1. On being old, healthy, and in prison or Ageing Prisoners: Can we afford them? Jim Hilborn Baltic Institute for Crime Prevention www.crimeless.eu jimhilborn@gmail.com

2. Graying Prisoners Exploring the Quality of Life for Ageing Prisoners With the support of the Nordic Council of Ministers, the Baltic Institute for Crime Prevention initiated the study of the health and quality of life of ageing prisoners in 2010-2012 in Belorussia, Estonia, Finland, Hungary, Latvia, Lithuania and Russia. …trying to better understand the prison experience of aging prisoners Who are these individuals, and what are their physical and mental health needs? How do they experience prison? What is the quality of their life as an older person in prison?

3. Losing Trio BAD - Mass Incarceration x Ageing Population = Massive Increase in number of Ageing Prisoners along with Collateral Damage to individuals, families and communities BADDER - Depopulation x Ageing Population = Fiscal Crisis BADDEST - Dependency on Mass Incarceration x Depopulation x Ageing Population = Fiscal Crisis & Public Health Crisis 1 st 3 rd 2 nd

4. Bad Situation – Penal Populism Mass Incarceration x Ageing Population= Massive Increase in number of Ageing Prisoners along with Collateral Damage to families and communities Presents a danger to rational penal policy through the politicalization of criminal justice. 1 st 3 rd 2 nd

5. USA-Mass Incarceration

7. 90 Years Sentence, 10 Done

8. Dying in Prison, Regretting Too Late, After Living Too Little

9. Hospice – Dying with Dignity

10. You Understand

11. Dying Alone

12. I Dont Want to Die in Prison

13. Where are we going?

14. Angola, Louisiana

15. Pain

16. Listening

17. Coffin

18. With dignity

19. Badder Situation POPULATION GROWTH 2005-2025 Top Twenty Growth Countries (in Purple) 1,047 million (73%) EU27 3.4 million (0.24%)

20. Badder Situation Depopulation x Ageing Population = Fiscal Crisis by 2030 the EU can expect to have 14 percent fewer workers and 7 percent fewer consumers than it does today 1 st 3 rd 2 nd

21. Badder Situation The social institutions most likely to experience strain from the twin trends of ageing and depopulation are the pension and health systems that comprise the crown jewels of the postwar welfare state.

22. Aging Europe – over 65

23. Growing Older in the 21st Century Economic and Social Research Councils (ESRC) Growing Older (GO) Programme, UK We already live in one of the oldest societies that has ever existed, but it is going to get even older. UK: The over 80s, who are the fastest rising segment of the population, are expected to treble in the next 25 years. Where in 1951 there were only 270 centenarians, there are already over 6,000 today with projections suggesting there could be 45,000 by 2030.

24. Growing Older in the 21st Century One of the greatest achievements of the 20th century must be the 25 years added to life expectancy. Yet, future social historians will be hit by a paradox. A society which was so successful in reducing the injuries of biological ageing was pathetically weak in addressing the injuries imposed by social ageing. Only one out of three men was in work at the end of the 1990s when they reached the official retirement age. And this was only one of many fronts where older people faced prejudice, discrimination and social exclusion. The economic cost of the redundant over 50s is vast, ranging in estimates up to £31 billion. (Malcolm Dean, 2011)

25. Depopulation 2050

26. Japan-Aging Prisoners

27. Japan - Low rate of Incarceration, but... Aging Prisoner Population is growing

28. Baddest Situation Mass Incarceration x Depopulation x Ageing Population = Fiscal Crisis & Public Health Crisis There is very little that can be done with the depopulation and ageing populaiton. However the rate of incarceration and the use of alternatives to incarceration can reduce the overall number of prisoners, especially the high costs of physical and mental needs of the older prisoners. The US data suggests that the older prisoners can cost 2 to 3 x the cost of the younger prisoner. 1 st 3 rd 2 nd

29. The Choice of Rate of Incarceration

30. EU Incarceration

31. Comparing different Prison Systems. Rate of Inceration Prison Population Occupancy Level Russia 529 per 100,000755,60091.6% Belarus 381 per 100,00036,533106.7 % Latvia 314 per 100,0007,05578.4 % Lithuania276 per 100,0009,139100% Estonia 252 per 100,0003,38197.2 % Hungary163 per 100,00016,328132.4% England & Wales 154 per 100,000 86, l131112.7 % Finland59 per 100,0003,18999.6%

32. What rate of incarceration is too low., just right or too much? A just right rate seems to range from a low of 50 to a high of 150 per 100,000. Above 150 the potential for mass incarceration increases. David Garland argues that mass incarceration has two components: One is sheer numbers. The other feature is systematic discrimination and the social concentration of imprisonments effects. Imprisonment becomes mass imprisonment when it ceases to be the incarceration of individual offenders and becomes the systematic imprisonment of whole groups of the population. It becomes collateral damage for individuals, families and communities. Ernest20 Decker calls it a plaque of prisons.

