INTRODUCTION AND ETHICAL ISSUES

The Global Wave of Climate Action is a worldwide initiative of many actions, protests and strikes including hunger strikes denouncing lack of action to deal with the climate crisis, with the purpose of influencing decision makers at the COP 28 and raising awareness and momentum for influencing world leaders. 

The Global Wave of Climate Action includes a spectrum of different activities, strikes, protests, synchronized meditations, planting days, end of the world parties, school and university strikes, and hunger strikes. 

Of all the activities, the hunger strike is the one of medical relevance. While understanding and being empathic with the criteria of a drastic measure for an extreme situation not being addressed at all, we feel as medical doctors the need to write down general guidelines and recommendations to preserve the health of the strikers and prevent complications, some of them life threatening and some of them potentially  irreversible. 

There is a difference between the concept of hunger strike and the one of a fast. While the former is a drastic measure of avoiding food that might put an individual at risk in order to have an essential demand met, the latter is an avoidance of food for a defined period of time, to show solidarity or for religious, personal, or meditational purposes. While a fast rarely is a health risk, the risks of complications and permanent consequences of a hunger strike rise with the duration of it.

There are ethical issues that have been addressed in medical literature on hunger strikes and medical attention, like the ethical conflict between advising against going into a hunger strike (or in favor of stopping it) and respecting the right of the patient to decide on himself and his health. The Malta Declaration on Hunger Strike by the World Medical Association states that forced feeding is never ethically acceptable and artificial feeding is accepted when the patient has consented or is unable to judge by himself but gave consent in advance, but in the lack of previous directives on patient preferences, the doctor might decide based on the good of the patient with no external interference The medical professional can decide to step down from the treatment of the person on a hunger strike on ethical grounds, provided that there is another professional who can be in charge.   

We remind that every medical professional works under the legal frame of his country and must abide by it.  Guidelines and general recommendations are only meant to be used as a tool for decision making and their recommendations are by no means compromising. The responsibility in every case lies in the patient-activist as his right of choice is preserved, and not in the medical staff themselves.

These guidelines are divided in 3 parts: 

1. Before the hunger strike (Criteria for recommending against, Setting for the hunger strike, preparation)
2. During the hunger strike (Intake, Controls and frequency, symptoms and signs for referral, mental health and support)
3. After the strike (Guidelines for Refeeding, Refeeding syndrome and other short term risks, long term complications). 

BEFORE THE HUNGER STRIKE

Criteria for recommending against going into a hunger strike

A hunger strike puts the striker at risk of many short and long term complications, some of them irreversible, might have physical and mental consequences, and of course lead to death if prolonged enough, We not only never recommend going into a hunger strike, but we must address the activist knowledge and understanding of the risks and prevention measures. While we understand and are empathic to the struggle and the use of this tool as a drastic measure, we strongly advise against it when medical pre-existing conditions can be aggravated by it.

Low weight 

We recommend against starting a hunger strike with a BMI less than 23 and strongly recommend not starting a hunger strike with a BMI less than 20. 

Renal impairment and Hepatic insufficiency

Acute or chronic kidney disease even if not in an advanced stage should prevent the patient from starting a hunger strike and we strongly advise against it as one of the main risks is fluid and electrolyte imbalance. If the patient strikes against our advice, we suggest increasing controls including Urinalysis and Chemistry panel with electrolytes, calcium, phosphorus, BUN and creatinine, and Complete Blood Panel once in the 1st week, every 48 hours the 2nd week and everyday if the strike is continued. Also, special measures must be taken during the refeeding period. Referral to the hospital must be considered in the case of any symptom or laboratory alteration.

Not compensated endocrine conditions (hypo or hyperthyroidism, adrenal insufficiency

These conditions generate  imbalances and affect many other systems by themselves, and the stress derived from deprivation of food can mask symptoms, trigger complications and jeopardize treatment efforts. Therefore  we strongly advise against starting a hunger strike in these cases. 

