Showing posts with label prison doctors. Show all posts
Showing posts with label prison doctors. Show all posts

Monday, 16 February 2015

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 18th century squalor and gaol fever, via the ‘model’ penitentiary with its system of psychological control, to late 20th 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 19th 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 19th 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).


Friday, 13 February 2015

Messing with minds: Pentonville, the New Model Penitentiary

[NOT INSIDE FOR THEIR HEALTH: Part 3,]


The prisoners must at no time during their imprisonment, whether at prayer or at exercise in the open air, see each other; nor may they converse with each other; every method is taken to prevent such an occurrence taking place, - and to such an extent is this carried, that even the pipes which convey the soil from the water closets are provided with valves, to prevent any communication through that channel; in fact every thing that human ingenuity can suggest has been employed to isolate the prisoner...
- The Times, May 20, 1841, commenting on the system adopted at Pentonville Prison.

Persuaded by favourable accounts, like William  Crawford’s 1834 report, of the ‘separate system’ operating in the United States, the British government adopted a variant of it as the keystone of its penal policy, as set out in the 1839 Act (2 & 3 Victoria, cap. 56). This made provision for establishing prisons on the cellular plan, with a standard code of regulations. The foundation stone of Pentonville on the Caledonian Road in North London – still there of course, a looming landmark -  was laid in April of the next year; it opened (and closed its gates on inmates) as the New Model Penitentiary in 1842. (1) For the remainder of the decade it was a primary focus of attention both for supporters and opponents of the new system, as they set about collecting and interpreting evidence on how it worked in practice.
It was a testing time for prisoners as well as for penal theories, such confinement having been originally intended as a probationary period, or ‘penal Purgatory’ for those sentenced to transportation, on the results of which their subsequent fate would depend. The initial intake was comprised of men aged between 18 and 35, physically fit, and judged to be mentally and morally suitable cases for the treatment they were about to receive: ‘model prisoners’ to match the model prison, as Hepworth Dixon remarked. (2) Each man was to be accommodated in an individual cell measuring 13 feet by 7 by 9, constituting a ‘workshop by day and bedroom by night’ and comparatively well appointed, even with heating in cold weather. There was to be no physical privation. Provision was made for exercise, instruction, religious observance and medical care; communication with officials of the prison was to be possible at any time, and the ‘schoolmaster’ and chaplain were to be always on hand to interrupt the isolation. But prisoners were on their own ‘as regards congenial society’ as one chaplain was quoted as saying (3), forbidden to have any contact with their fellows, and as far as possible denied individual identity. To this end, exercise yards were divided into one-man airing pens, chapel and schoolroom partitioned into stalls with high sides. Whenever a prisoner left his cell he had to wear a cap with a peak, pulled down over his face to prevent recognition, and cell numbers were used instead of names. A concomitant deprivation was that of personal initiative, since every detail of daily routine was prescribed by a strict schedule, which also applied to staff.
As the effects of this regime began to become evident, the debate about its merits or iniquity gained momentum. The country’s leading newspaper, The Times, not noted for its championship of the criminal classes, opposed it as cruel, ineffective and dangerous to health, going so far as to allege that the government was coolly contemplating a prospect of the multiple suicide of those subject to its discipline and punishment. (4) For this attitude it was criticised at length by devotees like Joseph Adshead, who claimed the prisoners were thriving – acquiring skills and education, happy in their work, and generally benefiting from the experience. According to Adshead, a Commissioners’ Report in the mid-1840s also showed their health to be ‘most excellent’ and their mental condition ‘highly satisfactory’. (3)
The Commissioners themselves, appointed to supervise Pentonville, were less uniformly complacent than this suggests. Mayhew and Binny referred to two of them, Sir Benjamin Brodie and Sir Robert Ferguson, warning that: ‘the utmost vigilance and discretion on the part of the governor, chaplain and medical attendants would be requisite, in order to administer, with safety, the system established there.’ Moreover, it transpired that some supposedly mitigating influences could turn out to have the opposite effect from that intended, as when, in September 1843, Commissioner Brodie and the first medical officer of Pentonville, George Owen Rees, had occasion to complain about ‘morbid symptoms’ induced in prisoners by the chaplain’s visits and preaching. Their misgivings were endorsed by Lord Wharnecliffe in an admonitory note: ‘... [W]hen the medical officers state to [the chaplain] that they apprehend ill effects from the state of spirits of any prisoners, he must attend to their suggestions... I will not allow the mental health of the prisoners to be risked,  as it appears to be now.’ (5)
