HEALTH CARE IN PRISONS: AN INTERNATIONAL CHALLENGE IN PRVEVENTIVE MEDICINE AND PUBLIC HEALTH

1. HEALTH CARE IN PRISONS: AN INTERNATIONAL CHALLENGE IN PRVEVENTIVE MEDICINE AND PUBLIC HEALTH Anthony J. Silvagni, D.O., Pharm.D., M.Sc., FACOFP dist. Professor of Family Medicine and Public Health Nova Southeastern University College of Osteopathic Medicine

2. The WHY of Correctional Health Care • Why treat inmates? • Civilization is measured by how it cares for society’s outcasts. (deToqueville) • It is the ethical and humane thing to do • In many countries it is the law (e.g. USA) • Diseases will spread within the prison population and when released, within the general population • The cost of providing appropriate health care to prisoners is most likely less than not providing the care due to the greater spread of diseases.

3. World Population of Inmates • Over 9 million inmates world-wide in prisons and jails • US, China and Russia lead the world in incarceration rates. (Probably other countries are high but data gathering is inconsistent)* • In many countries- remand to PRISON while awaiting trial- therefore people who are NOT CONVICTED of anything are in prisons (not jails) • Walmsley, R., Kings College London- International Prison Studies from http://www.scribd.com/doc/328143/World-Prison-Population-List-2007

4. Incarceration: a global response to crime and disorder

5. USA Incarcerated Populations, Midyear 2002 • >2,020,000 persons in prisons or jails • 1,360,000 in Federal and State prisons • 665,000 in local jails Source: Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2002 (4/2003) NCJ 198877 Source:Bureau of Justice Statistics Publication #, NCJ 198877 April 2003

6. USA IncarceratedPopulations, Midyear 2007 • >2,299,116 persons in prisons or jails – Approximately a 14% increase from 2002 • 1,528,014 in Federal and State prisons • 766,010 in local jails Source: Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2007 (http://www.ojp.usdoj.gov/bjs/prisons.htm) Source:Bureau of Justice Statistics Publication #, NCJ 198877 April 2003

7. Note Slower Pace- (Slope more level)

8. Source: Bureau of Justice Statistics. Correctional Populations in the United States, 1997 and Prisoners in 2004.

9. Typical Florida Prison (Jefferson Correctional Institution)

10. United Nations - Seven Standards For Medical Care • A medical officer with some knowledge of psychiatry is to be available to every institution. • Prisoners requiring specialized treatment are to be transferred to a civil hospital or appropriate facility. • A qualified dental officer shall be available to every prisoner.

11. UN - Continued 4. Prenatal, postnatal and related care are to be provided by women's prisons; when nursing infants are allowed to remain with their mothers, a nursery staffed by qualified staff is needed. 5. Every prisoner shall be examined by the medical officer shortly after admission; prisoners suspected of contagious diseases are to be segregated.

12. UN - Continued 6. The medical officer shall see all sick prisoners daily, along with those who complain of illness or are referred to his or her attention. 7. The medical officer is to report to the director a. those prisoners whose health is jeopardized by continued imprisonment b. the quality of the food, hygiene, bedding, and clothing c. physical regimen of the prisoners.

13. An UN Rule Regarding Food • UN requires wholesome food being prepared daily for prisoners • Not uncommon to see malnutrition in prisons, similar to, but worse than the malnutrition of the country’s indigenous population

14. United NationsStandard Minimum Rules for the Treatment of Prisoners Prison Cell in Austria “Where sleeping accommodation is in individual cells or rooms, each prisoner shall occupy by night a cell or room by himself. If for special reasons, such as temporary overcrowding, it becomes necessary for the central prison administration to make an exception to this rule, it is not desirable to have two prisoners in a cell or room…”

15. Prison Cell in East Africa Photo by New York Times

16. CARIBBEAN PRISONS • Jamaica – Patient (prisoner) held in Tower Prison infirmary without care. Doctors sent to hospital but patient died in hospital prior to being seen • Haiti - Malnutrition commonplace (beriberi) • HIV is frequent throughout the Caribbean prisons

17. NSUCOM International Medical Outreach in Jamaica Prisons

18. NSUCOM Student Teaching in Jamaica Prisons

19. Inside Towers

20. Removal of Bullet- Towers

21. TelemedicineLinking Prisoners to Specialty Care Telemedicine program at the Tower Street Prison, Kingston, Jamaica

22. Tremendous Opportunities for Education in Prison Health Care • Great Teaching Environment • Only environment where students can see long term effects of disease • With or Without treatment - PATIENTS HAVE TO COME BACK • Inexpensive to set up and run services • Tremendous wealth of pathology – some advantages over a university-based residency program • A truly needed area for care • Exponential effect on country’s public health