Diabetes type 1 and 2

Diabetes type 1 should prevent the patient from starting a hunger strike and we strongly advise against it as there will be drastic alterations in glucose levels, biological stress, fluid and electrolyte imbalance. Persons with diabetes type 2 should consider a hunger strike only if having mild diabetes without a history of complications, not treated with insulin. We advise on the duration of the fast to be of a maximum of 1 week and  only in the case of having available controls of sugar tests, and medical services where a chemistry panel and intravenous fluids can be prescribed. In any other case we recommend abstaining from hunger strike. In any case, a patient with a history of diabetes disease who considers to undertake a hunger strike is strongly advised to consult with an endocrinologist or to his General Practitioner before deciding.

Cancer

Any patient with an active cancer should not go into a hunger strike. The lack of food affects the immune system and the fight against the illness. Patients who have a past diagnosis of cancer with no actual need of treatment should consult their oncologist concerning participating in a hunger strike.

Infectious diseases

As said previously, the lack of food affects  our immune system thereby we strongly advise against going into a hunger strike while suffering any kind of infection. Any patient on a hunger strike who suddenly shows symptoms  of fever, cough or dyspnea, flu sensation, or burning while urinating should refer immediately to the medical service available. Any patient who develops fever while on a hunger strike is advised to go to a hospital for a check-up and consider stopping the hunger strike.

Autoimmune diseases

Also for autoimmune diseases we must consider the high levels of biological stress and the lack of intake that affect the immune system, which could trigger an exacerbation of a previously well controlled disease.

Pregnancy

Pregnant women should not start a hunger strike because it puts at risk both lives, the woman’s and the fetus’.

Mental Health

If the person has a past history of severe depressive or panic disorder, any kind of eating disorder, post-traumatic stress disorder, or personality disorders we recommend consulting a mental health professional, (preferably the one who treats the patient) and discussing with him the possible implications of joining a hunger strike. We also recommend discussing it with the rest of the group in order to better cope with any symptom that might appear if the participation is decided on.

Preparation for the hunger Strike

• We recommend increasing the fat intake to x2 the normal level during the 4-2 weeks before the hunger strike. An ideal reserve is around 3-4 kg weight increase.
•  The participants of the hunger strike must have access to medical attention at the hospital level and ambulance service for being transferred. This must be resolved before starting the strike and a coordinator must be informed of the medical services provider, affiliation or insurance of every striker considering the striker could faint and not be available to be consulted if an emergency medical service is needed.  
• A previously designated staff should take care of the media, social network, and receive visitors to minimize stress and preserve mental health. 
• A visit to the Family Physician – General Practitioner and a biochemistry and complete blood count work up is recommended to every person before starting a hunger strike. 

Medical recommendations on the setting of a Hunger Strike

• It is advised to reduce transport and traveling, so hunger strikers will prefer to stay at a fixed place. 
• The place must be illuminated, with circulation of air and nice temperature, minimizing the energy expenditure for preserving body temperature. 
• When there is a group of strikers, it is preferred that they be together in the same setting, to optimize mental health and sense of collective struggle. 
• The medical equipment must be that of a Primary Care setting: weight scale, blood pressure measuring device, thermometer, and ideally an electrocardiograph. A set for intravenous fluids can be included if the fluids can be well preserved in the setting but it is only necessary if a Hospital or Medical center is not readily available.

 

DURING THE HUNGER STRIKE

Intake

• Every striker must care about preserving fluid intake, preferably orally, from 1.5 lt. to 3 lt. a day, depending on the temperature and humidity of the setting. 
• It is highly recommended to take vitamin and mineral supplements, especially those including B vitamins, as a serious lack of vitamin B12 and (B1 in particular) are linked to permanent complications (Wernicke encephalopathy, neuropathy and anemia due to B12 deficiency). The importance of this recommendation is relevant when the hunger strike is for more than a week. 
• The most sensitive sign of dehydration is the drastic reduction in urine volume, so whenever this symptom presents it should prompt the striker to take more fluids, and consider blood and urine tests, for evaluating kidney function.

