DO PRISONS NEED SPECIAL HEALTH POLICIES AND PROGRAMMES?
Timothy W. Harding, University Institute of Legal Medicine, Geneva, Switzerland
Prison medicine has a strange identity, stranded in a no man's land between two major social systems, thatof health delivery and that of criminal justice. The uncomfortable and marginal status of the discipline is not the result of choices nor orientations of prison health care staff. It is caused by pressures created by criminal justice policy especially prisons' policy - and decades of neglect by the 'health establishment': ministries of health, medical associations and faculties of medicine have regarded prisons as extraterritorial, as far as health care is concerned. Until the AIDS epidemic, the World Health Organization had not devoted one single activity, consultation or study to the prison environment. Until 10 years ago, major medical journals almost never carried articles about health or medical care in prisons. The faililPres of prison health care have led to serious public health concerns within many prison systems. Concentrating on these failures may obscure an important consideration that prison medicine might be a false and misleading concept. Places of detention present such a degree of diversitN in terms of population, length of stay, regimen and factors affecting health that 'prison medicine' could usefully be subdivided into a number of component parts: health care for marginal groups; health provision in situations of rupture; combating environments conducive to transmission of airborne diseases; psychiatric care under conditions of security, etc, Prison medicine should wither away and be replaced by the pervasive presence of appropriate elements of public health, preventive measures and health care delivery.
There are statistics from the French penitentiary authorities on mortality and morbidity since 1828. In 19th century France, mortality rates in prisons varied from 40 to 400 per 1000 prisoners per year, depending on whether deaths were caused mainly by the almost continuous presence of tuberculosis or by additional factors such as cholera epidemics. Prison administrators soon demonstrated that adequate food, reducing overcrowding and basic hygiene could reduce mortality dramatically. However, for the first half of this century, most large prisons continued to have special units for tuberculous prisoners - the mouroirs of French penitentiaries.
But how have advances in medical care and pre, ventive medicine been applied to the prison environment? This paper starts with a critical appraisal of the identity of the prison physician. It then outlines the failure to analyse the dangers created by the association of multiple risk factors both in the incoming population of prisoners and in the environment itself. The developing public health crisis within the US prison system is analysed (in many ways the disaster had been predicted by Jessica Mitford in her book with its tragically ironic title, Kind and Usual Punishment, published in 197 1). Thisdisaster isenormous in scale, affecting nearly 1.5 million detainees. Concentrating on this one striking example is, of course, an arbitrary choice but reminds us of the scale offlealth problems that can be created within prisons and allows a number of conclusions to be drawn. For example, the availability of sensible and authoritative sets of recommendations has little effect in the face of criminal justice policy dictated by other interests. The US example is then compared with other settings and, in particular, Europe. A number of factors suggest that a similar disastercould be avoided in Europe provided pragmatic and courageous policies are pursued which correspond to public health principles. It is argued that human rights law and enforcement mechanisms can play a significant role in positively influencing health policy in prisons.
THE STRANGE IDENTITY OF PRISON
MEDICINE: AN ORPHAN OF TWO SYSTEMS
Physicians and nurses working in the prison medical services have an unusual professional identity. Withinprisons they are often seen by prison personnel and administration as foreign bodies, creating rather than solving problems, suspect in their motives in an environment dominated by values of,discipline, security and repression.
Prisoners themselves usually perceive health personnel as part of the system with, at best, divided loyalties between the medical needs of inmates and institutional needs for order and smooth running. At worst they are experienced as traitors to the hippocratic tradition of medical ethics, denying basic health needs, refusing to make independent medical assessments, e.g. after violent incidents, accepting the administration's vetos on preventive measures, such as access to condoms, and remaining silent about the risks to health created by overcrowding, poor ventilation and inadequate care.
The medical profession views prison doctors as a strange category of outsiders working in hidden places where the relationships between delinquency, deviance, marginality and ill health are complex and troubling (Lancet, 1991).