33. Health & Well-being Health & Well-being Age, Disease and the Aging Prisoner Penal Policy & Practices Penal Policy & Practices ResilienceSalutogenesis Healthy Prison The Quality of Care and the Quality of Prison Life for the Aging Prisoner

34. Age

35. Age: When is a Prisoner Old?...the age at which a prisoner is defined as elderly or older is arbitrary and varies between countries and studies. For example, in the United States and Australia, prisoners above the age of 50 are generally considered as elderly. In the United Kingdom those above 60 or 65 are considered to fall within this category, according to different studies The low threshold is said to be justified by the likelihood that prisoners have an individual age 10 years in advance of their counterparts in the community, due to chronic health problems, unhealthy lifestyles, alcohol and substance abuse, as well as the stress and harmful effects of imprisonment itself. (UNDOC, Handbook on Prisoners with special needs)

36. Age: When is a Prisoner Old? In the National Institute of Corrections program on Effective Managing Aging and Geriatric Offenders, the NIC used a definition based on the combination of two factors: Prisoners identifed as needing assistance with daily living (ADL) + Prisoners who are 50 years plus The NIC panel in the broadcast emphasized the importation thesis - that many prisoners entered the prison with significant,chronic health problems due to social determinants and lifestyle choices. The panel emphasized the need for a proper assessment and staff training. Though 50 years was the agreed upon age criteria, it was noted that even younger prisoners could have problems with daily living.

37. Coming Wave of Aging – 2009 data

38. Its Not Age, Its Agism A Good Age (Dr. Alex Comfort, 1981) Older people are, in fact, young people inhabiting old bodies and confronted with the physical problems of reduced vigour, changing appearance and specific disabilities affecting such things as sight and agility. Agism is the notion that people cease to be people, cease to be the same people or become people of a distinct and inferior kind, by virtue of having lived a specified number of years. Sociogenic aging is the role society imposes on people as they reach a certain chronological age when they can be condemned as unemployable, unintelligent, crazy, and asexual. As an 'old person' you will need four things-dignity, money, proper medical services, and useful work. (These are the things you always needed.)

39. Health

41. Salutogenesis Antonovsky: Rejecting the idea that health was the absence of disease. SalutogenesisPathogenesis Health-ease – Dis-ease Continuum Sense of Coherence (SOC) is a concept that includes the measurable independent variables of meaningfulness, manageability, and comprehensibility that Antonovsky documented to be associated with better health.

42. Positive Deviance (1) look at the data differently: instead of looking at those who have succumbed to a problem to find out why, look at those who are succeeding and try to find out why they are doing well; (2) persuade practitioners and researchers to ask about the factors related to success, not just factors related to problems; and finally (3) stimulate the formation of unique hypotheses generated to explain desired outcomes. Results from studies and practices that promote and develop positive health outcomes could then be the recommendations for promoting health.

43. Prison

44. Measure the Quality of Prison Life

45. Quality of Prison Life Harmony dimensions Entry into custody Respect/courtesy Staff-Prisoner relationships Humanity Decency Care for the vulnerable Help and assistance Professionalism dimensions Staff professionalism Bureaucratic legitimacy Fairness Organisation and consistency

46. Quality of Prison Life Security dimensions Policing and security Prisoner safety Prisoner adaptation Drugs and exploitation Conditions and Family Contact dimensions Regime decency Family contact Wellbeing and Development dimensions Personal development Personal autonomy Wellbeing Distress

47. WHO Health In Prison Project http://www.euro.who.int/en/what-we-do/health- topics/health-determinants/prisons-and-health/who-health- in-prisons-project-hipp Brenda van den Bergh Technical Officer, Prisons Health Phone: +45 3917 1401 Fax: +45 3917 1818 Email: bvb@euro.who.int

48. Some Key Conclusions of Graying Prisoners There is good evidence that the majority of prisoners have significant physical and mental health needs which they import into the prison. Health care is a human right. The prison should become a health promotion setting that provides both high quality medical healthcare and also health promotion. The Healthy Prison model developed in the UK is an good operational tool and the MQPL/MHPHAP would help maintain accountability. If the physical and mental health needs are not properly dealt with, the prison becomes a site for disease promotion. There is evidence that a significant number of prisoners acquire new health problems while incarcerated.

49. Some Key Conclusions of Graying Prisoners It is clear that there is profound risk that Injecting Drug Use leads to HIV/AIDS and the increased probability of TB. The number of active TB cases and the level of MDR-TB in several countries is already quite alarming. The increase in MDR-TB is a warning. There is a need for more co-ordinated action. A harm reduction strategy would provide either bleach for needle cleaning and/or needle exchange as well as the provision of condoms. We need DOTS both in prison and also on follow- up.

50. Best Choice Policy Reform Promote a Healthy Prison Reduce Rate of Incarceration Use Alternatives to Incarceration Reduce Social Inequality Social Reinvestment in Damaged Communities Evidence-based Crime Prevention Strategies (Early Intervention and Situational)

51. Next Steps Make the present report available to anyone who is interested. persons. Baltic Crime Prevention Institution should have a Graying Prisoners blog for interested parties the chance to discuss the issues, and to share information. There are issues of ageing prisoners that we did not examine in depth such as traumatic brain injury, palliative care for the dying, as well as issues of gender and sexual diversity. The work needs to continue.