Putting policy into practice on prison health

Abstract

Prisoners are known to be at high risk for many infectious diseases and it is widely accepted that public-health policies must not ignore this population. Now WHO's European Region Health in Prisons Project (HIPP) has released new guidance on how staff in European prisons can reduce the public-health risks from compulsory detention, in what are often unhealthy situations.Prisoners are at increased risk for a wide variety of communicable diseases, including tuberculosis, HIV, and other blood-borne diseases. Tattooing, piercing, and injecting drug use, for example, remain commonplace in many prisons. As well, it is estimated that there are at least 32 000 tuberculosis patients in prisons in Europe, mostly in eastern Europe. Evidence suggests that a typical prisoner is more likely to be a disempowered individual with a history of disease exposure and drug abuse, from a poor and marginalised community. Their disease risk is further compounded by overcrowded and substandard prison living conditions. To tackle communicable diseases in this context, says HIPP, policymakers and prison staff must better consider disease risks, which may differ between prisons, and be proactive in exploring suitable interventions.Most harm-reduction strategies—for example, substitution maintenance therapy, needle-exchange programmes, access to condoms and health promotion—can be cheaply and easily incorporated into prison health programmes. Models of best practice and strategies aimed at tackling communicable diseases in the prison context have been outlined in a plethora of published reports, guidance documents, and status papers in recent years. A series of technical papers, endorsed by WHO, the United Nations Office on Drugs and Crime, and UNAIDS—representing the largest systematic review done to date on the effectiveness of interventions to manage HIV in prisons —have recently been made available online and will be published in full later this year. These too provide further evidence that harm-reduction strategies, in this case aimed at reducing HIV prevalence, are effective.Although this new focus on prison health is a welcome one, many experts remain sceptical that the practical advances so urgently needed are not yet being made. Implementation of these guidelines has remained consistently poor across European countries to date. Most agree that progress where it matters most—namely at prisoner and prison level—is still too slow and too patchy to achieve the health gains so badly needed.Indeed, when it comes to prison health, it is often politics that get in the way of progress. Of course, prisoners themselves are rarely a top priority, in a context of limited national health-care resources. Of particular concern, however, is the extent to which public-health approaches continue to be undermined despite an ever increasing wealth of objective evidence to support them. Some governments have repeatedly rejected evidence-based strategies, including needle-exchange programmes, which they consider to be a tacit endorsement of illegal behaviour. The high prevalence of sexual activity in prisons has failed to be fully acknowledged. Furthermore, public-health strategies adopted in the community are ignored in the prison setting. Despite the high prevalence of hepatitis in prisons, for example, testing is rarely available to injecting drug users on entry into prison, nor access to health promotion and vaccination.What initiatives are in place remain inconsistent both within and across European countries. Priorities are largely determined by the individual prison administration, who often control their own local budgets, and rarely through a coordinated national public-health programme. Growing overcrowding in prisons makes implementation difficult.A major shortfall remains the notable gap in terms of dialogue, research, and the sharing of evidence-based best practice outside of the European context. For more than a decade, through HIPP, WHO has had a network of more than 30 countries of the European regions who have developed a wealth of evidence on what works best to make prisons healthier places. They have made commendable progress, but it is now imperative that this approach is expanded beyond Europe to settings where the communicable diseases threat will undoubtedly be far greater.We now face the formidable challenge of translating policy into practice. Addressing the dire state of public health in the prison context remains a moral imperative for policymakers in Europe and beyond. In a field where political and public support remains rare, WHO's role in providing leadership and direction internationally will be crucial. Prisoners are known to be at high risk for many infectious diseases and it is widely accepted that public-health policies must not ignore this population. Now WHO's European Region Health in Prisons Project (HIPP) has released new guidance on how staff in European prisons can reduce the public-health risks from compulsory detention, in what are often unhealthy situations. Prisoners are at increased risk for a wide variety of communicable diseases, including tuberculosis, HIV, and other blood-borne diseases. Tattooing, piercing, and injecting drug use, for example, remain commonplace in many prisons. As well, it is estimated that there are at least 32 000 tuberculosis patients in prisons in Europe, mostly in eastern Europe. Evidence suggests that a typical prisoner is more likely to be a disempowered individual with a history of disease exposure and drug abuse, from a poor and marginalised community. Their disease risk is further compounded by overcrowded and substandard prison living conditions. To tackle communicable diseases in this context, says HIPP, policymakers and prison staff must better consider disease risks, which may differ between prisons, and be proactive in exploring suitable interventions. Most harm-reduction strategies—for example, substitution maintenance therapy, needle-exchange programmes, access to condoms and health promotion—can be cheaply and easily incorporated into prison health programmes. Models of best practice and strategies aimed at tackling communicable diseases in the prison context have been outlined in a plethora of published reports, guidance documents, and status papers in recent years. A series of technical papers, endorsed by WHO, the United Nations Office on Drugs and Crime, and UNAIDS—representing the largest systematic review done to date on the effectiveness of interventions to manage HIV in prisons —have recently been made available online and will be published in full later this year. These too provide further evidence that harm-reduction strategies, in this case aimed at reducing HIV prevalence, are effective. Although this new focus on prison health is a welcome one, many experts remain sceptical that the practical advances so urgently needed are not yet being made. Implementation of these guidelines has remained consistently poor across European countries to date. Most agree that progress where it matters most—namely at prisoner and prison level—is still too slow and too patchy to achieve the health gains so badly needed. Indeed, when it comes to prison health, it is often politics that get in the way of progress. Of course, prisoners themselves are rarely a top priority, in a context of limited national health-care resources. Of particular concern, however, is the extent to which public-health approaches continue to be undermined despite an ever increasing wealth of objective evidence to support them. Some governments have repeatedly rejected evidence-based strategies, including needle-exchange programmes, which they consider to be a tacit endorsement of illegal behaviour. The high prevalence of sexual activity in prisons has failed to be fully acknowledged. Furthermore, public-health strategies adopted in the community are ignored in the prison setting. Despite the high prevalence of hepatitis in prisons, for example, testing is rarely available to injecting drug users on entry into prison, nor access to health promotion and vaccination. What initiatives are in place remain inconsistent both within and across European countries. Priorities are largely determined by the individual prison administration, who often control their own local budgets, and rarely through a coordinated national public-health programme. Growing overcrowding in prisons makes implementation difficult. A major shortfall remains the notable gap in terms of dialogue, research, and the sharing of evidence-based best practice outside of the European context. For more than a decade, through HIPP, WHO has had a network of more than 30 countries of the European regions who have developed a wealth of evidence on what works best to make prisons healthier places. They have made commendable progress, but it is now imperative that this approach is expanded beyond Europe to settings where the communicable diseases threat will undoubtedly be far greater. We now face the formidable challenge of translating policy into practice. Addressing the dire state of public health in the prison context remains a moral imperative for policymakers in Europe and beyond. In a field where political and public support remains rare, WHO's role in providing leadership and direction internationally will be crucial. Tackling communicable diseases in prisonsAccording to experts, communicable diseases in the prison population still remain an important issue that has not been fully addressed, with wider implications for public health. Full-Text PDF