Prison Health is Community Health : Prisons, Health and Human Rights

1. Prison Health is Community Health:Prisons, Health and Human Rights Rick Lines MA, LLM Executive Director, Irish Penal Reform Trust Health Promotion Winter School Dundalk Co Louth 11 January 2007

2. Prison Populations Worldwide • Over 9 million people incarcerated in prisons at any one moment Republic of Ireland • Approximately 3,200 prisoners at any moment • Government proposes to expand this number to over 4,000 • Over 5,000 people committed each year • 85% of all committals in 2005 were for non-violent offences (90% for women) • 78% of all committals under sentence in 2005 were for 12 months or less (89% for women) • 39% of all committals under sentence in 2005 were for 3 months or less (55% for women)

3. Prisoners’ Right to Health • People do not surrender their rights when they enter prison • The right to the highest attainable standard of health is explicitly retained • “States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees…to preventive, curative and palliativehealth services” -UN Committee on Economic, Social and Cultural Rights • States have a legal obligation under the European Convention on Human Rights to safeguard the health and well-being of people they hold in custody

4. The “Principle of Equivalence” • People in prison have a right to access a standard of health care equivalent to that available in the outside community • United Nations General Assembly • World Health Organization • United Nations Office on Drugs and Crime • UNAIDS • Council of Europe • European Prison Rules • Prison policy and/or legislation in most European States, including Ireland

5. Determinants of Health and Determinants of Incarceration • A significant proportion of prisoners in most countries are members of groups that suffer social, economic or ethnic/racial discrimination in the broader society. • Poverty • Unemployment • Early school leaving/low-literacy • Members of groups racial or ethnic groups that experience systemic discrimination • Homeless/under-housed • People who use drugs • People with mental illness

6. Determinants of Health and Determinants of Incarceration • “Penitentiary populations contain an over-representation of members of the most marginalized groups in society, people with poor health and chronic untreated conditions.” - WHO • Blood borne diseases (HIV/AIDS, Hep B&C) • Mental illness • STIs • Tuberculosis • Drug related health issues • Multiple health issues in combination

7. Health Problems Concentrated in Prisons - TB • Tuberculosis as many as 100 times higher among prison populations • MDR-TB common in prisons due to inconsistent treatment access • Risk of spreading TB and MDR-TB heightened by poor and overcrowded prison conditions

8. Health Problems Concentrated in Prisons - Mental Illness • WHO Europe estimates that up to 40% of people in prison suffer from some form of mental illness • UN Special Rapporteur on Health has expressed concerns that people with mental health problems are often “misdirected towards prison rather than appropriate mental health care or support services” • UN Special Rapporteur on Violence Against Women has noted that “mentally ill women are at high risk of sexual abuse in custodial settings”

9. Mental Illness in Irish Prisons • 60% of women and 35% of men have suffered from mental illness at some stage in their lives. • The rate of severe mental illness among remand prisoners is almost 40 times higher than in the general community; 13 times higher among sentenced prisoners (Kennedy, 2006) • 35% of prisoners who were homeless on committal said they had been diagnosed with mental health issues, and of them two-thirds had been hospitalised in a psychiatric institution. • Two-thirds of female prisoners homeless on committal stated that they had previously been diagnosed with a mental health problem (Seymour & Costello, 2005)

10. Health Problems Concentrated in Prisons - Drug Use Proportion of people who use drugs among prison population in the EU

11. Health Problems Concentrated in Prisons - HIV and HCV • Mass incarceration of people who use drugs means mass incarceration of people living with HIV and/or HCV • Zero tolerance approaches (supply reduction, mandatory drug testing) promotes injecting as a method of ingesting drugs • Denial of access to harm reduction measures (i.e. sterile injecting equipment) increases high risk injecting and potential transmission of disease

12. Health Problems Concentrated in Prisons - HIV and HCV • HIV - Rates of infection are typically more than 10 times higher than outside prisons • Spain: estimated at 16.6%, with figures as high as 38% among some prison populations • Italy: 17% • France: 13% • Switzerland: 11%; • Netherlands: 11% • Hepatitis C - The vast majority of peer-reviewed published studies have found that between 20% and 40% • Injecting - 0.3% - 34% of prisoners in the pre-expansion EU and Norway inject while incarcerated • 0.4% - 21% first injected in prison

13. HIV and HCV in Irish Prisons Allwright, et al (1999) – Study of 1,200 prisoners • HIV infection rate of 2% • HCV infection rate of 37% • Nearly half of women tested HCV-positive Long, et al (2000) – Study of 600 committal prisoners • HIV infection rate of 2% • HCV infection rate of 22%. • Among women the HIV seroprevalence rate was nearly 10% and HCV infection rate was 56%.