Health administrations have largely ignored the needs of prisoners and have been more than willing to leave the thorny problems of health in prisons to prison administrations. In addition, medical schools, professional associations and scientific journals have, until recently, paid scant attention to prison health. As a result, prison medicine has developed largely as a marginal and poorly defined discipline (Harding, 1991).
The professional identity ofprison doctors is characterised by the particularities of health problems in detention and by the impact of the criminal justice system. They encounter extraordinary patients, in terms of notoriety, public condemnation and punishment. They deal with automutilation, body pack syndrome, swallowing of strange objects, prolonged voluntary fasting (hunger striking) or prisoners refusing medical care. But in concentrating on the extraordinariness of the prison environment and such unusual problems, the prison doctor often fails to assess the epidemiological realities of overall health status, i.e. the morbidity and mortality of the prison population.
Prison doctors also tend to see health problems as existing within the closed environment and to underestimate the flow of health problems into and out of prisons. Prisons are part of the community, both in terms of the dynamics and spread of transmissible diseases, but also in terms of institutional care for marginal and deprived populations.
THE INGREDIENTS OF DISASTER
In 1974, the medical director of the US Bureau of Prisons, responsible for health care provision in all US federal prisons, spoke at the Annual Meeting of the Medical Society of the State of New York on 'Problems of health care delivery in penal institutions' (Brutsche, 1975). He spoke of the 'great frustration' in attempting to deliver health care and of how the 'attitude and behaviour of a very large segment of an inmate population tends to militate against a satisfactory interface between the offender and the health services delivery system'. Prisoners have'already demonstrated a difficulty with integrity, impulsive and devious behaviour and a variable disregard for society, its members and its rules of contact'. Thus, according to Dr Brutsche, prisoner patients tend to seek medical attention for 'secondary gain' - to pass the time of day with other inmates or staff, to avoid work or other undesirable activity, to seek various advantages by the fabrication or exaggeration of complaints, to seek tranquillising medication to sell to other inmates, to thieve drugs or other hospital items, to harass health services staff, to prepare an escape plot.
Prisoners, Dr Brutsche laments, manipulate prescribed treatment to distort the expected result and falsify their objective medical signs. The picture painted by Dr Brutsche is clear: prisoners knowingly and deviously distort the doctor-patient relationship: health care staff spend most of their time'ferreting out real health problems'; communication between staff and prisoners breaks down; and few health services staff remain to work under such conditions. The word 'frustration' or'frustrating'occurs 10 times in Dr Brutsche's text. However, what is frustrating in his analysis of health care delivery in penal institutions is the complete absence of any reference to actual health problems in prisons.
At roughly the same time, Novick (197 7) provided good epidemiological data on the health status of prisoners entering New York state prisons. Despite the fact that the prison population is made up largely of young adults, Novick found strikingly high prevalence rates of infectious diseases and a wiel. variety of morbidity from non-communicable diseases. Only 40% of prisoners were found to be in good health. The most frequently occurring problem at entrywas substance abuse and dependence (41 % on ilLcit drugs and 18% on alcohol). Other significant health problems identified were recent trauma, eye abnormalities, dermatological disorders and serious dental problems. A total of 13% of the sample suffered from an active psychiatric disorder.
Other, more general, observations about health status were a poor nutritional state and a lack of inf rmation about preventive care. A comparison of Brutsche's lament with Novick's epidemiological data leads directly to the conclusion that health care in US prisons in the 19 7 Os was inadequate and unresponsive to the health needs of prisoners. The frustration experienced by prison doctors, including the most senior administrators, was viewed as being a product of devious, manipulating and antisocial prisoners/patients, but was in fact a product of their ownfailure to see the public health realities, the need for appropriate preventive care and to be responsive to the whole range of health problems.
