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 palliative health 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
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
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 % increase in “natural deaths” of prisoners
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