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What happens to hunger strikers after the strike ends?

Jerusalem24 – Palestinian administrative detainee Khalil Awawdeh suspended on 31 August a six-month open-ended hunger strike which left his life “in immediate danger”, according to the medical opinion of Dr. Lina Qasem-Hassan of Physicians for Human Rights Israel.

42-year-old Awawdeh was protesting his being held without charge or trial, and ended the strike after securing a written agreement with Israeli authorities to release him at the end of his current detention period on 2 October, provided the military found no new “security” information to prolong his detention. The agreement also provides for Awawdeh to remain in Assaf Harofeh Hospital in Israel until he recovers.

Awawdeh’s actual recovery time is likely to outlast both his remaining stint in detention and the media interest in his situation. Little attention is paid, in fact, to hunger strikers after their strike ends.

A very political medical issue

This discrepancy in coverage, as well as the misconceptions and general lack of awareness that exist surrounding the long-term health effects of a hunger strike, are questions that Physicians for Human Rights Israel (PHRI) has concerned itself with through its work.

“It’s a great question,” Oneg Ben Dror, Project Coordinator for the Prisoners & Detainees department at PHRI, tells Jerusalem24. “I would say that in Palestinian media there is interest of health issues of people in prison – but I don’t know why the issue of the physical effects of the hunger strike during the strike, and afterwards, is less covered.”

Both in Palestine and Israel, most media coverage hinges on the politics of the hunger strike – including the ethics of force-feeding, an issue brought to the fore in Israel in 2015 when the Knesset passed the “Law to Prevent Harm Caused by Hunger Strikers” which allows for the force-feeding of prisoners in extreme circumstances. The law was meant as a deterrent, says Ben Dror, in response to mass hunger strike action amongst Palestinian prisoners which became increasingly common after 2012.

On the medical ethics concerning the practice, Ben Dror is categorical: “Physicians shouldn’t be involved in force-feeding.”

“Apartheid in health”

Founded in 1998 by a collective of physicians, PHRI provides humanitarian aid to people with little access to medical services through mobile clinics in the West Bank and Gaza as well as an open clinic in Jaffa. PHRI also works towards changing “discriminatory and abusive structures and policies against Palestinians, detainees, undocumented workers, migrants, and residents of Israel,” explains Ben Dror.

“We analyze the health system as ‘apartheid in health’ – not only because of the militarization of medicine and how the so-called security considerations prevail over everything, but also because of the segregation in the health fields.” 

PHRI also offers assistance to Palestinian detainees and particularly hunger strikers: “We work together with the lawyers of the people and according to what they would like us to do. In the past, and also in the case of Awawdeh, our physicians visited Awawdeh in the hospital, we submitted medical opinions, and we also worked to put pressure on Israel and activate the international community.” 

Rewriting the medical literature

Awawdeh is one of many Palestinian prisoners who have resorted to hunger strikes since at least 1968 in order to protest their arbitrary detention or their detention conditions by Israel.

While none have died since the 1980s (deaths that were all associated with either force-feeding, or re-feeding, a delicate process “that should take place gradually and be done carefully,” says Ben Dror) many suffer long-term and sometimes irreversible health effects – particularly as the duration of hunger strikes has increased in recent years. Three Palestinian prisoners led hunger strikes of over 100 days in 2022 alone.

Awawdeh survived just under 180 days of fasting by ingesting vitamins sporadically throughout his strike.

Ben Dror explains that the emergence of these longer-term hunger strikes may warrant a re-examination of what is known on the subject: “I would say that it does change the medical literature on hunger strikes in general – and some of this is still unknown.”

“Before, we were able to tell quite accurately what would happen after 40 days, and usually, between 60 and 70 days, the body would collapse and the person would die.”

Vitamins changed that, she explains, in prolonging the duration of time a body can survive without food. Also unknown, is how vitamin-intake affects the recovery and long-term health of the hunger striker.

Ben Dror cautions against making generalizations based on this development, since a variety of different vitamins tend to be taken sporadically and inconsistently amongst hunger strikers. “One person can take a few vitamins on days 56, 73, and 100, for instance, and another one can take more or less than that on other days.”

Irreversible damage

Through their work with Palestinian prisoners in Israel, PHRI has observed first-hand and documented the myriad health effects of a hunger strike on the human body. 

“At first, it damages fat tissues, then causes muscle thinning, and can cause severe body pain and an extreme sense of cold. The deficiency in vitamins can cause bleeding – which is why at some point during a hunger strike you stop brushing your teeth.”