Prison health care was based on the notion of a 'sick call' integrated into the daily routine of prison life, much as in the army. In this context, it is hardly surprising that in 1976, the US Supreme Court delivered a seminal decision in the case of Estelle v Gamble. The court held that 'the deliberate indifference to the serious medical needs of prisoners' constitutes 'unnecessary and wanton infliction of pain' and therefore violates the Eighth Amendment of the US Constitution. This important decision has often been said to create a substantive 'right to treatment' for prisoners in the USA. However, it should be noted that the decision was clearly limited. The court indicated, for example, that 'inadvertent failure to provide adequate medical care' or'negligent ... diagnosis or treatment [of] a medical condition' would not constitute such a violation.
By the end of the decade of the 1970s, the situation in the USA was characterised by the triad of inappropriate healthcare provision for prisoners and failure to recognise the realities of health problems
an epidemiological profile of morbidity corresponding to the health status of the urban, poor, marginal populations and to the growing extent of substance abuse in these populations
legal intervention recognising that authorities are not permitted to disregard the health needs of inmates but failing to define effective means of redress.
THE UNFOLDING OF THE PUBLIC HEALTH DISASTER IN US PRISONS
Within a few years, the AIDS pandemic was to expose in a dramatic and tragic manner the structural weaknesses and management failures of health care provision in US prisons. Ted Hammett's successive studies demonstrated the failure of US prisons at local, state and federal levels to respond to the challenge of the AIDS epidemic. The high prevalence of HIV infection reflects, of course, the high proportion of intravenous drug users in the prison population (Hammett, 1994).
Thus, a major public health problem was effectively created by a series of political, legislative and administrative decisions. The US National Commission on AIDS (iggi) has stated succinctly: 'By choosing mass imprisonment as the federal andstate governments' response to the use of drugs, we have created a de facto policy of incarcerating more and more individuals with HIV infection.'
The American College of Physicians went further in its position paper published in 1992. It pointed out that the prison population in the USA had doubled in a decade: most inmates were male, young, poor and from minority groups, and the problems were rapidly being exacerbated by the National Drug Control Strategy, also known as the War on Drugs which started in 1989. The paper concluded that:
the national policy on drug control must be reconsidered
prison health care budgets should reflect the growing mental and physical health needs of the inmate population. It should provide integrated care to treat substance abuse and associated conditions, such as HIV infection and hepatitis B, and also respond to the needs of female inmates and mentally ill inmates
prison health care must be recognised as an integral part of the public health sector
prison facilities must implement and maintain standards of 'minimally adequate health care delivery systems'
health care delivery must evolve from the present 'reactive'sick call system into a'proactive'system that emphasises screening, early disease detection and treatment, health promotion and disease prevention.
These are worthy and wise conclusions and could be widely applied both within and without the USA. Unfortunately, the position paper came too late and had almost no political impact.
The most recent and alarming development in US prisons is the emergence of tuberculosis as a major and widespread problem and, in particular, in multidrug resistant forms (MDRTB). The incldence of TB among New York State prisoners rose fivefold in the decade 1980-90 to 134 per 100,000 (Glaser et al., 1992) while outbreaks of MDRTB were reported in New York (Valvay et al., 1994) and then in California (Center for Disease Control, 1993). By 1995, the US Department of Justice acknowledged the extent of the tuberculosis epidemic in US )risons and the need for widespread preventive meaures both for inmates and for staff. In a report comissioned by the authorities, Wilcock et al (1995) conclude:
The resurgence of tuberculosis in the United States, the occurrence of several major outbreaks of TB in prisons, and the concentration in prisons and jails of individuals at high risk for TB suggest the need for treatment and control measures at all phases of the system - from pretrial release to incarceration to parole... This (prison) population at relatively high risk for TB ... tends to be poor and includes disproportionate numbers of racial and ethnic minorities, recent immigrants from high-risk countries, injection-drug users and individuals infected with HIV In general, this population is characterised by poor access to health care.
