Prison health: a threat or an opportunity?

Abstract

Last week, WHO distributed to all European ministries of health one of the most important documents on prison health ever published. The report, Status Paper on Prisons, Drugs and Harm Reduction, brings together the wealth of evidence that shows that infectious disease transmission in prisons can be prevented and even reversed by simple, safe, and cheap harm-reduction strategies. Perhaps most importantly, the paper affirms WHO's commitment to harm reduction, despite opposition from many governments who view such approaches as a tacit endorsement of illegal behaviour. The public-health case for action is strong, but political commitment to this method of combating health problems in prisons remains elusive. Indeed, health problems in prisons are numerous. Prisoners are often from the poorest sectors of society and consequently already suffer from health inequalities. Being in prison commonly exacerbates existing health problems—incarcerating anyone, especially vulnerable groups such as drug users and those with mental illness, has serious health and social consequences. High rates of injecting drug use, risky sexual practices, and overcrowding have made prisons a perfect habitat for the spread of infectious diseases. In parts of Europe and the USA, up to 20% of inmates are HIV-positive; and in some prisons tuberculosis infection rates are 100 times that of the civilian population. A study by Anna Shakarishvili and colleagues in this week's Lancet highlights the need for interventions targeting vulnerable groups in detention centres to curtail the rapidly growing HIV epidemic in Russia. Harm-reduction efforts in prisons aim to prevent or reduce the negative health effects associated with certain behaviour patterns, imprisonment, overcrowding, and adverse effects on mental health. Initiatives such as needle-exchange programmes are effective and viable for controlling the spread of HIV, and do not obstruct the safety or effectiveness of drug-use prevention policies. However, the prison systems that have achieved the most success in preventing the spread of HIV have promoted harm reduction and treatment strategies together—making bleach, condoms, methadone maintenance, needle exchange, and other drug treatment available. Despite these positive outcomes, the response to the HIV/AIDS epidemic in prisons has been slow and piecemeal, and most governments continue to ignore the strategic importance of prison health care to public health. Most strategies for dealing with HIV in prisons focus on a zero-tolerance approach to drug users. The fact that infection rates are still climbing confirms that this approach does not work, but governments have been reluctant to endorse alternative strategies. Rather than a lack of evidence that key interventions work, the prevention of infectious disease transmission in prison is hampered by a bizarre denial of governments of the existence of injecting drug use and sexual intercourse. Sadly, prison health is not high on the list of the public's concerns, so there is also little domestic pressure to address the problem. Some UN agencies, such as the United Nations Office on Drugs and Crime, still question the efficacy of harm-reduction measures, despite much scientific evidence to the contrary. The influential role played by the UN's four major donors—the USA, Sweden, Italy, and Japan—which all favour prohibitionist approaches to drug use in prisons, means that harm-reduction measures have not been given the credit and status they deserve. The failure of governments around the world to implement measures that have repeatedly been shown to reduce harm wastes a vital opportunity to improve the health of a population that is often beyond the reach of public-health efforts. This failure is utterly shameful. Prisoners, a “captive group”, present a crucial opportunity to address behaviours that pose a high risk of disease transmission in society in general as well as in prisons, with proven, easy, and cheap harm-reduction measures. It is important to remember that these health issues do not remain confined to prisons: the high level of mobility between prison and the community means that the health of prisoners should be a fundamental issue of public-health concern. Infectious diseases transmitted or exacerbated in prison inevitably become public-health issues when prisoners return to their communities. It is time for a global approach: to acknowledge the contribution of prison health to health inequalities; and to make prison health a priority by convincing governments that health policy must be based on evidence and not political prejudice.