1559

EDITORIALS

A European committee looks atdegrading treatment in custody

The European Committee for the Prevention ofTorture and Inhuman or Degrading Treatment(CPT) has the power to visit and report on all places ofdetention in countries ratifying the Convention whichestablished the committee and which came into forcein 1989. The likely medical implications of theConvention were predicted to be on the risk ofinhuman or degrading treatments to patients admittedinvoluntarily to psychiatric hospitals and the

adequacy of health care for prisoners. The CPT,which had four doctors among its members, in thefirst year of operation visited five countries-Austria,Denmark, Malta, Turkey, and the United Kingdom.The Convention provides that reports on visitsbe submitted to governments confidentially.Governments can request that reports be published,and can then require that their own comments orinterim reports be published simultaneously. In thepast few months, reports of CPT visits to threecountries have been published, the most recent beingthat for the UK visit. Here are some of the conclusions

directly relevant to health and to medical practice.

Denmark

In September, 1991, the Danish Government

published the CPT report on Denmark, withoutcomment. Few serious criticisms were made, the visithaving been conducted "in a spirit of greatcooperativeness". Nevertheless, the problems relatingto the Herstvedester Institution, as well as those

relating to lengthy solitary confinement of remandprisoners, are of considerable medical interest.Herstvedester is now a prison establishment housingindividuals undergoing psychiatric treatment for

serious mental disorders, personality disorders, andsexual aberrations. The institution ws noted to have anambivalent attitude to the use of constraint and

confinement, with serious divergences between themedical staff and prison personnel. The CPTrecommends that ordinary mental health legislationshould apply to mentally disordered prisoners,particularly in relation to coercive treatment and theuse of isolation for acutely ill prisoners.

At the Western Prison, Copenhagen, some remandprisoners are subjected to an unusually harsh form ofsolitary confinement, often with prohibition of lettersand visits. This regimen of total isolation, applied forup to 21 months, is regarded by prisoners as a form ofpsychological torture used by the police to obtainconfessions. The psychological effects are serious-almost all such prisoners report anxiety, nervousness,disturbed sleep, and difficulties with concentrationand speech, and there are numerous instances of"isolation syndrome" (suicidal thoughts, repetitivedreams, loss of appetite and weight, depression,paranoid ideas). Medical recommendations to

terminate solitary confinement are more often thannot ignored, priority being given to "securityimplications". The CPT judged that such lengthysolitary confinement could amount to inhuman anddegrading treatment and called on the authorities toensure that, whenever a prisoner held in solitaryconfinement asks to be seen by a doctor, a medicalexamination is conducted without delay and theresults are forwarded to the competent authorities.

Austria

A month later the Austrian Government followed

suit, by authorising the publication of the CPT reporton Austria together with an 11-page set of comments.The report is harder-hitting than that for Denmark,dwelling in particular on allegations of serious illtreatment of detainees in police custody. The

interrogation cells of the security bureau in Viennawere indicated independently by several prisoners asthe scene of physical abuse. The CPT referred tomedical reports of a perforated ear drum, contusions,and bruising. Furthermore, there is adverse commenton the medical care of persons in police custody. Thereport is generally favourable on conditions inAustrian prisons, which are administered by theMinstry of Justice (whereas police custody comesunder the Ministry of the Interior). The CPTintervention in Austria, begun with a "satisfactorydegree of cooperation" at high level but with"reticence" at subordinate levels, seems to have bornefruit in bringing pressure on the Ministry of theInterior and the police authorities to accept the needfor change.

United KingdomIn the UK, the committee concentrated on "local"

prisons, visiting Leeds, Brixton, Holloway,Wandsworth, and Bullwood Hall prisons, and also