14. Injecting Drug Use in Irish Prisons • 1997 – 1 in 3 prisoners injected while incarcerated, 84% of them sharing syringes. 1 in 4 of this group was HIV positive. (O’Mahony) • 1999– 1 in 5 prisoners who injected drugs first injected while in prison. Nearly half injected while incarcerated, 3 in 5 of them sharing injecting equipment. 87% of those who had shared tested positive for HCV. (Allwright, et al) • 2000 – 1 in 5 prisoners who injected drugs first injected in prison. 2 in 5 shared injecting equipment while incarcerated. 90% of those who had shared tested positive for HCV. (Long, et al) • 2000 – 51% of clients accessing MQI’s needle exchange had been incarcerated. 2 in 5 reported injecting while in prison, 70% of them sharing equipment. (Merchants Quay Ireland)

15. Environmental Health in Prisons • Overcrowding/lack of space • Poor sanitary conditions • Inadequate lighting and ventilation • Extremes of temperature • Insect and rodent infestation • Insufficient/non-existent personal hygiene supplies • Poor or underdeveloped medical infrastructure

16. In Summary • The people committed to prison are those whose social and economic marginalisation place them at increased risk of physical and mental health problems. • They are incarcerated in overcrowded, unsanitary and stressful conditions, alongside others who share the same increased health vulnerabilities. • As a result, the prison environment is one marked by disease transmission, environmentally exacerbated health decline and death

17. Prison Health Case Study: Lithuania • 2002 - HIV outbreak among prisoners who inject drugs was identified at the Alythus Prison • 263 prisoners tested positive for HIV within the space of a few months • Prior to the outbreak, testing had identified only 18 HIV infections in Lithuania’s entire prison system, and only 300 persons were known to be living with HIV in the country as a whole.

18. Prison Health Case Study: South Africa • High rates of both HIV and TB • 1995 to 2000 - 584% increase in “natural deaths” of prisoners • 1999 - Department of Correctional Services examined post-mortem reports and concluded that 90% were HIV-related • Based upon these figures and the continuing growth of the South African prison population, the study predicted that by 2010, 45,000 people would die in SA prisons

19. Challenges for Health Providers • High needs population, often with multiple and complex health problems • Housed in an environment that is not conducive to promoting health • Prison authorities/structures not always welcoming of “outsiders” • Access • Time • Confidentiality • Community health authorities not welcoming of prisoners • Seen as the responsibility of Justice/Prison Service not Health • Health workers not trained or comfortable in working in prison environment or with prisoners

20. Opportunities for Health Providers • Prisoners are often very motivated about health issues • Prisoners will have greater trust with external health workers than with prison health workers • Prison health staff are often overburdened and under-staffed, and welcome support from external health professionals if approached correctly • Engagement with prisons by outside professionals can contribute to improved conditions and wider prison reform

21. Responsibilities of Health Providers • To respect and promote the right to health of people in prison just as we do people outside of prison • Respect the individual autonomy of people and prison and their right to make their own decisions about their health • Respect the expertise of prisoners and ex-prisoners and work with them in developing effective interventions

22. Responsibilities of Health Providers • To integrate prisons within our broader concept of community when developing overall regional/national health strategies • To understand and conceptualise prisons as a source of harm to health (both individual and community) • To take or initiate opportunities to build our skills in working with people in prison and in the prison environment • To be an advocate for prisoners’ health rights and prison reform

23. Prison Health is Community Health “Health is a fundamental human right indispensable from the exercise of other human rights.” UN Committee on Economic, Social and Cultural Rights Kamiti Prison Nairobi, Kenya

24. Rick Lines, Executive Director rlines@iprt.ie Irish Penal Reform Trust www.iprt.ie