Larry Gostin in a thorough review of the public health, legal and societal implications of the 'resur,ent tuberculosis epidemic in the era of AIDS' Gostin, 1995) devotes a substantial portion of his tudytoprisons. His conclusions are even more alarmng than those published under official auspices.
If a person were to set out to design facilities that efficiently transmit airborne diseases, then that person might well emulate the physical conditions found in congregate settings in America such as ... correctional facilities ... residents live, eat and sleep in small enclosed spaces; beds are inches or feet apart; buildings are dark and poorly ventilated. Moreover, the residents ... are impoverished, malnourished and overrepresented in populations that have disproportionately high rates of communicable diseases ... and have significantly impeded access to health care services.
At the time Gostin prepared his study, 1. 12 million ersons were resident in correctional facilities - well over 400 persons per 100,000 population. Present policy on drug use, on crime in general and tighter immigration controls mean the rate will rise to more than 5 00 persons per 100,000 population and nearly 1.5 million persons over the coming years. Between 10% and 25 % of people in correctional facilities are infected with tuberculosis. The incidence of active pulmonary infection is about 10 times that found in the general population.
The prison TB epidemic is closely associated with the HIV/AIDS epidemic, but affects many prisoners and staff who are not HIV infected. The inadequate housing, with gross overcrowding and poor ventilation, is forcing prison authorities to apply energetic control measures, such as screening forTB infection, isolation, compulsory treatment regimens and the return of noncompliant parolees to prison. There is also an additional and renewed pressure to carry out systematic and obligatory screening for HIV infection. In this respect, the measures taken in the US prison system at local, state and federal levels in response to the HIV/AIDS epidemic can be summarised as follows:
compulsory HIV antibody testing on entry and during detention in about 25% of systems
special housing (segregation) for HIV-infected prisoners in about 40% of systems
restricted access for HIV-infected prisoners to work and leisure activities in about 80% of systems
information on HIV transmission and prevention provided to prisoners and staff in about 80% of systems
early release forprisoners with advanced AIDS in about 15 % of systems
access to condoms in less than 5 % of systems
access to disinfectant for needles and syringes in less than 1 % of systems.
This is a telling indictment of the failure of internationally approved recommendations to have a significant impact at national level: the conclusions of the two WHO consultations on HIV/AIDS in prison (WHO, 1993) are almost entirely ignored.
A further damaging element to health in US prisons is their use forcustodial care of the seriously mentally ill. 'Quietly but steadily, jails and prisons are replacing public mental hospitals as the primary purveyors of public psychiatric services for individuals with serious mental illnesses in the United States' (Torrey, 1995). Torrey estimates (conservatively) that there are nearly 170,000 people with major, active psychiatric illnesses (e.g. schizophrenia, manicdepressive disorder, organic psychosis) in US prisons. These individuals are subject to abuse and physical assaults and rarely receive any effective treatment. This is a consequence of the deinstitutionalisation of the mentally ill - 'the largest failed social experiment in 20th-century America'.
I have dwelt at some length and, I hope, not unfairly on the situation of health care provision in US prisons because it provides a historical perspective of the making of a health disaster which should have been predictable and preventable. It is largely a governmentmade disaster, with the health authorities and the medical profession as bemused and passive bystanders. The excellence of the recommendations in the report Crisis in Correctional Health Care (American College of Physicians, 1992) is matched only by its lack of significant impact.
IS THE US EXPERIENCE PREDICTIVE OF DISASTER ELSEWHERE?
It is more difficult to analyse the diverse and sometimes rapidly evolving situation in other countries. But the US situation has great relevance for many other parts of the world. The prevalence of tuberculosis is increasing rapidly inAsian and African prison populations and is by no means always associated with HIV infection. Coninx and his colleagues from the ICRC medical division have described the tuberculosis problem in the prisons of the former Soviet republics in the Caucasus and Central Asia: they point out that successful interventions are possible but require careful planning and adequate resources (Coninx et al., 1995).
