1. The Hunger Games, Corrections
Style
Jeffrey E. Keller MD FACEP CCHP

2. Faculty Disclosure
• “I do not have any relevant financial
relationships with any commercial interests.”

3. Objectives
• Describe the historical roots and modern
definition of a “Hunger Strike.”
• Identify reasons inmates may refuse to eat
and the appropriate assessment, diagnosis
and treatment for each.
• Outline a step-by-step approach applicable to
all types of fasting inmates that incorporates
medical monitoring, housing, mental health
and legal considerations.

4. “Hunger Strike”
• The term “Hunger Strike” is often used
inappropriately for any inmate who refuses to
eat

5. Bobby Sands
• Member of the Irish Republican Army
• Wanted to be considered a Prisoner of War
rather than a common criminal
• Announced fast on March 1, 1981
• Died 66 days later
• Generated international publicity for his cause

6. Criteria for a true Hunger Strike
• The person intends to commit suicide
• The suicide is done for a political or religious
reason
• A goal is to generate maximum publicity

7. Suicide by Starvation?
• Buddhist monk setting himself on fire to
protest totalitarian rule in Myanmar.
• Al Qaida “suicide bombers”
• Easier to push a button detonating a bomb
than to not eat for 66 days.

8. Most Inmates Who are Fasting are not
“Hunger Strikers.”
• Religious fasts
• Extreme dieting
• Manipulative inmates who are secretly eating.
• Tantrum throwers
• Mentally ill inmates
• Protesters (but not suicidal)
• True Hunger striker.

9. The Approach to Each of These is
Different
• Housing. Special housing. Monitoring.
Audience
• Mental Health. Suicidal? Psychotic?
• Medical monitoring? Weights, Vital signs, labs
• Legal. Commitment? Involuntary feeding?

10. Step by Step Approach
• Initial interview
• Initial Physical Exam
• Setting up a care plan
• What about inmates who actually fast for a
long time?

11. Initial interview--Questions
• Are you expecting to die?
• Are you protesting something?
• Total fast or will you eat something?
• How long will you fast?

12. Initial Interview--Education
– You can fast for awhile
– We cannot allow you to harm yourself
– Court ordered feeding if necessary

13. Initial Interview Results
• Suicide by starvation
– True Hunger Strikers
– Impulsive
• Those who deny suicidal intent
– Dieters
– religious fasts
• Psychotic and delusional

14. The Physical Exam
• Weight
• Fat reserves
• Overall health
• Labs?

15. Care plan--Housing
• Suicide precautions
• Who can Remain in the Dorms?
• Separate from support group
– Psychological support
– Surreptitious feeding

16. Care Plan—Mental Health Evaluation
• Suicidal
• Psychotic
• True Hunger Strikers
• Protestors

17. Medical Monitoring
• Repeat medical evaluations
– Weights
– Food logs
– Vitals
• Do not be an Enabler
– “I don’t want a tray. I won’t eat it anyway.”
– Don’t feed attention seeking more than necessary.

18. Care Plan--Legal
• Psychotic inmates
– Commitment
• Hunger strikers
– Timing is important
– Aggressive interventions must be court ordered

19. Case 1—Extreme Dieter
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

20. Case 2—Religious Fast
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

21. Case 3--Protester
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

22. Case 4--Manipulator
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

23. Case 5--Psychotic
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

24. Case 6—True Hunger Strike
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

25. True Hunger Strike—Week 2
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

26. True Hunger Strike—Week 4
• Housing?
• Medical monitoring?
• Mental Health?
• Legal?

27. True Hunger Strike
Involuntary Feeding
• WHO
• Guatanamo experience
• How it is done

28. Summary
• “Hunger Strike” = “Suicide by Starvation”
• Hunger Games Response
– Housing
– Medical monitoring
– Mental Health
– Legal

29. Questions? Comments?