Annie Bartlett is an experienced clinician who describes how her clinical practice is affected by ethical, social and political considerations.
The recent movie “Suffragette” includes some disturbing scenes inside HMP Holloway, a large London women’s prison in which c 500 women are detained. Force-feeding is portrayed; the doctor in the prison, inevitably at that time a man, participates in an alarming restraint. He is attempting to prevent women hunger strikers, suffragettes, dying of starvation. Compelling film making, not least to those of us who have worked in the prison more recently and been confronted in a daily basis with different but equally complex, clinical and moral dilemmas.
There are less than 5000 women prisoners in England and Wales, distributed around 12 prisons. Their needs are complex and their health status often poor. Since 2006, the NHS has been responsible for prison health care. There has been a serious attempt over the last decade to provide these women with health services on a par with those in the community. Women present with a mixture of health problems. Most women in prison are less than 35 years old but they come with the consequences of chaotic lives, poor nutrition, minimal regular exercise and often significant drug and alcohol problems. Many will have lost contact with parents, friends and their own children. Importantly, they will usually have been subject to physical and sexual victimisation, often within their families or from their adult partners; they carry the psychological scars of these experiences as well as, sometimes, showing remarkable resilience.
So the challenge for those of us involved in their care is often to know where to start and to agree, with them, a plan of campaign. Frequently, this will involve rapid decisions about the substitution of prescribed medication for illegal/ toxic drugs of abuse. When they are through the detoxification regime, it means seeing what problems lie beyond the fog of self-medication for a damaged life. This demands not only sound clinical skills but the imagination to see into others’ lives and to work with people not diagnoses. This is a challenge to those who might see the practice of medicine as only a science.
The seriousness of these women’s health problems can be juxtaposed with the usually minor nature of their offences. These are women for whom the appropriateness of imprisonment is hotly debated, not least because their chances in life are worsened by the experience of jail, not enhanced, whatever clinical care we provide. So, medicine sits in a politicised arena of care. Doctors and other clinical staff are potentially morally contaminated by such a close relationship with a still coercive and perhaps misguided state but also obliged to offer care to those who most need it. Luckily, the last ten years has also provided considerable opportunity to thrash these issues out publicly; health commissioners and providers and prisoner patients have found some space to have conversations about what health care can and should do.
Annie Bartlett is Professor of Offender Health Care at SGUL
Corston, J. (2007). A review of Women with particular vulnerabilities in the Criminal Justice System.
Home Office http://www.justice.gov.uk/publications/…/corston-report-march-2007.pdf
Ministry of Justice (2012) Prisoners’ childhood and family backgrounds. Ministry of Justice Research Series 4/12 March 2012. Ministry of Justice: London.