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In a set-up featuring techniques that have been plausibly likened to those of brain-washing, advocates of the system were able to claim it had had a degree of success in obtaining a certain number of apparently reformed and repentant wrong-doers. Not all of these would have been working the system, having learned to make the right noises and faces; prisoners did, however, soon develop ways to adapt and survive. Most cases termed ‘overt insanity’ occurred shortly after admission – if they survived the initial shocks of subjection to the regime, they had a chance of surviving the rest of their sentence. In 1847 Captain Maconochie, who had long experience of managing convicts, described  Pentonville prisoners as being in a state of ‘complete physical and mental prostration’ but later modified his view to of an initial stage of ‘extreme mental irritation’ followed by a sort of acclimatisation. (6)  Hepworth Dixon asserted prisoners could perfectly well recognise each other in spite of masks and partitions, and that anonymity was a fiction connived at by officers and their charges alike. (2) As for reform, he adduced evidence form projects in the colonies and from public works in England to show that the men, once outside the walls, were quite ready to revert to their bad old ways and  even, allegedly, to riot when confronted with hard work.  While attesting to a certain robustness of mind, this was hardly an indication of the kind of character-building the new prison was designed to promote.
 All the same, if the state and its advisers underestimated the capacity of the human mind, even when incarcerated, for adaptability, cunning and sheer perversity, they also underestimated its vulnerability. There would always be a certain number for whom the stress would be too great, and the number was large enough to bother the authorities; eventually it impinged sufficiently to lead to some modification of the system. The period of separate confinement was reduced from 18 to 12 months, then to nine; an element of association was introduced when the realisation began to dawn that complete isolation from human society might not be the best preparation for a trouble-free return to society.
In the first half-dozen years of its existence Pentonville had become notorious for its high death rate and incidence of insanity. Mayhew and Binny (5) produced official figures giving an annual rate of ‘removals from Pentonville to Bedlam on the ground of insanity’ averaging 27 per 10,000 prisoners from 1842 to 1849, rising to a peak of 32  per 10,000 in 1850, but halved in the following two years, The annual figure for cases of insanity as distinct from ‘removals’ to Bedlam was put by the medical officer at 120 per 10,000 prisoners in 1843 to 1852, with half as many in 1853. This was compared with the figure of 5.8 ‘criminal lunatics’ per 10,000 prisoners in all the prisons of England and Wales during 1842 to 1849. Even allowing for a fairly wide margin of error, such statistics leave little room for doubt that the incidence of mental disturbance in Pentonville was several times that of ordinary gaols, and that the ending of the first, strictest phase of experimentation with the new system bought a definite improvement in this  respect.
It might therefore be expected that a conclusion would be drawn to the effect that the experiment was not proving a success, and that the verdict of those in charge would go against the separate and silent system, but such was not the case. During the 1840s, 54 prisons were built or extended on the Pentonville model, and at the end of the decade the House of Commons Select Committee on Prison Discipline concluded that, “If properly regulated, the separate system was more efficient than any other as a deterrent and a reform measure.’ (7) There were reasons for its appeal, as a writer (quoted by the Webbs) pointed out in the same year, 1850: ‘The officials like it; it gives them very little trouble, so, without pretending to understand its complicated effects, moral or mental, they almost all swear by it.’ (6) Its attractions included the fact that there was little chance of escape, prisoners could be kept in a state of ‘harmless docility', and once the building had been constructed, admittedly at considerable expense, it was thought to be reasonably economical to keep going.
From the official point of view, lessons had been learned and put into practice, so that it was now less likely that physical and mental health problems in prisons would obtrude themselves upon the notice of the public. Inmates would be mostly out of sight, out of mind – and unlike the old Newgate, neither offensive to the sense of smell nor a source of infection to those outside – kept securely in the hands of the responsible authorities. Another result was that it had become more difficult for outside to investigate and report on conditions within the walls. Hepworth Dixon (2) complained about having to obtain warrants from designated officials, while Flora Tristan (8) found in 1842 that foreign visitors were barred from eight of London’s prisons. Not that this meant an end to or a lull in controversy over penal policy. Many new developments were still to come, along with some backtracking, but in some respects a pattern had been set that was to last throughout the next century and beyond. Reformers still found multiple causes for concern, even if purely medical considerations constituted a smaller proportion of these – for a time at least.
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Towards a judicial summing-up
The State
Whatever bodily sufferings and ailments, up to and including death, were incurred by prisoners in 18th-century gaols, they could generally be seen as the inadvertent results of neglect and inaction on the part of those responsible for the prison establishment, Local government, such as it was, left things to the private enterprise of gaolers (who could of course be deliberately cruel and sadistic rather than merely venal and indifferent) while national government preferred to keep its distance, until something like a ‘Black Assizes’ occurred to carry the problems out into the wider world, Faced with the threat of deadly infection, the rulers could be spurred to take action, and to seek advice, which when acted on led to the implementation of some reforms, even if these were patchy, piecemeal and imperfect. This necessarily entailed increasing state regulation and control, and went along with an expansion in the prison population in a process that was far from unique to Britain and has been described by historians as ‘the great incarceration’. As a new interest in and commitment to penal administration took hold in the 19th century, different kinds of damage were inflicted as a consequence of government policy and the experimental testing of various theories on its powerless captive subjects, rather than the lack of any intervention.
