Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A Balancing Act
- A.A.W. Amarasinghe,M.D., (29 July 2005)
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The Cost may be Higher than the Price
- Andrew J Ashworth (29 July 2005)
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Why do physicians work in prisons?
- Ruth Elwood Martin, Gavin C. E. Stuart, Dean, Faculty of Medicine, UBC (30 July 2005)
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Retributive justice rebounds
- Mark Struthers (3 August 2005)
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Europe's initiaive and progess should be noted
- Alex Gatherer (9 August 2005)
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A.A.W. Amarasinghe,M.D.,, Consultant Psychiatrist Metro State Prison, Atlanta,Georgia. United States of America
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Providing health care to prisoners has never been simple and never will be. The contemporary society can feel proud when compared to the Gulag - Auschwitz - Andersonville days where there was absolutely no health care for those incarcerated. Not in hundreds but in thousands, they were huddled together. The oft repeated words were, " too bad to get sick." Each society has to deliberate a balancing act with their prison health care costs at one side and their cherished value systems at the other side. Ofcourse, these are not apples and oranges and that summarises the crux of the matter. Competing interests: None declared |
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Andrew J Ashworth, GP Principal Davidson's Mains Medical Centre, Edinburgh, EH4 5BP
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By focussing on the price of prison healthcare, the BMJ has done a major disservice to communities that pay for poor (in both meanings of the word) prison healthcare in non-fiscal ways. Cost & price are not interchangeable concepts. The prison is a particular environment that gives access to healthcare for those who are often excluded from healthcare in other settings: the price of the care should be set against the cost of its absence. Degradation of the wider public health (for example the through the “culturing” of blood borne diseases in prisons with inadequate services to prevent needle sharing) and degradation of public order by the reoffending that follows issues such as inadequately addressed forensic mental health problems are costs borne by populations but hardly noticed by Criminal Justice Ministers. While locking less people up may keep us safer from disease, it carries political risks that are difficult to take in democracies. More mechanisation would inevitably reduce the good interpersonal work done by many Prison Officers: it carries the inevitable risk of increasing the social and health costs of imprisonment. Governments reward Agencies providing custodial facilities custodial objectives (not escaping) much better than care objectives (not reoffending or getting sick). Until the costs of incarceration are measured as well as its price, the public health will remain threatened by the inadequate resources directed to healthcare in prisons. Competing interests: Former Prison Doctor and past Chariman of BMA Civil Service Committee. |
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Ruth Elwood Martin, Clinical Assistant Professor UBC Department of Family Practice, 5804 Fairview Crescent, Vancouver, BC, V6T 1Z3, Canada, Gavin C. E. Stuart, Dean, Faculty of Medicine, UBC
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Dear editors, We are writing to provide additional ideas that will contribute to the discussion raised by Niyi Awofeso’s editorial, "Making prison health care more efficient". Our hypothesis is that many fine clinical and academic health care providers would want to work in prisons if they realized how satisfying prison work can be, and if they felt supported in their desire to provide exemplary and cost-effective clinical and preventative medical care. A family practice resident, Dr Andrew Cheong, recently conducted an exploratory qualitative study of British Columbian prison physicians, to understand why they become involved in prison medicine and what factors help them to continue in their work. Dr Cheong's study revealed that prison physicians require a special knowledge and skill set, a compassionate heart and the ability to manage manipulation and boundary setting. Interviewed prison doctors described their work as interesting, satisfying, personally rewarding and stressful<1>. In April 2005, the Department of Family Practice, Faculty of Medicine, University of British Columbia hosted an inaugural meeting of the 'UBC Collaboration for the Enhancement of Prisoner Health'. At this meeting, prison physicians, nurses, interdisciplinary providers and the provincial prison health care contractor gave reasons for their work. Their stories confirmed Dr Cheong’s findings. The 'UBC Collaboration for the Enhancement of Prisoner Health' plans to facilitate teaching, service and scholarly work among prison health care providers in order to enhance the health care provided to prisoners in British Columbia. We encourage every medical school to respond to the call for social accountability by providing respectful and academic support for their region’s prison health care providers. Yours sincerely, Ruth Elwood Martin, MD, FCFP.
Gavin Stuart, MD, FRCSC
Reference: 1. Cheong, Andrew. Considerations that Influence Prison Doctors. (Paper in revision). Abstract available at http://www.familymed.ubc.ca/residency/research/resabs05.htm#Cheong Competing interests: None declared |
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Mark Struthers, GP and prison medical officer Bedfordshire, UK mark.struthers@which.net
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As the UK stands shoulder to shoulder with the US in troubling times, it is pertinent that Niyi Awofeso should look at the ideologies and compare the efficiencies of the two prison systems. The fact that the annual cost of custody in the US was nearly half that in the UK ($28,000 US to $53,000 UK) will tempt the UK government ‘cherry picker’ with cost cutting ideas from the prison-industrial complex across the Atlantic. The ‘cherry picker’ will have noted the huge economies of scale and the high efficiency of managed health care as cruel and unusual punishment in US prisons. In June 2004 there were 2,131,180 US citizens in jail. At 486 inmates per 100,000 citizens, the US has the highest rate of incarceration in the world. The UK now has the highest rate of imprisonment in the European Union at 139 per 100,000. At the end of 2003 the prison population in the UK stood at 74,000. The previous decade had seen a 25,000 rise in the number of prisoners. The rehabilitation of prisoners has clearly given way to retribution as the dominant philosophy of America’s criminal justice system. As usual the UK looks set to follow suit. The reality is that punitive incarceration policies do not work and do not keep our societies safe. Anne Owers, Chief Inspector of Prisons in her Annual Report of December 2002 said: "The debilitating and chilling effect of prison overcrowding threatens all four of the Inspectorate's tests of a healthy prison - safety, respect, purposeful activity and resettlement. There can be no doubt that prisons are less safe than they were a year ago and many are also less decent places. They will also be less able to protect the public by reducing re-offending. The fruit growing in the US cherry orchard is unhealthy. Prison healthcare ‘cherry pickers’ from the UK must beware. Competing interests: None declared |
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Alex Gatherer, Retired public health physician N/A
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While it is very useful to be reminded about the need for cost efficiency in prison health services, the importance of effective prison health services to public health in general should also be stressed. In Professor Awofeso's valuable leader, he has not had the space to underline the public health importance of good prison health. His concentration on USA, UK and Australia's experiences has paid insufficient attention to initiatives in Europe. For example, the World Health Organization's Health in Prisons Project, launched in 1995, now has ten years experience in promoting health in prisons and custodial settings. 32 countries of Europe are committed at prison health policy level to the Project, showing a willingness to develop on the basis of all their evidence and experiences, best practice guidance in preventing disease and promoting health in prisons. All countries are facing the same important public health issues, to which good prison health can make a worthwhile contribution. It is time for a global initiative, so that all regions of the world can learn from each other in this challenging area of public health. Competing interests: I am linked as a temporary advisor to the WHO Regional Office for Europe's Health in Prisons Project |
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