The hunger strike in California prisons, which began on July 8, will enter its fourth week on Wednesday. With each passing day, more inmates are abandoning the strike, but even as they resume eating, this period of fasting may have caused lasting health problems. Reintroducing food too quickly could even be deadly.
Dr. Andrea Garber, a chief nutritionist at UCSF Medical Center and an expert on starvation, said this is not the time you want to have a big pasta dinner.
After three weeks of fasting, the strikers' energy reserves of sugar and fat are depleted, said Garber. Stores of the charged particles called electrolytes are at dangerously low levels, she said. Muscle function, the P-H level of blood and amount of hydration all have changed. Then, said Garber, reintroducing food sets off a new chain of events: glucose rushes into the cells, dragging electrolytes with it. The shift of electrolytes from outside the cell to the inside can cause big problems, said Garber.
"There are massive fluid shifts. People can get heart arrhythmias; they can even go into cardiac arrest," she said. "Some patients experience delirium, and finally, there is a serious risk for death."
This set of complications, called "refeeding syndrome," has been studied extensively since starved prisoners-of-war returned from World War II. Garber said the syndrome usually can be managed, but it takes patience and medical supervision.
"They refeed very, very slowly, starting with fluids, and electrolyte-containing solutions," said Garber. "Then they very gradually introduce food. It's a long process that can take weeks."
A federal receiver is overseeing medical services for the inmates, who are striking over state policies that result in long periods of isolation in special security units. Dr. Janet Mohle-Boetani, chief of the public health unit for California Correctional Healthcare Services, said they have both the staff and the expertise to provide proper care.
"We have evidence-based guidelines for clinicians to use to ensure that our population can start eating again in a safe fashion," said Mohle-Boetani.
So far, most inmates who have quit the strike are being monitored from their cells, although at least three patients have been hospitalized. But later this week, as inmates enter the fourth week of the strike, the potential for refeeding syndrome will rise. Mohle-Boetani said high-risk patients who have lost a lot of weight will be moved to a licensed medical setting with 24-hour nursing.
"We're going to be giving them a very limited caloric diet; we're going to be monitoring their labs, providing them with supplements as needed, and slowly and carefully advancing their diet," said Mohle-Boetani.
Inmates with pre-existing medical conditions, such as diabetes or hypertension, could be at increased risk for complications. According to California Department of Corrections guidelines, there will be no forced feeding of inmates who are capable of giving informed consent. Inmates have received written notice that they are in danger of lasting medical harm, and may die, even after they start to eat again.