Health services for prisonersBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d351 (Published 22 February 2011) Cite this as: BMJ 2011;342:d351
The World Prison Brief currently records 9 949 696 prisoners in the world,1 a decrease from the number reported in the BMJ in 1997.2 Russia has released many prisoners, but China still accounts poorly for its prisoner numbers. Notably, it is the reporting of prisoner numbers that has improved. If a state deprives citizens of their liberty, then at the very least they must be publicly accounted for.
The number of countries abolishing the death penalty or implementing alternative sentences is increasing.3 Fifty six countries executed prisoners in 2001, but only 18 did so in 2009. The death penalty is the ultimate denial of a person’s health, and its continued use must be vigorously opposed by health professionals⇓.
The World Health Organization acknowledges the public health risks of incarceration and the potential opportunities for connecting with otherwise inaccessible citizens to engage in health interventions.4 Since 1995, the Health in Prisons Programme has helped the vestigial health services in former Eastern Europe to improve their governance, adopt independent and professional clinical standards, and acknowledge the place for minimisation of harm in dealing with mental illness and drug dependence among prisoner populations. The programme is now expanding to the Western Pacific region (personal communication, S Del Pino, 2010). The focus of this initiative is to document the state of health services for prisoners in the region. Four regional offices still need to identify the health of prisoners as a priority.
If a state deprives citizens of their liberty, then at the very least they must provide competent health services and measure the health gains. Where competent prison health services are provided, the health seeking behaviours of prisoners improve. But even where health services are provided, continuity of healthcare on release is not achieving its full potential.5
Independent prison inspection, including inspection of the prison health service, should play an increasing role in improving both access to services and their quality. The Council of Europe provides the strongest support for this, through the Committee for the Prevention of Torture.6 The adoption of the Optional Protocol to the Convention Against Torture by more countries will increase the spread of independent reviews—57 countries had acceded to it by September 2010 (www.apt.ch/). However, this is still less than half the world’s sovereign states.
The World Medical Association and the International Committee of the Red Cross continue to support health professionals who choose to work with prisoners. A web based freeware course for prison health workers is now in its second edition.7
Research will contribute to the better description of the health of prisoners and an understanding of the health determinants of “criminality.” In the interim it is safe to assume that prisoners are no different from other socially excluded population groups—that is, they are characterised by unstable housing, poor employment history, poor educational achievement, high levels of mental illness, high prevalence of addictive behaviours, and unstable social and family relationships. The evidence for all these is building, as is the amount of ethical prisoner health research.8
Nearly every country recorded in the World Prison Brief reports overcrowding of existing facilities. Physical and sexual violence are a constant health threat to prisoners. Diseases such as HIV, tuberculosis, and hepatitis C continue to spread among prisoners and their families, simply because effective control measures are impeded by prison authorities.9
Barrier contraception may not be sanctioned, and contaminated injecting equipment continues to circulate because draconian drug policies mean that sterile equipment is not provided. Suicide in prison10 and death after release are unacceptably high.11
A range of health motivated alternatives to imprisonment are being trialled, such as drug courts and mental health referral services. “Justice reinvestment” is an explicit attempt to “disinvest” from prison services and invest in health and social welfare services instead.12 Several trials in the United States are showing benefits to the criminal justice system and financial savings. The health benefit is that prisoner numbers are decreasing in all the trial sites.
Prison services, their supporting health programmes, and health professionals must increase their coverage and attain the standard of care available to free citizens in the community. Redefining addiction and mental illness to come under the auspices of health, and not criminal justice, offers the greatest hope for reducing the number of people deprived of liberty.
In 1997 the BMJ stated that “prison health services should be as good as those for the general community.” The world’s prisoners have not yet achieved this, but there has been progress, and there are reasons for ongoing optimism.
Cite this as: BMJ 2011;342:d351
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.