HIV infection and AIDS are major problems in prisons in Thailand and Brazil, where 'preventive' policies are similar to those adopted in the USA and equally ineffective and inappropriate. The prisons in the great lakes region of Africa provide the most extreme examples of the combination of overcrowding, malnutrition, high rates of tuberculosis and mortality rates which, expressed in terms of one week, exceed those in most other countries expressed in the terms of one year.
The seriously mentally ill frequently end up in police stations and prisons of many countries. In India, an investigation ordered by the Supreme Court revealed that in many Indian states, the courts ordered the mentally ill to be confined in prison, even when they had committed no offence. Tens of thousands of mentally ill men and women were found to be detained for periods of sometimes more than 10 years, with no adequate mental health care.
Australia is grappling with a similar set of problems to those in US prisons, with varied responses by state authorities. However, good epidemiological research has been carried out, including on the spread of bloodborne viruses (Crofts et al., 1995) and on hepatitis C prevalence. Public health-oriented policies are more widely adopted and the prison population has not increased in such a dramatic fashion. The state of Victoria is one of the best and largestscale examples of health authorities taking over responsibility for health in prisons: prevention, health promotion, screening, health care provision, substance abuse and psychiatric care.
THE SITUATION IN EUROPE: IS GUARDED OPTIMISM JUSTIFIED?
In Europe, many of the ingredients of the US situation are present: prison populations are rising along with the incidence of tuberculosis. In at least one country (Spain), multi-drug resistant tuberculosis is a major problem in prisons. Many psychotic patients end up in prison after committing minor offences (Gunn et al., 199 1). About 30% of prisoners in Europe were illicit drug users before imprisonment and drug use is widespread within prison. Overcrowding and inadequate accommodation are major problems in Italy, Spain, France, UK, Belgium and most East and Central European countries. Some of the highest rates of HIV prevalence have been recorded in European countries: Spain (28% in 1987; 20% in 1992) and Italy (17%) (Harding, 1987). In the Republic of Ireland, 17% of all known cases of HIV infection were reported among the prisoners in Dublin's main prison (168 known cases).
And an outbreak of HIV infection clearly related to the random sharing of injection equipment has been documented in a Scottish prison (Taylor et al., 1995). However, despite these alarming indicators, there are good reasons to believe that a public health disaster on the scale of the US example can be avoided in European prisons, provided adequate policies are adopted, strengthened and carried out rapidly, energetically and with sufficient resources.
What are the factors that justify some guarded optimism.?
(a) Prison populations, although rising, do not seem likely to rise to US levels. Overall, among the members of the Council of Europe (but excluding the newest member, Russia) rates of detention are well under onethird of that recorded in the USA. There is also considerable variation in detention rates. Most governments, with the possible exception of the UK and Poland, seem intent on avoiding penal policies, especially in the area of drug control, which would lead to further rapid rises in prison populations.
(b) The basis in human rights law for adequate health care is stronger and more actively enforced than the Estelle v Gamble decision in the USA. The European Commission of Human Rights has established clearly that failure to provide adequate health care for a prisoner would constitute 'inhuman and degrading treatment' and thus violate article 3 of the European Convention of Human Rights. In a series of decisions involving Switzerland (the Bonnechaux case 1979), France (the De Varga Hirsch case, 1983) and Italy (the Chartier case 1982 and the Patanye case 1986) the need to provide 'appropriate health care' has been spelt out.
The work of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) has further strengthened the human rights approach to health care in European prisons. The CPT, through its visits to prisons and other places of detention, has identified health care as one of the priorities in ensuring the rights of prisoners.
The CPT in its Third General Report (Council of Europe, 1993a) devoted a chapter to health care services, providing a de facto set of guidelines. The essential elements are strikingly similar to the recommendations of the American College of Physicians, but come from an official intergovernmental committee. These are the elements: access to a do(--tor with the direct support of a fully equipped hospital service; equivalence of care to that available in the community; respect of principles of confidentiality and patient's consent to treatment; adequate preventive care; and the need for professional medical independence (Bertrand and Harding, 1993).
