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BMJ No 7120 Volume 315 Editorial Saturday 29 November 1997
Prison health servicesShould be as good as those for the general communitySee Paper p 1420, Education and debate p 1447On any day the number of imprisoned people throughout the world will number 30 to 50 million. Most periods of incarceration are short, so that four to six times those numbers pass through prisons every year. As imprecise as these figures are, one thing is certain: the numbers are increasing. Prison is a regulated but not a closed system, simply because of the numbers of people who enter, leave, and re-enter custodial institutions. So health problems in prison move between the two sides of the wall, in a seemingly chaotic manner.(1) Incarceration means that personal freedoms are denied to the prisoner - loss of choice over sanitation, diet, recreation, and cell mates to name a few. Moreover, overcrowding provides ideal circumstances for stress related disorders and transmission of diseases such as tuberculosis and HIV, as illustrated in this issue by Reyes and Coninx (p 1447).(2) The more prisoners' freedoms are limited, and the worse the general prison conditions, the greater the responsibility of the state to protect prisoners: this leads to a misunderstood principle that prisoners actually acquire rights while in custody, principally protection from harm and access to services, including health services.(3) Prisoners are far from being representative of the general population. They are predominantly male, young (15-44 years), and poorly educated and belong to minority or migrant groups. Many have lived on the margins of the community, and there they are likely to return. This complex of factors ensures the greatest chance of ill health, optimal conditions for infection to progress to severe disease, and minimal opportunity for early diagnosis and adequate treatment. Not surprisingly, excess prevalences of hepatitis, tuberculosis, HIV, and mental illness are reported among prisoners from many countries. In fact, a prison sentence can turn into a death defying experience.(4) And the increased risk of illness and death continues after release.(5) Yet the period of imprisonment could offer opportunities to improve the health of prisoners and at least minimise the risk of poorer health to the community. "Doing time" could improve nutrition; reduce consumption of tobacco, drugs, and alcohol; and provide remedial education programmes and job training, so improving the health of prisoners. Access to the prison health service may be the first opportunity for an inmate to receive medical care in an otherwise disordered life. Moreover, a visit to the clinic may be one of the few distractions to the boredom of prison life, or a haven in an otherwise violent environment. Health services in prisons should therefore be free and readily accessible. Regrettably, prison health care is too often the subject of criticism - either for its failings or because it is perceived as providing excessive services.(6) Prison specific health problems such as transmission of infectious diseases due to overcrowding, non-consensual sexual activity, illicit drug use, and physical violence are difficult for the community to comprehend. When prison care is adequate the costs of providing it are questioned. Reduction of costs leads to deteriorating services, which may in turn prompt prisoners to react to "inhuman or degrading" treatment (dissatisfaction with prison health services has contributed to riots in British jails). The only protection from this is the principle of equivalence: that services provided to prisoners should be as good as those the state provides for the general community. Equivalence is affirmed by the United Nations and the Council of Europe. Even in prison services which have moved the furthest toward equivalence, such as those of Norway and France, problems are nevertheless encountered. Norway, for example, integrated penitentiary and community health care, but increased mobility between prisons and the community created security and logistic problems.(7) An effective process to monitor progress in prison health services is undertaken by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. Since 1992 the committee has undertaken preventive inspections of prison health services in most member states of the Council of Europe; many have resulted in public reports.(8) Opening prison services to public scrutiny is the most effective way of ensuring accountability and maintenance of standards. As Reed and Lyne report, there is a long history to this activity, it is difficult to do, but very informative (p 1420).(9) The lack of attention paid to prisoners' health is reflected in the almost universal absence of the prison population from national health statistics. Prison statistics exclude health data, with the exception of deaths. Performance indicators for prison health seem to be limited to suicide rates.(10) This lack of baseline data inhibits the assessment of current services and future needs. Winston Churchill said that society could be measured by the way prisoners are treated. The importance of excellent health care transcends considerations of ethics and human rights: it also simply makes good sense for the community as a whole. I thank Professor Katarina Tomasevski (Danish Centre for Human Rights) for help in preparing the manuscript. Michael Levy
Visiting fellow
References
1 Glaser J B, Greifinger R B. Correctional health care: a
public health opportunity. Ann Intern Med
1993;118:139-45.
2 Reyes H, Coninx R. Pitfalls of tuberculosis programmes in
prisons. BMJ 1997;315:1447-50.
3 Tomasevski K. Prison health. International standards
and national practices in Europe. Helsinki: HEUNI, 1992.
4 Salive M E, Smith G S, Brewer T F. Death in prison: changing
mortality patterns among male prisoners in Maryland, 1979-87. Am
J Pub Health 1990;80:1479-80.
5 Harding-Pink D, Fryc O. Risk of death after release from
prison: a duty to warn. BMJ 1988;297:596.
6 Warren N, Bellin E, Zoloth S, Safayer S. Human
immunodeficiency virus infection care is unavailable to inmates on
release from jail. Arch Fam Med 1994;3:894-8.
7 Tomasevski K. Prison health law. Europ J Health
Law 1994;1:327-41.
8 European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment. Third general report on
the CPT's activities covering 1 January to 31 December 1992.
Strasbourg: Council of Europe, 1993.
9 Reed J, Lyne M. The quality of health care in prison: results
of a year's programme of semistructured inspections.
BMJ 1997;315:1420-4.
10 Biles D, McDonald D, ed. Deaths in custody Australia,
1980-1989. Canberra: Australian Institute of Criminology,
1992.
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