Prisoners' health: a test for civilisation

BMJ 1997; 315 doi: (Published 05 July 1997) Cite this as: BMJ 1997;315:0

If you are interested to assess the degree of civilisation of a country then don't visit its parliament or theatres but its prisons. A visit to its prisons will show that Britain can make only a weak claim to being a civilised country. Its prisons are sumps. They contain many more of the sad and the mad than the bad, and they are overcrowded, unsanitary, and a threat to health. As several papers in this issue show, prisoners receive poorer health services than the rest of the population.

Prisons are dreadful places because nobody cares about prisoners—until they become a threat. Concern about the health of prisoners grew in the 19th century because of fears about typhus spreading out from the prisons. Now history might be about to repeat itself because prisons are being recognised as places where blood borne viral diseases flourish—because of the concentration of drug misusers.

A study of 548 adult male remand prisoners admitted consecutively to Durham prison showed that almost two thirds were using illicit drugs (p 18). A quarter had injected drugs, and a third of them had shared needles. Only a small proportion of those misusing drugs were detected by prison doctors, and only 5% who needed a detoxification regimen were actually given it. A study from Liverpool showed that a third of new prisoners had injected drugs and that 16% of them had injected in prison (p 30). Some injected drugs for the first time while in prison.

A study from Scotland, confirming that many prisoners had injected drugs in prison (p 21), found that only 4% had been offered vaccination against hepatitis B, although most used sterilising tablets when injecting. Most are denied methadone, and all are denied needle exchange. The authors observe that the “limited access to harm reduction … represents a serious gulf between the standards of health care and public health available to the same individuals in prison and outside.” Data from Marseilles found that more than a quarter of prisoners were positive for hepatitis B and that vaccination against the disease is possible in prison (p 61).

The picture in Britain is of a serious health problem and an inadequate response. Luke Birmingham offers an explanation of why (p 65). Many prisoners see prison doctors as “them” and are reluctant to disclose information. One prisoner described how he reported that he felt suicidal after the death of his brother: “… they put me in strips. You wouldn't treat a dog like that. I won't tell them anything now.” Birmingham argues that those developing health services for prisoners must listen to them.

Finally, Douglas Carnall celebrates a year of Career Focus (p 6). He thinks that medicine needs both a good appraisal system and a means to provide career counselling. All Career Focus articles are available on the BMJ's website (

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