At the end of the first cycle of periodic visits, the overall impression is that governments are responsive to the CPT's recommendations in the field of health care and are prepared to make more resources available. The CPT's work has certainly promoted awareness of the relationship between detaining drug users, problems of HIV/AIDS and tuberculosis, as well as recognition of the extent of psychiatric problems. The published reports demonstrate many inadequacies in health care provision but also a willingness by the authorities to make substantive reforms (Harding and Bertrand, 1995).
(c) The response of prison authorities in kuropean countries to the HIV/AIDS epidemicLs been notably more constructive and denotes a significantly greater adherence to WHO directives (WHO 1987, 1993), backed up by the Council of Europe's own recommendation (Council of Europe, 1993b). Thus, when the policies of 32 prison systems in 17 European countries were reviewed, it was found that: information was provided to prisoners in 30/32 systems (92 %); there was compulsory HIV testing in only 2/32 systems (6%); segregation in special units in 4/32 systems (12%); restricted access to workshops in 7/32 systems (19%); and early release procedures for prisoners with AIDS in nearly all countries (30/32 systems, 92%). Condoms were available in 24/32 systems (75%) and disinfectant for needles and syringes in 9/32 systems (28%) (Schaller and Harding, 1995). The differences with the situation in the USA are striking.
(d) In Europe, health authorities at national or regional levels (e.g. Uinder in Germany, cantons in Switzerland, autonomous regions elsewhere) have become more directly involved in prison health.
This may be through a joint venture financed by both the health and the criminal justice sectors, according to the model already cited of the Australian state of Victoria. This is the case, for example, in the Spanish region of Catalonia. Other countries have well-resourced health facilities within the prison system e.g. Holland and Finland. But the most striking examples are the countries in which health care comes entirely under the responsibility of the health ministry, as in Norway since 1993 and France since 1994 (psychiatric services were already a health ministry activity for more than 10 years before that).
In the Canton of Geneva, prison health care has developed within the health and social services department over the past 30 years asan independent, university-based service. Thus, there appears to be a growing realisation by the health authorities of the importance of health care in prisons and the need for policy formulation, training and, above all, resources. Of course, there are major deficiencies and even sordid scandals. The descriptions in reports by the CPT of Brixton Prison's F Wing (Council of Europe, 199 1 ) or of the Lantin Prison psychiatric annexe (Council of Europe, 1994) make harrowing reading; and news about women giving birth while shackled to their beds (in Marseilles, 1991 and in London, 1995) raised storms of indignation.
More generally, primary health care in most prisons remains unsatisfactory, characterised by a lack of intimacy and confidentiality; inadequate response to immediate symptoms; overprescribing of tranquillisers because of a lack of alternatives; and failure to provide any preventive measures. Nevertheless, the authorities no longer seem blind to these deficiencies and there are signs that, politically and socially, prisons are no longer seen as a hidden world where ordinary criteria of health and hygiene can be ignored.
RETHINKING PRISON MEDICINE
Police stations, remand prisons, jails, lock-ups, penitentiaries, half-way hostels, closed j uvenile centres - the semantics of places of detention shows great variety. In human rights law, all such places can be conceptualised in a singular fashion - deprivation of liberty (for example, in terms of article 5 of the Euro, pean Convention of Human Rights). Yet, the diver, sity of places of detention has important imp lications for health; 'prison' is a loose concept for which a single epidemiological model simply does not exist.
