (http://www.merhcongress.com/)
1. UNESCO. The Race Concept: results of an enquiry. Paris: UNESCO; 1952 1952.
2. Krasnik A, Bhopal RS, Gruer L, Kumanyika SK. Advancing a unified, global effort to address health disadvantages associated with migration, ethnicity and race. Eur J Public Health. 2018.
Competing interests: No competing interests
Immigration Detention in the UK damages health and frustrates healthcare
The ‘Windrush’ scandal exposes one aspect of an immigration system which explicitly aims to create a ‘hostile environment’ for migrants. Dexter and Katona’s article provides a timely reminder of another, the locking up of thousands in Immigration Removal Centres (IRCs) .
NGOs, official inspectorates, parliamentarians and others have repeatedly drawn attention to systemic failings in IRCs and a recent review identified an overreliance on immigration detention, too many vulnerable people detained for too long, inadequate healthcare provisions and failure of existing safeguards . An associated literature review concluded that detention in and of itself impacts negatively on health .
Detention can disrupt continuity of care and put people’s health at risk. This is compounded by inadequate healthcare provision and the inappropriate detention of vulnerable people (such as victims of torture, rape and those with serious mental health issues) despite Home Office policy to the contrary. Detainees frequently report a ‘culture of disbelief’ among staff and this easily leads to a ‘contamination of contempt’ among healthcare staff which makes building therapeutic relationships difficult .
As highlighted in the recent BMA report, IRCs can be a challenging environment for clinicians with expectations of condoning a function that could harm their patients . Clinicians may find their clinical opinion ignored and may face situations of dual loyalties, for example when asked to assess whether the patient is fit to fly or fit to be detained.
Detention is harmful and indefinite detention is particularly harmful. However, a time limit will never adequately address the problems with immigration detention. NGOs frequently encounter detainees for whom even a single day in detention is too much and results in ongoing damage to health. Immigration detention is supposed to be exceptional. Presented by successive governments as essential to maintaining effective immigration control, this is simply not true. Political choices have led to expansion of the use of detention but this was never inevitable or irreversible. Most migrants stay in the community awaiting decisions on their immigration status. The UK is an outlier in detaining so many for so long . Fewer immigration detainees would mean less avoidable ill-health from detention. We echo the BMA’s call for an end to immigration detention.
Kristine Harris and Hilary Pickles
1. BMJ 2018;360:k1446
2. Steven Shaw’s “Review into the welfare in detention of vulnerable persons” https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
3. Bosworth M. Mental health in immigration detention: a literature review. Review into the welfare in detention of vulnerable persons. Stationery Office. 2016 http://ssm.com/abstratct=2732892annex to Shaw
4. “Immigration Removal Centres in England - A mental health needs analysis” Centre for Mental Health. Dr Graham Durcan, Jessica Stubbs and Dr Jed Boardman. 9 January 2017.
5. British Medical Association. Locked up, locked out: health and human rights in immigration detention 2017. www.bma.org.uk/collective-voice/policy-and-research/ethics/health-and-hu...
6. APPG. The report of the Inquiry into the use of Immigration Detention in the UK. A joint report by the All Party Parliamentary Group on Refugees and the All Party Parliamentary Group on Migration 2015 https://detentioninquiry.files.wordpress.com/2015/03/immigration-detenti...
Competing interests: Kristine Harris works for and Hilary Pickles volunteers for Medical Justice, a charity that supports immigration detainees
Dexter and Katona entitle their editorial : Hunger strike renews concerns over health in UK detention centres. Extensive experience of examining people who are on hunger strike protesting the reasons for and conditions of their administrative detention or denial of asylum shows that those concerns are extremely well-founded.
From 2005-2011, as an independent doctor visiting Immigration Removal Centres (IRCs) under Detention Centre Rules 33(7) or 33(11),  I examined 30 people who had undergone some 14-50 days’ food refusal and/or up to 8 days near-total fluid restriction. One was seen in prison, 23 in IRCs, and 6 camped outdoors of whom 3 had sewed their lips
Of the 23 in IRCs at least 19 were released from detention, usually by. Nine were re-fed in hospital under expert supervision. Many of these people were subsequently determined by the Home Office or the courts to have well-founded claims for asylum because they had fled torture; a few have been awarded substantial damages for unlawful detention. To my knowledge, all but one have recovered from their food/fluid refusal, although many put their health at risk in pursuing their protests.