1560

looked at four police stations in Leeds and London.The comments on police custody are generallyfavourable, though the committee requestedassurances about the right of a detainee heldincommunicado to be examined by a doctor otherthan a police surgeon and concern about the

interrogation of mentally disordered persons andindividuals with drug withdrawal states. The maincriticisms are about conditions in prisons.Overcrowding of an "outrageous level" existed atLeeds prison, with two-thirds of the prisoners three toa cell. In Leeds, Brixton, and Wandsworth prisonershave to defaecate and urinate into buckets, in theconfined space used as a living area: the committeejudged this degrading both for the bucket-user and forthose who are obliged to listen and smell. The manyhours spent with the excreta-filled buckets and the

slopping out process "are scarcely less objectionable",are obviously unhygienic, and are also debasing forprison officers. The lack of work, training, and otheractivities means that many prisoners spend over 22hours a day locked up in their cells. In the opinion ofthe CPT, the combination of overcrowding, lack ofsanitation, and inadequate activities constitutes"inhuman and degrading treatment". This is an

explosive conclusion with extremely grave

consequences: it implies violation of the EuropeanConvention of Human Rights on a massive scale,involving several thousand persons, any of whomcould introduce a complaint against the UKGovernment to the European Commission of HumanRights.The assessment by the CPT of medical care for

prisoners, already the subject of widespreadcriticism,1 is shocking. The description of medicalconsultations shows that normal ethical standards are

systematically violated: examinations are perfunctoryand confidentiality is at hazard; the medical servicesare overwhelmed by day-to-day needs and unable toplan preventive measures. At the time of the CPT’svisit there were 163 men in Brixton’s F wing, many ofthem with major mental disorders. The conditions inF wing were thought likely to exacerbate rather thanalleviate psychiatric disorders, with patients spendinglarge amounts of time locked in single or double cells.Seriously disturbed or violent patients are placed in abare cell with only a mattress on the floor. As inHerstvedester, there is serious ambivalence about thestatus of mentally disordered prisoners: F wing is nextto the hospital wing but not regarded as a psychiatrichospital in terms of the Mental Health Act. Transferto F wing is not subject to consent, but once thereprisoners do not benefit from the legal rights andaccess to treatment of patients admitted involuntarilyto hospital. A further medical issue raised was thesegregation of HIV- infected prisoners. At Leeds andBrixton such prisoners are housed in the hospitalwings. At Wandsworth, they are housed on K wing,together with prisoners "who it was feared might beHIV + but who refused to take the blood test". The

regimen is described as very impoverished anddiscriminatory. In Holloway no such segregation ispractised. The CPT underlined the patentdiscrepancy between the stated policy of the PrisonMedical Service (no routine segregation of HIV-infected prisoners) and the realities of prison life.

In its reply, the UK Government rejects theassertion concerning inhuman and degradingtreatment but accepts that improvements are

necessary. Indeed, it maintains that substantial

changes have been made since the CPT’s visit, inparticular concerning overcrowding at Leeds prison.Provision of integral sanitation is being given highpriority: slopping out will end in 1994 in Brixton andWandsworth prisons and in 1996 in Leeds. Theresponse concerning medical and psychiatric care isessentially that a working group and a task force havebeen established and consultants have been engaged.Since then, the Home Secretary has appointed SirDonald Acheson as chairman of the new Health

Advisory Committee for the Prison Service.

In these three reports the CPT has shown initiativeand imagination. For health workers the messages arethreefold: objective medical examinations can provideevidence of physical and psychological ill treatment,including the effects of lengthy solitary confinement;the health care of prisoners requires a clearly definedframework independent of the prison administration,providing a quality of care akin to that available in thecommunity, and good health care cannot readily beprovided in an environment of squalor and

unnecessary suffering. The blame for the piteous stateof medical care for prisoners does not lie with thosewithin the prison medical services. The healthestablishment as a whole-health authorities,professional associations, and medical schools-hasby neglect allowed unethical and unsound practices todevelop. The CPT will help to overcome the

psychological and administrative barriers that

separate prison from society and prison health fromcommunity health.

1. Editorial. Health care for prisoners: implications of "Kalk’s refusal".Lancet 1991; 337: 647-48.

Nitric oxide in the clinical arena

Endotoxin and certain cytokines (eg, interferon-y,tumour necrosis factor [TNF] and some interleukins)enhance endogenous synthesis of nitric oxide (NO) viainduction of an NO synthase in both endothelial andvascular smooth muscle cells.1 This inducible enzymediffers from the constitutive isoform found inendothelial and other cell types, and is now believed tobe responsible for the sustained vasodilatation,hypotension, and pharmacological hyporeactivity thatcharacterise septic shock.l-4 Some studies have

suggested that enhanced NO formation may bebeneficial. Thus, administration of exogenous NO