A prolonged hunger strike can also cause damage to the spinal cord, and in the case of a severe vitamin D deficiency, chronic neurological problems such as vertigo, dizziness, sluggish thinking, and severe memory problems may develop.

It is nevertheless hard to determine beforehand what will constitute irreversible damage: “Each body responds differently and each body has different reserves.”

In Awawdeh’s case, the medical opinion submitted by PHRI both to the Israeli military and the High Court of Justice in early August assessed he was suffering “severe neurological symptoms and cognitive impairment, which might be irreversible.”

But despite the advocacy work PHRI engaged in on Awawdeh’s behalf, this did not lead to his immediate release. “In Israel […] what they consider as dangerous or a threat surpasses any other considerations,” says Ben Dror. “You can say they also ignore medical opinions – and even just serve as an authority in medical decisions.”

If and when an agreement is reached between the hunger striker and Israeli authorities, a long road to recovery lies ahead.

“They’re relying on medical care”

Immediately after the end of a hunger strike, and until the date set for their release, prisoners generally remain in Israeli prison hospital care.

According to the information gathered by PHRI, long-term hunger strikers are then often transferred to hospitals in the West Bank or East Jerusalem. The Palestinian Prisoners’ Club has also said they provide support with various medical and psychological ailments.

“Because it’s a long process, you need a follow-up. You need an orthopaedic follow-up, physiotherapy treatment where we have to rebuild the muscles, blood tests should be monitored. It is very important that people have a long-term rehabilitation process after a prolonged hunger strike.” 

PHRI are hoping in future to be able to engage in longer-term monitoring with their physicians and partner organizations, after patients pass the one-year mark in recovery. Former hunger strikers are still subject to widespread, adverse health effects even after this extended period of time.

For instance, says Ben Dror, hunger striker Maher Al-Akhras spoke in an interview a year after his strike had ended of the long-term ailments he suffered, including a total loss of balance and struggling to read or walk in a straight line. Ahmad Ghannam was diagnosed after his release with weakened heart muscles and the early stages of type 2 diabetes.

“They’re relying on medical care.”

And what of their mental wellbeing? “We do know it affects their mental health; we don’t know how with each person.”

A last resort

With such adverse, lifelong health effects – and beyond the obvious hardships of food deprivation – how do hunger strikes remain such a widespread practice among Palestinian prisoners and particularly administrative detainees?

“I would say it’s a last resort,” muses Ben Dror. “As a frustration from the administrative detention, of being detained for an unknown time and unknown reasons… I would say that it is a last resort.”

But while individual hunger strikers may be successful in securing a promise that their current administrative detention will not be extended, “it doesn’t mean that a month afterwards it will not be renewed or a new one be issued.”

Just yesterday, former detainee Hisham Abu Hawash who was released in February this year at the issue of a 141-day hunger strike, was arrested by Israeli forces in Hebron in the occupied West Bank. He was released later in the day.

Mass hunger strikes can be more effective in securing improvements, according to Ben Dror. “Individual hunger strikes don’t influence other conditions, while a mass hunger strike can change something within the Israeli prison service and [for] the people in prison.”

Earlier this month, a mass hunger strike of 1,200 Palestinian prisoners was called off within hours after prison authorities agreed to meet some of the prisoners’ demands.

“Not a matter of human rights”

As long as there will be Palestinians detainees in Israeli prisons, it is likely there will be hunger strikes. And as long as there are hunger strikes, it seems likely Israel will come up with policies to contain the fallout.

In an interview with Channel 10 in March 2014, legal advisor to the Israeli Ministry of Public Security Yoel Adar said: “If a hunger striker dies in prison, it causes riots, in prison, in Judea and Samaria [the Israeli name for the occupied West Bank], in Palestinian territories. This has a definite implication on Israel.”

While no hunger strikers have died in nearly 40 years in Israeli custody, it was announced several times that Awawdeh himself was on the verge of death, and nearly three weeks passed after PHRI Chairperson Dr. Qasem-Hassan’s assessment that Awawdeh’s life was “in immediate danger” before Israeli authorities agreed he would be released.

For Israeli authorities, says Ben Dror, “I would say that, unfortunately, it’s not a matter of human rights.” She thinks other interests – such as the likelihood for riots and external pressure on Israel – rather than medical opinion, are likely to constitute the criteria for a prisoner’s release.

Could it then be a deliberate policy to let the health of hunger striking prisoners deteriorate to the point that, even released, they are no longer deemed a “security risk”?

“I mean obviously we hope that it is not the case – but it is likely to assume so.”

Listen to the full interview on Wake Up Palestine.

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