Of those in custody, none were receiving medical care compliant with established Guidelines for clinical management of hunger strikes . The Guidelines give precise, helpful advice on the roles and responsibilities of doctors; competence of patients and advanced directives; risks and management of starvation, dehydration and refeeding. They were published in current form in 2010 by the Department of Health and Ministry of Justice and have been endorsed by NICE.
Between 2005 and 2018 little seems to have improved despite the introduction of the Guidelines, which continue to be transgressed. One of the recent hunger strikers at Yarl’s Wood whom I have examined twice during her attempts to re-feed herself after more than 14 days, was unable to keep down fluids let alone solids. The medical notes at Yarl’s Wood in my possession showed no effective attention to, or monitoring of, her dehydration and malnutrition. She has now been released and is seeking appropriate medical care.
On the hundredth anniversary of the first law allowing some women to vote, the Prime Minister publicly praised “Marion Wallace Dunlop … who staged the first suffragette hunger strike” Mrs May said “the right to vote was not handed over willingly. Rather it had to be forced, over many years of struggle, from the hands of those who held it for themselves.” . The protest (led by women) at Yarl’s Wood started 15 days later.
The 2017 report on Yarl’s Wood IRC by the Prisons Inspectorate  found that “Health care had deteriorated substantially since the previous inspection, with potentially serious consequences for the physical wellbeing of detainees.”
Dexter and Katona  echo the BMA [ref 7], and many other experts in arguing that “the only way to protect health in immigration detention centres was to end the policy of detention altogether” They base this findings on extensive evidence that the severe and avoidable medical harm is intrinsic to the process of administrative detention.
The politics of the use of indefinite detention as a deterrent aside, the damage is not only to patients but also, potentially to doctors employed in IDCs.
The GMC requires all doctors to raise concerns about, and not to comply with, “systems, resources and practices”  that violate our professional duties even when the doctor is subject to competing loyalties ). The GMC also requires that concerns, when raised must be investigated thoroughly by responsible officers of the providers and purchasers of healthcare. Adequate governance then requires that improvements are implemented on the basis of evidence obtained through well-designed audit cycles.
It is time the GMC and the CQC required, and NHS England conducted, robust, verifiable audits of healthcare practitioners and practices in IRCs for the protection of all, not least the healthcare practitioners .
1) Dexter E, Katona C. Hunger strike renews concerns over health in UK detention centres. BMJ 2018;360:k1446
2) Detention Centre Rules http://www.legislation.gov.uk/uksi/2001/238/article/33/made33(7)
3) Department of Health. Guidelines for the clinical management of people refusing food in immigration removal centres and prisons 2010. https://www.medact.org/wp-content/uploads/2018/03/dh_111690-Published-Gu...
4) May T. A speech by Prime Minister Theresa May at Westminster Hall, marking this year’s centenary. https://www.gov.uk/government/speeches/pms-vote-100-speech-6-february-2018
5) Her Majesty’s Inspectorate of Prisons. Report on an unannounced inspection of Yarl’s Wood Immigration Removal Centre. 2017. https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/si...
6) British Medical Association. Locked up, locked out. 2017. https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/policy%20re...
7) General Medical Council. Good Medical Practice 2013. https://www.gmc-uk.org/guidance/good_medical_practice/respond_to_risks.asp
8) General Medical Council. Raising and acting on concerns about patient safety. 2012. https://www.gmc-uk.org/Raising_and_acting_on_concerns_about_patient_safe...
9) British Medical Association. Medical Ethics Today. Wiley. London. 2012.
10) Arnold F etal. First do no harm – Clinical roles in preventing and reducing damage to vulnerable immigration detainees. Medact 2017. https://www.medact.org/2018/resources/first-no-harm-clinical-roles-preve...
Competing interests: Frank Arnold examines asylum seekers during and after their detention and frequently writes medico-legal reports about them; he is sometimes paid for doing so. He is a trustee of Medact.