Salah Mohsen of Adalah interviews Anat Litvin, the director of the Prisoners’ and Detainees’ Department of Physicians for Human Rights-Israel, on the hunger strike of Palestinian political prisoners.
(Haifa and Tel Aviv, 22 April 2012)
Salah: Last week, Palestinian political prisoners being held in Israeli jails took up a mass hunger strike. How many prisoners are now on hunger strike and why are they striking?
Anat: According to Palestinian organizations, about 1,600 prisoners went on strike, and according to the Israel Prisons Service (IPS), about 1,200 prisoners are striking. It seems that with every passing day, more prisoners join the strike. They declared that the strike is open-ended, until their demands are achieved. Their demands include ending administrative detention, resuming family visits, stopping the practice of solitary confinement, gaining proper medical treatment, ending violent and humiliating body searches, and the protection of other aspects of their basic human rights. In both Nafha and Shikma Prisons in Ashkelon, all political prisoners are striking. The extremely harsh prison conditions of Palestinian prisoners held in Israeli prisons, almost all of whom are classified as “security prisoners,” have been deteriorating. The prisoners are on hunger strike to try to change their very severe conditions, which may amount to cruel, inhuman and degrading treatment, certainly when considered all together.
Salah: Are there any hunger-strikers who are very ill?
Anat: Sick prisoners were asked not to strike to prevent severe damage to their health. Nevertheless, Physicians for Human Rights-Israel (PHR-I) have been approached to help one severely ill prisoner who has been striking for over a week.
Salah: What does PHR-I try to do for the prisoners on hunger strike?
Anat: We try to send independent physicians to visit and accompany the hunger-striking prisoners. We can only do this partially, since the IPS is not interested in allowing an independent doctor into the system during a hunger strike, although this is crucial and is a tenant of the ethical guidelines of various agencies such as the World Medical Association and the Israeli Medical Association.
Salah: Why is an independent physician necessary?
Anat: Unlike the prisons’ physicians, who are placed in a situation of “dual loyalty”—both to the patient’s health and to the system (IPS) that employs them--–an independent doctor can earn the patient’s trust. S/he can explain potential problems, the consequences of the hunger strike on the patient’s health, the expected deterioration in his/her medical condition, and what he or she needs to do to maintain his or her health and life. For example, the doctor can offer vitamins or minerals or suggest that the patient receives a blood transfusion, which does not count as breaking the hunger-strike. The involvement of an independent physician can have a decisive influence and can prevent severe medical damage and even death.
Salah: Why can’t the IPS doctors perform this function?
Anat: Following our involvement in several hunger strikers’ cases, we fear problems with the health care provided and a lack of compliance by IPS staff with medical ethics. We fear that the IPS uses healthcare workers as a tool to break the hunger-strike. We fear that non-medical personnel make medical decisions. For example, in the case of Hana Shalabi [a Palestinian woman prisoner who recently went on hunger-strike for forty-four days—SM], one of our doctors required that she be transferred to a hospital because of her deteriorating health, but her transfer was postponed because of IPS’s refusal. Even Bilal Diab and Thaer Khalayleh, who are on their sixtieth day of hunger strike today, are kept as patients by the IPS and are not hospitalized. We believe that at such an advanced stage of hunger strike, an individual must be monitored in a hospital rather than in the IPS medical center.
Salah: At what point during a hunger strike do health problems arise?
Anat: The World Medical Association stresses that every hunger striker risks different dangers. We must take into account that every person will respond differently to a prolonged fast, with factors including age, gender, and health status affecting them before the hunger strike. Accordingly, in general, the first two weeks of a hunger strike are usually safe, provided that the person drinks water. Appetite and abdominal pain disappear after the second or third day. After fifteen to eighteen days, dizziness, general weakness and unsteady gait set in, and the striker has difficulty standing. These effects are accompanied by a slowing of heart rate and a drop in blood pressure. At the end of the first month, symptoms can be severe enough to justify hospitalization. It is particularly important to prevent dehydration, while avoiding excessive transfusions.
Thirty-five to forty-two days after beginning the strike, the person’s situation may deteriorate including causing damage to eye muscles, which creates difficulty moving the eyes, light flashes, and double vision. Hunger strikers experience acute vertigo, uncontrollable vomiting, difficulty swallowing water, and crossed eyes. They often describe this as the most difficult stage.