23. Why Bother Teaching Students in US Prisons • One of the few environments that is NOT dominated by reimbursement and insurance policies • 1. Write Orders • 2. Progress Notes • 3. History & Physical Opportunities • 4. Triage • 5. Really sick people

24. Universal Finding Among Incarcerated Populations: High Burden of Disease Inmates typically have few economic resources and little access to health care prior to incarceration They have disproportionately high rates of substance dependence, mental health disorders, high-risk sexual activity, prior violence-related injuries, head trauma, and complications of chronic illnesses High rates of infectious disease including HIV, TB, STD’s, hepatitis, etc. Prisoners in Thailand

25. Infectious Diseases in Prison • BRING THEM IN WITH THEM • Despite the movies- the HIV in prison is NOT prisoner-prisoner transmission- less than 0.032% in FL-DOC and 0.033% in FBOP for P-P transmission • Hepatitis C- 20-65% of inmates infected primarily due to IVDU on the outside • FDOC had not had a TB death (12 total cases in 2002 all from the outside)

26. Translating Infectious Disease Treatment into Correctional Practice •  Correctional physicians care for a population with a burden of infectious diseases disproportionate to their numbers in the community. • For example, the prevalence of hepatitis C among releases' is approximately ten times that among the general population, and one-third of all hepatic C disease is born by those leaving prison and jails. However, the prevalence of infectious diseases does change time over time. Best practices for the management of specific infectious diseases also change, so an update on the medical management of communicable diseases is essential!

27. Prison HIV PreventionHarm Reduction Strategies • Prison Condom Availability • Examples: Australia, Brazil, Canada, most European Countries, South Africa, and more • Prison Needle Exchange • Examples: Switzerland, Germany, Spain, Moldova, Kyrgyzstan, Belarus, and Iran

28. Tuberculosis Behind Prison Walls “Prison walls curtain the freedom of prisoners, but not the freedom from spread of tuberculosis. Prisons form a reservoir of tuberculosis which threatens not only prisoners, but also prison staff, visitors, and the wider community.” WHO and ICRC Guidelines for the Control of Prisons, 1998

29. Tuberculosis in Russian Prisons • Over one million prisoners • In the 1990’s, approximately one in ten with active TB • At least 20% sick with MDR-TB The Global Impact of Drug-Resistant Tuberculosis. Harvard Medical School. 1999

30. OTHER DISEASES AND CASES • Acute & Chronic cases and FREQUENTLY SEVERE • Hypertension; Seizure Disorders; Cardiac Disease; Asthma; Cancer; Diabetes; Hepatic Disease; Psychiatric; Behavioral; Trauma (including self-inflicted); Etc. • It is the only setting where you can see the natural course of untreated disease- WHY? Rights of inmates and close monitoring

31. Intentional Trauma • The following slides are from one inmate who has a compulsive swallowing disorder and exacerbated by sticking things into his wounds • HE HAS NO AXIS 1 PSYCHIATRIC DIAGNOSIS • He does have an anti-social personality disorder

35. Special Care Unit for HIV Positive Inmates in Florida Prison

37. Crop Garden at Same Prison

38. Correctional Medicine Fellowship PROGRAM DIRECTOR: David Thomas, MD, JD

39. 2 Year Fellowship Program • 15 months in various correctional facilities as a fellow (post-residency) • Prison Hospital • Reception Facility • Women’s Facility • Jail • Private Facilities and Public facilities • About 9 months in administrative and legal experience and field experience for the MPH Degree • Only 1 year if fellow has an MPH Degree

40. Requirements to Finish • Successful completion of two year program including completion of MPH Degree • Competence in: • QM/QA- Quality driven programs • Mortality Review • Systems Design • Hands on Patient care • HIV; Hepatitis; Seizure Disorder; Acute Detoxification; Chronic Illness clinics; etc

41. Admission Requirement • Board Eligible or Board Certified in a medical or surgical specialty • Acceptable to Federal, State, and Private partners • Dedication to underserved and/or corrections • Desire to get or have the MPH Degree • Desire to become Competent in Correctional Health care and Correctional Systems and be a Board Certified Correctional Medicine Physician

42. Goals of Fellowship • Create a cadre of physicians competent in all aspects of correctional care • Public sector - State and Federal • Private Sector - Contract or owned • Jails • Prisons • Systems Approaches • Raise the Quality and Efficiency of Correctional Healthcare

43. At Conclusion of Program • Graduating Fellows should: • Be readily employable at the senior levels of large systems (Regional Medical Director or Executive Director of a large and complex facility) • Be readily employable as the Medical Director of a smaller system with system-wide responsibilities • All of our partners have agreed to give preferential hiring to graduated Fellows.

44. Sample Resources on Correctional Health

45. www.icpa.ca International organization dedicated to advancing professional corrections with a mission to contribute to public safety and healthier communities. Newly formed Health Care Committee 2007 Conference attended by 300 delegates from more than 50 countries