Health effects of prisons
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7273.1406/a (Published 02 December 2000) Cite this as: BMJ 2000;321:1406All rapid responses
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Editor,
The medical profession should be embarrassed that the responses to
Allwright et al's study (1) of blood-borne viral infection in Irish
prisons give an impression that a) nothing can be done and b)
politicians, not doctors are responsible.
Smyth(2) points out that community interventions may not be relevant
in prisons where some may find that prison stops them using drugs (and
presumably increases their risk of post-liberation overdose death through
reduction of opiate tolerance) but he ignores evidence that 10% of all
prisoners (including non-drug users) in a Scottish Prison(3) and a fifth
of drug injectors in Irish prisons(1) reported having injected for the
first time in prison. Langkamp(4) argues that needle exchange may be
harmful in prison where most new inmates may have already caught the
viruses we are currently aware of. McCarthy(5) goes so far as to challenge
the political legitimacy of incarceration in prisons where safety cannot
be assured, presumably opting for the alternative of letting dangerous
criminals walk the streets for their own safety!
Previously Crofts et al(6) pointed out that needle exchange may be
inadequate to prevent the spread of Hepatitis C even in community
settings.
When employed as a prison doctor I was demonstrated the efficacy of
Buprenorphine for preventing injecting behaviour in single case (an HIV
positive injector who ceased injecting with the treatment). To address the
issue of diversion the sublingual tablets were contained in a porous
"Tbag" throughout sublingual administration. The Buprenorphine was
administered within a strict behavioural routine where the presence of new
injecting sites led to withdrawal of a dose of medication. I have termed
this technique SHaRP (Secure Harm Reduction prescribing). Unfortunately,
the Scottish Prison Service, despite clear advice from BMA Council, has
further reduced the clinical freedom of its prison doctors and thereby
prevented further development of this technique in state prisons.
While McCarthy(5) rightly praises this journal for its robust stand
on the health needs of prisoners in general, it found this new Harm
Reduction intervention technique unworthy of publication. It would be
possible to carry out a controlled trial of SHaRP (perhaps against
Methadone prescribing, needle exchange and a control) in UK prisons with
the objective of reducing the transfer of injecting skills to injecting
naïve drug users on remand but this would need the political will, not of
the major political parties, but of our colleagues who advise them. We may
have to rely on profit motivated private sector prisons to carry out this
basic scientific work for commercial advantage: publication is likely to
be impeded by "a lack of general interest".
Safe alternatives to community interventions for drug using prisoners
could be developed but, until doctors in Her Majesty’s Prisons are
guaranteed the clinical autonomy enshrined in Statute but ignored in
practice by civil servants with the complicity of responsible Ministers,
prison will remain a testament both to the State’s failure to protect the
victims of the International drugs trade and the indifference of the
medical profession (including this journal) to this vulnerable group.
A J Ashworth MRCGP
Former Head of Medical Practice HMP Perth,
Past Chairman BMA Civil Service Committee,
Clinical Research Fellow (Addictions),
Forth Valley Community Alcohol & Drug Service,
Bannockburn Hospital,
Stirling,
1Allwright S, Bradley F, Long J, Barry J Thornton L, Parry JV.
Prevelance of antibodies to Hepatitis B, hepatitis C, and HIV and risk
factors in Irish prisoners: results of a national cross sectional survey.
BMJ 2000;321:78-82. (8 July)
2Smyth BP. Many Injectors stop injecting while imprisoned BMJ
2000;321:1406 (2 Dec)
3 Gore S M, Bird A G, Burns S, Ross, Goldberg D Anonymous HIV
surveillance with risk factor elicitation: at Perth (for men) and Cornton
Vale (for women) Prisons in Scotland. International Journal of AIDS and
STD;1997 8(3):166-75
4 Langkamp H. Risks of Syringe exchange programmes in prisons prevail
BMJ 2000;321:1406 -1407(2 Dec)
5 McCarthy N Legitimacy of punishment systems should be addressed BMJ
2000;321:1407 (2 Dec)
6 Crofts N, Caruana S, Bowden S, Kerger M, BMJ 2000;321:899 (7 Oct)
Competing Interests
The Author holds world Patents for the Tbag device,
The Author is approved as a parliamentary candidate by the Conservative
Party
Competing interests: No competing interests
legitimacy of punishment regimes
EDITOR- I was astonished at Dr McCarthy's letter on this subject.
The difference between judicial amputation and the risk of infection from
shared needles in prison is that the amputations are not voluntary.
I go into a prison on a regular basis. The inmates, apart from those who
have committed serious offences as a first offence, have been through all
the non-custodial regimes before ending up where they now are.
To make comparison between this situation and amputation for theft, for
example, is not sensible.
Patrick Beauchamp, Retired G.P.
Competing interests: No competing interests