The Medics
Doctors were to the fore in the movement for prison reform. Some of them were ready to undertake the regular medical care of prisoners at a time when most members of respectable society were afraid to enter a gaol, not so much because of its dangerous inmates as on account of the health hazards known to abound there. They were often prepared to badger the authorities into taking measures they saw as medically necessary or beneficial. When called in at times of crisis, they took seriously the responsibility of investigating what was happening, the impact conditions were having on prisoners’ health, and what might be done to make the prison environment less life-threatening. Later, in the newly designed purpose-built edifices of the Victorian era, doctors became an integral part of prison establishment, involved in the daily working of the system. In theory this accorded them the status and power to supervise, advise and mitigate its worst rigours; in practice they could hardly help being identified with the establishment and thus forfeiting some of their patients’ trust, even if they believed themselves to be independent and objective.
 The Prisoners
The viewpoint of those incarcerated is generally the most difficult aspect to elucidate when investigating prisons. Apart from a minority of celebrities and dissidents who were able to give an account of their experiences and articulate their reactions to it, what the inmates themselves thought was usually mediated by the voices of visitors, concerned professionals or officials whose background was very different from theirs. Such people might often have an agenda of their own, whether collecting picturesque anecdotes, compiling a dossier of evidence or justifying a particular position. Much the same would apply to writers who took the prisons as their subject, in fiction or otherwise – always a popular one with readers avid for details of what it was ‘really’ like inside – and sometimes fostered myths that could be reinforced by supposedly genuine ‘memoirs’.
It is possible to discern, however, that in spite of the successive, variously dehumanising regimes that ruled their lives, prisoners were not so hopelessly unthinking and unable to express their thoughts and feelings as the prevailing stereotypes would suggest. Collective petitions, more or less organised ‘trouble-making’ and individual statements could break through the silence, indicating the survival of the will to resist. One thing they were clear on, before, during and after the crucial hundred years under consideration here, was that they were not in prison for their health. Old problems confronted and new ones created between 1750 and 1850 were not going to go away. Many of them are still very much with us, and especially with those concerned to safeguard, as far as possible, the health and welfare of prisoners.
Postscript, 1916-19
During the First World War hundreds, perhaps thousands, of conscientious objectors (COs) were imprisoned, some sentenced repeatedly to terms of hard labour, after the introduction of conscription in early 1916; quite a lot were not released until well into 1919. The appalling details of the treatment to which many of them were subjected caused a scandal at the time, with protests and questions in parliament, and has been well documented since. (9) In several cases prison doctors were implicated in the deaths of young COs, through conniving at harmful conditions and ill- treatment, neglect, or failing to take their symptoms seriously and give an accurate diagnosis. But many COs were not only worried about themselves. Horrified by what constituted life inside even for ‘normal’ prisoners in normal times, they continued to campaign for  improvements in conditions after the war, providing significant impetus to the work of prison reform.
E. A. Willis
Notes   (Numbered separately from Parts 1 and 2)
1. Websites with information on and/or illustrations of Pentonville:
2. Hepworth Dixon, The London Prisons. London, Jackson & Walford, 1850.
3. Joseph Adshead, Prisons and Prisoners, London: Longman, Brown, Green & Longman, 1845.
4. The Times, (London), 25 November 1843.
5. Henry Mayhew and John Binny, The Criminal Prisons of  London and Scenes of Prison Life (1862). London, Frank Cass,  1971; p.113.
6. Quoted in Sidney and Beatrice Webb. English Prisons under Local Government. London: Longmans, Green & Co, 1922.
7. W R Cornish, Crime and Law in Nineteenth-Century Britain. Dublin, Irish Academic Press, 1978; pp.71-93.
8. Flora Tristan, The London Journal of  Flora Tristan, 1842 (Promenade dans Londres). Translated by J. Hawkes. London, Virago, 1982.
9. David Boulton, Objection Overruled: Conscription and Conscience in the First World War, Dent, Cumbria: Dales Historical Monographs in Association with Friends Historical Society, 2014.

Further reading (relating to all three parts)
Joe Sim, Medical Power in Prisons: The Prison Medical Service in England, 1774-1988 . Milton Keynes, Open University Press, 1990.
Geoffrey Howse. History of London's Prisons. Stroud, Pen Sword Books, 2014.
Sean McConville, History of English Prison Administration: 1750-1877. London, Routledge & Kegan Paul, 1981.
R. Creese et al., eds.  The Health of Prisoners: Historical Essays. Amsterdam, Editions Rodopi, 1995. 
Richard Smith, Prison Health Care. London, BMJ Publishing Group, 1984.