This book is very much in the style of smash hit. This is Going to Hurt by Adam Kay and has a strong influence from A Bit of a Stretch by Chris Atkins (whom, interestingly, the opening anecdote of the book – the story of a bewildered person committed to prison for fraud - may relate to). In a sense, it’s a fusion of the subject matter of those two books.
In the manner of This is going to hurt, we are told shocking anecdotes relating to the mental and physical health conditions of the people the Doctor is there to treat – and are invited to be repulsed by them, pity them, and laugh at them, to various degrees. In the manner of A Bit of a Stretch, we get an insider’s view of what it’s like inside a jail, this time of course from the point of view of a medical professional and member of prison staff. The doctor peppers his stories with admissions that the system and facilities don’t work at all: there are extremely serious failures in both safeguarding the vulnerable and treating the many other medical emergencies that arise.
The prison is an open sewer, populated by rats and inmates whose moral proclivities (bullying, extortion, sexual misconduct) mirrors those of those much maligned members of the rodent family. Every screw, of course, has a heart of gold and “just wants to help people”, which is why they are putting up with horrendous work conditions when to all accounts, it would be better to just walk out (and, mentioned in the course of the book, many do). “They’ll think all deaths are avoidable and people only come to harm because we don’t care. They don’t know how hard we work and how dedicated we all are.” The good intentions of the staff – with, what are admitted in one short section, to be only slightly marred by either officialdom or staff sadism in rare cases – are contrasted with the mendacity of the inmates. The inmates only seem to respond to one thing, which could be summarised as “tough love” – with the emphasis on tough. No you can’t have any more tramadol, diazepam, or gabapentin – leading the patients to feign sometimes quite complicated illnesses. “
Each time we brought him back from the brink we told him how lucky he was to be alive. ‘This isn’t a life,’ he said once as we were leaving.” What goes unexamined in the book is very telling. Yes, many inmates engage in “medication seeking” behaviours, and may be chemically dependent on prescribed drugs.
To my experience – and I’m a pharmacist who has worked in both hospital and community sectors – this kind of behaviour is very common in the outside population. The crisis related to mental health patients, mostly driven by cuts to services and for seemingly ideological reasons, is as bad outside of jail as it is inside. The inmates extort one another “double bubble” and bully each other for meds, food and other items. But if they didn’t have to pay for the essentials - toiletries, food, treats and so on - through the extortionate “Canteen” system, they wouldn’t need to resort to this, or bothering the doctor for simple items.
There is a culture of bullying and intimidation - but if the system didn’t bully and brutalise them physically, and instead helped them work through their feelings and navigate conflicts, this would not be there. The inmates use drugs as an escape - but all the good research shows, if you don’t live in a high stress environment, you won’t need to depend on them. Though the doctor describes a jail which is physically filthy and totally under-equipped, not just for treating patients but also for housing living people at all, and he also points out the parts of the system that keep it this way – the staff cuts, the deliberate underfunding, the uncooperativeness of the prison governors – there is a significant omission.
No matter how well intentioned a screw is, or how golden their heart shines, the rotten system is carried on their backs – they support and uphold it. Systems of abuse in jail – whether physical, financial or sexual – are held in place by the punishment culture maintained and upheld by the screws. It is to the shame of the medical service there that the one thing that is keeping the inmates from being able to improve or recover, is the one thing they can’t prescribe for – being in jail in the first place.
To me, the only viable way to begin to help the people in jail is to consider the abolitionist approach. Though following the example of Norway is mentioned in this book, the reformist approach will not be able to sort through the many intrinsic problems of the system – described at great length in this book- and make it “fair”. It seems absurd.
The doctor says that he doesn’t want to know what the inmates (who he insists that he refers to only as “patients”) did to end up inside. At first glance, this seems noble, but when he does find out what some of his patients have done, he is repulsed, and displays the sorts of judgemental reactions that keep inmates in their low station in society – fear, moralising, being judgemental and so forth. I was struck that, for all the description of how bad things are inside the doctor refers to the presence of certain prisoners being due to them having been brought to “justice” by “victims”.
To be banged up for twenty-three hours a day, and marinated in a holistic culture of abuse – how does that seem like justice for anything? I will end by giving a fictionalised anecdote of my own. On a night shift in a hospital, a patient who had been a visitor to A&E, handed in a prescription. There were two medications on it to treat epilepsy, along with an obvious, hastily scrawled addition – “diazepam”. The added item was quickly noticed by colleague, who proceeded to give the patient a hard time over it. While the patient waited, my colleague called the cops. Probably feeling that something was up, the patient ran off. The police duly showed up – bored, bearded, burly – and began to ask for a description of the patient, along with the details on the prescription that would have included their real address.
When my colleague talked to me about it later, I explained that I didn’t think involving the cops was the right move – it caused the person to run off without not only the diazepam they wanted, but also the epilepsy medication which I presume they will be worse off without. The patient already had a bruised, bloody face, presumably from a fall which had taken them to A&E in the first place.
Jail and the cops would be no help to them. I could only imagine that my colleague was feeling the legal and regulatory pressure most pharmacists feel, to deal with the “crime”. I tried to explain my take – that the law would only do more harm to this person, so whatever we “had” to do in that situation, I felt that the actions she took could not be described as moral or ethical - “first, do no harm”.
Reading this book reinforced my opinion.
*If you would like to review a book, pamphlet or other publication then why not get in touch, email: ireland@iww.org.uk
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