” Prisoners are fathers, mothers, brothers, sisters, sons, daughters, loved ones and part of our communities. They have a right to health that must be realized”
Quote from Prison Health NOW online campaign
I imagine prison health is not a topic many of us stop to think about. Dr. Fiona Kouyoumdjian is an exception, a Dalhousie trained MD completing a research fellowship at Saint Michael’s Hospital in Toronto is looking at the health inequity between the average Canadian and average incarcerated individual.
Before this lecture, I had only a vague notion of the health inequities facing inmates. As such, the required reading from the Lancet was shocking. While the data cited was not from Canada, the study reported on the the United States which has a much higher incarceration rate, the strong association between incarceration and variety of poor health outcomes such as mental illness, substance abuse and infectious diseases startling. Do prisoners suffer from poor health which makes them more likely to be incarcerated or is their incarceration a cause of poor health or it is a mixture of both and what about external factors that might be contributing to both?
“Male prisoners leaving Washington state prisons were 29 times more likely to die from all causes in the first week of release than age, gender, and race adjusted general population, whereas female prisoners were 69 times more likely to die. “
Before describing her research Dr. Kouyoumadjian shared her perspective on working in preventive medicine and why she cares about prison health. I was intrigued by her description of focusing efforts. Dr Kouyoumadijan was frank in her motivations for working in prison health. From her view prison health is an area where there is great need in Canada and such an opportunity to make changes with big impact. She mentions the law of diminishing returns in a public health context and the public health paradox. The paradox of working in public health is that if your job is done too well, it become more difficult to receive funding. Public health gets the most funding when there is a clear population health emergency, not when a population’s health is doing well. I feel this line of conversation could be expanded to included medicine more broadly but that it another topic of discussion.
Dr. Kouyoumdjian then explained what prison health focuses on: individuals who are incarcerated, not the general criminal population. She estimated there are 40,000 Canadians living in a prison facility, with the mean time of provincial incarceration being around 20 days. Any person sentenced to over 2 years is incarcerated in a federal facility. I was surprised to learn that in Ontario the Ministry of security, not of health, administers health care within prisons. While I can understand practically such a system came into being, the Ministry of security has a conflict of interest in providing care for inmates. Not all provinces in Canada have this structure with Nova Scotia and Alberta have amended this oversight
After this introduction Dr. K started explored the unique challenges in providing health care to inmates. One of the essential components of the patient-physician relationship is confidentiality. However, in the prison setting confidentiality during a physician visit can not be assured. It is unlikely the physician is allowed to talk with a inmate alone, a minder will be present and this changes the dynamic of the conversation between inmate and doctor.
Drug use in prisons is a cause of preventable and significant mortality and morbidity for incarcerated and just released prisoners. Dr. K explained that while incarcerated drug users find it harder to source their preferred drug and as such their tolerance may decrease. Upon release the individual may resume their drug habit at the same amount they needed before release resulting in an inadvertent overdose with possible death. Such events are preventable through education in prisons and recognizing drug use is happening whether there is tough on drugs stance or not. Another consequence of ignoring the use of drug use among inmates is the spread of blood borne diseases through shared contraband needles. The HIV legal network has an excellent series of videos that looks at Prison Health, especially blood borne drug disease. While data is not easy to come by, hepatitis C and HIV is being spread among the prison populations.
Another component of the conversation was the relationship between prison health and politics. Incarcerated individuals or “criminals” can evoke powerful emotions within us. These emotions leads to widely differing and contradictory opinions on how society should “deal” with criminals. The Canada Health Act outlines health should be accessible to all populations. As such, incarcerated individuals should be able to access the same standard of care as any other Canadian. Of course, in practice many Canadians do not enjoy the same standard of care and there may be anger that inmate health is prioritized over other groups which some may view as more deserving of care.
The polarization of opinion relating to prison health can be seen in the different programs liberal and conservative governments support in federal prisons. For example, to decrease Hep c spreading in prisons the liberal government had safe tattooing programs where clean needles were provided. The conservative government cut the funding to this program and has pushed a tough on drugs approach, pushing more people into prisons. . Such harm reduction plans make sense for reducing the burden on the general health care system, in addition to helping improve the quality of life for prisoners,
Web videos: HIV legal network
Corrine, a prisone Support worker
80% of owmen in federal prisions have experienced abuse,
1/5 sturggles with mental health issues.
More than half of all charges laid against women are non-violent, property and drug offence.
http://www.prisonhealthnow.ca/
Required readings:
Fazel S and J Baillargeon. The health of prisoners. Lancet. 2011. 377: 956-966.
Rose, Geoffrey. Sick individuals and sick populations. International Journal of Epidemiology. 14(1): 32-38. 1985.
Reflecting on Global Health 