The length of stay; the age, sex and social parameters of inmates: the detention environment itself - all these factors and many others vary so that the health profile of places of detention can have almost infinite forms. A detention centre for asylum seekers at a major international airport; a closed hostel for disturbed, delinquent adolescents; a remand prison with more than 2500 inmates serving a large urban area with up to 100 entries and discharges or transfers every day; a maximum security prison with 200 inmates in solitary confinement, most of whom have been in the same facility for at least five years; a detoxification centre for remand prisoners with heroine dependence; a large penitentiary hospital; a medium security penitentiary with a 300 acre dairy farm; a sociotherapy unit for prisoners with severe personality disorders. All these can be called 'prisons'but their dissimilarities in terms of morbidity and health needs are greater than their similarities.
This is why we should reanalyse the prison experience in public health terms and rede;ign health interventions in relation to needs.
This also helps us to understand that the results of the study by Clavel et al. (1987) showing decreased mortality among male prisoners was misleading, since it was limited to the population of conderuried prisoners serving sentences in penitentiaries. The study, therefore, overlooked excess morbidity and mortality in remand prisoners and, in particular, the risk of suicide. The study was also carried out at an unusual time of falling population of condemned prisoners and in the years before the AIDS epidemic.
First of all, prisons should be seen as an integral part of the community, with a constant flow in both directions. The dynamic relationship between inside and outside means that walls are not epiderniological barriers. Inadequate health care in prisons will have adverse consequences on public health in thecommunity, e.g. interms of transmissible diseases and the consequences of severe, untreated mental disorders. A telling illustration of an effect of the prison environment following release is the striking increase in mortality during the early weeks of liberty, persisting for up to a year: four times the age and sex adjusted rate in the general population (Harding-Pink, 1990).
The health problems of marginal groups, of poverty, of foreigners, of drug users and alcoholicdependent persons tend to congregate in prisons. But the same problems are seen in other institutions, on the streets and in health facilities serving the indigent or poor, underprivileged areas.
The same individuals pass from prisons to municipal health clinics, to hostels for the homeless and back to prison. Health delivery services should follow the clients and provide linkages, continuous care and social support across the institutional barriers.
Psychiatric care should be integrated between the community, mental health facilities and prisons. This would avoid the phenomenon of passing the 'difficult patient' down through a spiral of decreasingly resourced services to end up in a remand prison.
The problems of entry into prisons is not specific to prisons - it occurs during sudden migration, after mass catastrophes and in conflict situations. Thus we can understand why two studies on diabetes control in prison come to completely different conclusions. 'Good diabetic metabolic control is usual in prison' (MacFarlane et al., 1992); or, alternatively that 'inadequate access to care gives rise to frequent diabetic ketoacidosis' (Keller et al., 1993). The first observation was of men serving sentences in a large prison in Britain, the second was in jail'holding' facilities in New York City. The authors of the second paper point out that inadequate care in the early weeks of detention frequently gives rise to acute exacerbation of asthma, hypertension, seizure disorders, as well as creating risks of infectious disease transmission. What is needed, therefore, is one model of medical care adapted to social discontinuity, rupture and crisis and a completely different model for long-term institutional care. Neither need be specific to the prison environment.
'Prison medicine' as an entity in public health terms also risks to make official condone or normalise unacceptable aspects of the prison environment. Prison medicine might be seen as necessary to counteract the harmful effects of overcrowding, lack of ventilation, promiscuity, lack of physical activity and violence. Gostin rightly describes such unhealthy environments in 'congregate settings' ranging from nursing homes, mental institutions, homeless shelters, Indian reservations, migrant worker camps, etc. Grossly unhealthy environments are unacceptable in any of these situations and no medical speciality should be identified with them. There should be concerted pressure by all public health bodies to proscribe all such environments; indeed they should be construed as a form of inhuman and degrading treatment and therefore as collective forms of human rights'violation. Therefore, it is proposed that prison medicine may be a dangerous and counterproductive concept. There should be a coalitioncif health delivery services operating in prisons, with a blend of interventions adapted to needs. Continuity of care, by the same carets, should be ensured on entry and on discharge, if possible. Finally, prisoners should not been seen as passive recipients of care, but actively involved in health promotion and preventive measures.
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