Mental health and general recommendations

• Food deprivation always causes biological stress. Furthermore, any person or group of persons going into a hunger strike do so for a reason, which they perceive as an essential struggle, worthy to sacrifice their own health and even life for it. The more the hunger strike goes on, the more extremely stressful it be, and the harder it will be for the striker to cope with it mentally and not only physically. 
• It is very important to provide the strikers with a setting, to help  with messages and visits of support, and to have someone in charge of taking care of press, media, social media, and every other practical issue for them.
• Any kind of mental health symptoms, abnormal or suicidal thoughts or behaviors most be referred immediately to the heath staff so a mental health professional can evaluate them and act promptly.
• It is advised to have some minimal physical activity, for example walking 500 meters a day, because the lack of activity leads to further loss of muscle proteins.
• It is advised not to stay all the time at the setting, and preserve hygienic habits as normal.  

Controls

• Medical staff must be available 24/7 to address any kind of symptoms that may appear. 
• In any case we propose a medical check-up every 72 hours the first week, every 48 hours the 2nd week and every day from the 3rd week. 
• Control must include anamnesis of symptoms, intake, fluid and dehydration signs, measure of weight and blood pressure. 
• An evaluation of mood state and mental health symptoms must be proactively performed in every visit

Criteria for referral 

• Weight loss of more than 15% of BMI
• Fainting for any reason
• Bradycardia symptomatic or bradycardia less than 45 although asymptomatic
• Intercurrent infection or acute disease
• Dehydration 
• Confusion, 
• Seizures, 
• Psychosis, 
• Suicidal thoughts.

AFTER THE HUNGER STRIKE

Refeeding guidelines and prevention of refeeding syndrome

• Refeeding syndrome is a life risk condition that has been studied mainly in severe eating disorders, and patients with severe weight loss due to biological conditions who have been aggressively refeeded. Although less research is found in the literature about the syndrome in hunger strikers, it is generally recommended to consider its prevention when the hunger strike lasts 10 days or more. 
• The most important electrolyte alteration to consider is hypophosphatemia followed by hypokalemia and hypomagnesemia
• Vitamin deficiencies, Thiamine (vitamin B1) and salt and fluid retention are other possible complications to be considered. 
• Clinical manifestations are variable and not specific, depending on the alterations and it severity. Expected symptoms are weakness, rhabdomyolysis, peripheral edema, arrhythmias, seizures. 
• We recommend that the process of refeeding be followed by a nutritionist. 
• Caloric intake must return to normal gradually to prevent refeeding syndrome.

      We recommend following this rule: 

• • 1st day: 330 calories
  • 2nd day 660 calories
  • 3rd day 1000 calories
  • 4th day 1350 calories 
• Increasing by 350 calories (1000 calories every 3 days) until the normal intake 
• Blood tests should be ordered every 72 hours the 1st week and weekly for the first month, including Sodium, Potassium, Calcium, Phosphate, Magnesium, Creatinine Kinase. Vitamin B1 and B12 levels must be obtained at least once in the first week after the ending of the strike. 
• Physical activity must be resumed gradually and supervised by a physiotherapist or personal trainer. 
• Every abnormal symptom must be referred to the doctor in charge of the follow up
• Because mood changes and severe depressive symptoms have been noted weeks following the end of a hunger strike, we recommend checking proactively for symptoms of anxiety or depression. When the hunger strike is performed by a group of persons, we recommend having a mental health professional taking care of the group from the initial steps until 2-3 months after the end of the strike 

CONCLUSION

• A hunger strike is a drastic measure of a person or a group of people who are ready to risk their health and their life for a change in a situation they cannot accept. Hunger and food depletion are important stressors apart from the condition itself. Although medical literature on hunger strike is infrequent and mainly points to ethical issues, we know there are risks and ways to prevent them 
• This document is meant to serve medical professionals and hunger strikers in general but was written in particular for the massive hunger strike of the Global Wave of Climate Action. 
• The professional care of a hunger striker or a group of them, and also these guidelines do not imply, by any means, approving, promoting or inducing a hunger strike.