Views on the health of prisoners (from 1995)

Book Review: [Has Anything Much Changed?]

R Creese, W F Bynum, J Bearn, eds.  The Health of Prisoners: Historical Essays. (Wellcome Institute Series in the History of Medicine). Amsterdam, Editions Rodopi, 1995, 184pp.

The treatment meted out by societies to those who transgress their rules has sometimes been referred to as in index of those societies’ level of civilisation; it has an obvious bearing on their commitment or lack of it to the idea of human rights. A symposium held at the Royal Society of Medicine in London in March 1993 brought together historians of medicine and members of both the medical and legal professions to discuss past practice and current problems in the provision of medical services and health care for prisoners in the UK. The proceedings, published in the form of a short book of eleven chapters, do not present the simple tale that might have been expected, of progress from 18^th century squalor and gaol fever, via the ‘model’ penitentiary with its system of psychological control, to late 20^th century humane enlightenment.

As we are constantly reminded, many problems remain unsolved and policy is slow to change, in spite of more or less permanent criticism and campaigns. Some topics tackled in the collection are perhaps of more interest to the historian than to critics and campaigners – the finances of Stafford Gaol (A J Standley), biographies of John Howard and others (Roy Porter). Generally, though, they are placed in the wider context of their time and also made relevant to ours. This can bring surprises, as in a sidelight cast by Anne Summers on the views of reformer Elizabeth Fry, whose daughter reported her as warning those who sanctioned ‘a degree of power which few men were fit to have’ that they might be building ‘dungeons for their children – if times of religious persecution or political disturbance should return.’ Examining the role of Benthamism in forming 19^th century policy Martin J Wiener notes (p.45) that: ‘Prisons were always shaped more by politics than science.’ He perceives an ongoing struggle between the conflicting ‘rules’ of lenity, severity and economy. Statistics came in on all sides of the debate as  a standard procedure evolved  for reforming abuses by publicity, investigation, legislation and inspection. (p.52) Meanwhile, the state emerged as a direct causer of wrongs incurred and suffering undergone, and mental health of prisoners was acknowledged to be at risk, so that: ‘the possibility of unsoundness (of mind, and the possible falling into illness) must be taken into account as one of the results of being in prison at all.’ (p.54)

What then of the doctors? In ‘The Prison Medical Service (PMS), 1774-1895’ Anne Hardy describes the growth of a cadre of convict-prison medical officers as a distinct group, whether functioning as prisoners’ friends or lackeys of authority. They were implicated as complicit in the use of diet as punishment, hard labour, and the notorious treadmill, as well as the ‘separate system’ with its associated mental problems. Alleged malingering was the sort of issue that gave rise to vicious circles of conflict; ‘Convict prison medical officers were not uniformly benevolent.’ (p.76)

More forcefully, Joe Sim, author of Medical Power in Prisons (1991) expounds on ‘The  PMS and the deviant, 1895-1948’. Subverting the usual ‘hierarchy of credibility’ (p.103), he looks at prisoners’ autobiographical accounts published from the late 19^th century on, as well as at the work of prisoners’ rights organisations. He focuses on how medical power and gender interact, Foucaultian views of a disciplinary society, the punitive gaze and the imperative of order. Prisons providing unique access to, surveillance of and individualised documentation on inmates could serve as laboratories for research directed towards the moral health of society at large. Prison doctors and psychologists increasingly set the parameters for debates on crime and criminality while institutions remained in a state of crisis, with chronic overcrowding, escape attempts and disturbances. Prisoners displayed scepticism about psychological discourses, resisted theories and mechanisms of control, and were aware of medical involvement in repression. The issue  of consciously political ‘deviants’ was raised in discussion, a need for more research in this area being indicated, although the case of suffragettes subjected to forcible feeding had been mentioned. (pp.116-117)

In a chapter on prison doctors and suicide research, Alison Liebling and Tony Ward argue that despite suicide having been shown to be a management rather than a psychiatric problem it is still addressed by endowing prison doctors with a disproportionate measure of power and responsibility in assessing its risk. Deaths in prison are politically a sensitive topic, reflecting badly on policy, but they still happen: studies ‘vindicate’ current theory while old strategies of prevention linger on, employing crude techniques instead of the broader approach indicated by research. The discussion alluded with cautious optimism to new initiatives. (pp.130-133) That these have not been conspicuously successful was shown by the Howard League report (BBC Radio News, 8 January 1997) stating that a record number of prison suicides occurred in 1996, more than half of them among prisoners on remand.

Richard Smith, editor of the BMJ (British Medical Journal), whose series of articles for that journal formed the basis for his book Prison Health Care (1984) highlights ambiguities in the assumptions underlying health service provision for prisoners. Recent history had brought rhetoric but (again) little change. British prisons, squalid, brutal and over-crowded, with second-rate health care, are still some of the worst in the developed world – isolated institutions lacking a clear mission beyond that of serving the courts. Supposed since 1895 to exist ‘as’ not ‘for’ punishment, they inflict suffering on inmates by their fallacious rationales and obsession with security. Prison doctors, aligned with ‘Them’ not ‘Us’ from a prisoner’s point of view, are closely involved with management, within an obstinately primitive and highly judgemental prison culture, as shown in the response to HIV infection. Among the ethical dilemmas and conflicts of interest mentioned were the problematic question of quality of ‘consent’ for receiving available treatment, and that of the situation of young children confined with their mothers. Discussion touched on the purchaser/provider issue, the need for self-respect as a key determinant of health status, and the fate of whistle-blowers.

 Two participants firmly ensconced in the establishment contribute their critiques. Sir Louis Bloom-Cooper QC decides, after weighing the historical evidence, that the criminal lunatic asylum should be consigned to the museum of mental health. (p.169) (Incidentally, his text, unlike most of the volume, seems oddly garbled in places, for example in the quotation on pp.156-7 criticising the policy of seclusion.) Then Judge Stephen Tumim, looking at ‘The Woolf Report and after’, draws attention to the gross overweighting with higher ranks that exists in the PMS, the nature of prisons as complex closed establishments, and the need for systematic work to be undertaken.

Finally, Stephen Shaw sums up some overall lessons in ‘Concluding thoughts’ with reference to reform movements, historical continuity and the requirement to fill gaps in research by further exploration of certain themes, one of these being ethnicity. One male prisoner in six and one female prisoner in four was (at the time) from an ethnic minority background. Current initiatives included closer integration with the NHS, something that was again in the news in early 1997, along with the publicity about shackled prisoners in acute medical situations. This useful publication, reminding us that elements of the medical profession have been involved in such processes for more than 300 years, provides substantial help, and frequent correction, in the continuing debate on the question of their proper role.

L.W.

Original published in Medicine, Conflict & Survival, vol.13, no.3, 1997, pp.270-2.

(Some adjustments of style have been made here).