After forty-two days, a sense of weakness, fatigue and lack of energy settle in, accompanied by stupor (slow thinking, confusion, difficulty or inability to concentrate), apathy to the environment, and lack of coherence. At this point, it may not be possible to assess mental abilities and determine the hunger striker’s condition. Any decision of the medical staff to determine the treatment of a hunger striker needs to be taken and accepted in advance by the hunger striker.
After this stage, even more serious complications arise including hearing loss, blindness, bleeding gums, and problems with the intestines and esophagus. At forty-five to seventy-five days, death can occur because of cardiovascular collapse, vascular collapse or severe arrhythmias. There is also a high risk of infection because of immune system suppression. Usually death occurs due to these factors, and not from neurological or cardiovascular problems.
Salah: Have there been any cases of force-feeding?
Anat: According to the IPS, force-feeding can be done intravenously. The topic came up for discussion in the IPS Ethics Committee during Khader Adnan’s [a Palestinian political prisoner who recently survived a sixty-six-day hunger strike—SM] hunger strike. In the case of Khader Adnan, the Ziv Hospital Ethics Committee decided that he would be force-fed intravenously. When PHR-I learned of this decision, we turned to various active groups in Israel and abroad and asked for urgent intervention. Force-feeding a patient when he is of sound mind and has expressed his opposition is a serious violation of medical ethics and guidelines of the Malta Declaration, the World Medical Association Tokyo Declaration, and the ethical code of the Israeli Medical Association. Force-feeding was finally averted because Khader Adnan reached a deal and stopped his hunger strike, but we want to believe that Ziv Hospital doctors would have refused to carry out the decision.
Salah: When is a prisoner transferred from the IPS to an outside hospital?
Anat: The Medical Center at the IPS is not a hospital. The IPS admitted this in response to a Supreme Court case in 2002 (See HCJ 3274/02, Physicians for Human Rights-Israel v. the Minister of Public Security, et al.) The state’s attorney in a response to the petition dated 15 December 2004 stated: “As the petitioners claim that the prison clinic functions completely as a hospital, we would like to refer the petitioners to the detailed argument on this in the State`s response from June 2002, and to the report of the Israeli committee, according to which this clinic is not a hospital but more resembles a prison sick room." (paragraph 25, response on file with PHR-I). The IPS ward is not a place that can care for hunger strikers in advanced stages of their strike. It does not have the required medical equipment, including a heart monitor, or sufficient personnel. The clinic`s cells do not have emergency call buttons. Opening the cells at night requires special time-consuming clearance that could cost the life of whoever needs to be urgently evacuated. Further, as mentioned earlier, the IPS doctors have problems of dual loyalty. We fear that if the patient’s interests conflict with the prison wardens’ systems, the system will win.
Salah: Have you encountered obstacles and limitations in supporting the hunger strikers?
Anat: Getting the IPS to allow our doctors to see prisoners is not easy. We have almost always had to go to court for the recent hunger strikers cases. Almost every doctor’s visit on behalf of PHR-I was only possible after an appeal to court. The IPS does not have any guidelines or provisions for independent doctors from outside of the prison system to regularly assist hunger strikers. The IPS has stated during litigation that a prisoner does have the right to meet with a second doctor and receive a second opinion, and on this basis, it only allows a meeting once a month. Unfortunately, the District Court also ignores the rules of medical ethics and guidelines and often follows the IPS’s opinion.
Even when independent doctors visit the sick, the IPS does not allow a private meeting, which therefore harms the normal trust and connection between hunger striker and physician. During Hana Shalabi`s strike, our doctor was given inadequate medical information about her blood test results over the telephone. Even forty-one days into her hunger strike, Hana was transferred from the hospital back to IPS. The doctor who was helping her was not informed of her transfer. The IPS also prevented lawyers from meeting with her. We fear that her deliberate isolation led her to eventually end her hunger strike and agree to be deported to Gaza.
Currently there are two administrative detainees on hunger strike, who have been striking for sixty days, Bilal Diab and Thaer Khalaile. Our doctor was allowed to visit them only recently, on 9 April 2012. Our doctor says that the blood tests results and the physical examination conducted by the IPS physicians are insufficient. The IPS did not answer our next request for another visit, and again we had to go to court. At a hearing yesterday Judge Avraham Tal ordered that a doctor’s visit take place before 1 May 2012, and another visit in May if it is a medical necessity.
[Originally published in Adalah’s Newsletter, Volume 92, April 2012.]