Agenda Item Four
Health Issues in Corrections

Introduction

Effective offender management requires the provision of adequate health and welfare services to prisoners. A failure to provide such services can jeopardise the safety and well-being of staff as well as prisoners. It can also lead to prisoner unrest and disorder. As the paper from China put it : "Whether a state has a legal guarantee of medical and health services to prisoners and whether various epidemic diseases can be controlled and treated in a prison ... (are) ... important indicators of prison civilisation".

It is not surprising, therefore, that health issues have been discussed as formal agenda items in at least six previous APCCA conferences. The country papers and discussion at this conference show that the topic is of continuing interest and importance. Australia, Brunei Darussalam, Canada, Hong Kong (China) and Tuvalu spoke formally to the topic and there were numerous important contributions from other participants.

The Prerequisites for Prison Health

Most of the conference papers focussed on questions relating to medical and mental health treatment. However, Vietnam stressed the importance of a proper diet. In addition, a safe water supply, a proper diet and a hygienic living environment are basic prerequisites. In some parts of the region, including Cambodia and Mongolia, it has not always proved possible to meet these fundamentals. Foreign assistance is still required to meet the basic needs of ordinary citizens as well as prisoners.

The representative from Tuvalu pointed out that health problems have sometimes arisen as a consequence of the poor physical state of prison buildings. Fortunately, a major renovation program is under way. Another basic requirement, mentioned by Brunei Darussalam and Tonga, is that of access to fresh air and exercise facilities.

Prison and Community Health Standards

All nations adopt the principle that "prisons should set up medical living and health regulations" (as stated in Article 54 of the Prisons Law of the People's Republic of China). The basic philosophy is that health services for prisoners should equate to those which are available to people in the wider community. However, while every nation agrees with this basic philosophy, it raises a number of practical difficulties. One of these was identified by Cambodia and Indonesia, who stated that there is a shortage of doctors and paramedics in the country as a whole. This makes it difficult to provide medical treatment in prisons.

The conference also discussed the possibility that prisoners may, on occasions, receive better medical services than ordinary citizens. For example, the Hong Kong (China) representative stated that prisoners can often obtain appointments with specialists more quickly than ordinary members of the public. Given the duty of care which prisons owe to their inmates, and the requirements of international standards for corrections, prison authorities should ensure prompt access to treatment. However, the representative from Thailand pointed out that it would be paradoxical if prisoners could access treatment which is beyond the means of citizens in the wider community. This will always remain an issue and the extent of the problem will depend on general community health standards.

The representative for New South Wales (Australia) agreed that in terms of medical, psychological and psychiatric services, some inmates were better off in prison than when living in the community. He further suggested that there is a real danger of "over servicing" with some inmates. Canada agreed that a small number of prisoners tend to request or require a large range of services. However, they pointed out that these same people may also seek and require extensive medical intervention when living in the community. It is therefore hard to generalise about the possible problem of over servicing. This is an area in which further research would be of assistance.

Organisational Arrangements

There are a number of different models for the provision of medical services in the region. One model is that adopted in Japan, where there are ten specialised facilities; four prisons are designated as "medical prisons" and another six are given priority in the allocation of resources. The more common model is for medical services to be divided between all prisons, with specialist units and medical centres within those prisons.

One of the most interesting organisational questions is whether the provision of prison health services should be the responsibility of Government Health departments or of Corrections departments. Australia provides a particularly interesting case study on this question. There are, in fact, three models in operation. In Queensland, Victoria and Western Australia, responsibility lies with the Correctional authorities. In New South Wales, South Australia and the Australian Capital Territory, it is the responsibility of the Health authorities. In Tasmania, responsibility is shared between Corrections and Health.

The papers from across the region suggest that the provision of health care in prisons is generally regarded as the responsibility of Corrections Departments. However, some obvious questions arise as to the most appropriate arrangements in terms of both efficiency and accountability. Although Corrections Departments generally have formal responsibility for the provision of services, services may, in practice, be sub-contracted rather than performed by employees of Corrections Departments. This can make it difficult to track expenditure and ensure effective accountability.

Countries with a federal system of Government may face additional problems. In Canada, the most serious offenders fall under the authority of the Correctional Service of Canada, a federal body: however, health care is generally the responsibility of the provinces. In Australia, the Federal/Commonwealth government largely controls funds for public medical services, but the individual states and territories have responsibility for the incarceration of prisoners.

Infectious Diseases: Prisoner and Staff Safety

One of the core concerns of all correctional services is to control the spread of infectious and blood-borne diseases. By their very nature, prisons pose risks with regard to the spread of disease, especially if they are overcrowded. Further, as pointed out by Japan, many prisoners belong to high risk groups at the time of admission.

Discussion in the papers focused on three main areas of concern - Hepatitis C, tuberculosis (TB) and HIV/AIDS. The prevalence of such diseases varies across the region. TB was identified as a problem in Mongolia, China, Kiribati, Korea, Macau (China), Singapore and Thailand. As pointed out by New Zealand, some groups are at significantly higher risk of TB than others; Maori being six times more likely to have TB than Europeans, and Pacific Islanders ten times more likely. TB was not identified as a major issue, at present, in either Australia or Canada. However, both these countries identified Hepatitis C as the major health problem with respect to infectious diseases.

Most of the papers discussed the issues associated with HIV/AIDS. On the positive side, this does not appear to be a major problem in most parts of the region. Canada puts the prevalence of HIV at 2 per cent of the inmate population. In Australia, the figure appears to be less than 0.5 per cent. However, Malaysia reported that around 4.6 per cent of the total prison population is HIV positive. Whilst New Zealand does not face a major problem with the majority of inmates, Maori and Pacific Islanders tend to have a higher rate of infection.

Although HIV is not the most pressing health issue in prisons in the region, it has brought some important issues to the fore. In particular, the question arises as to whether HIV positive inmates should be segregated or held with the mainstream prison population. Practices differ across the region. In Brunei Darussalam and Malaysia, for example, the policy is one of separation due to concern about the possible spread of the disease through the sharing of needles or sexual activity. In Canada, Hong Kong (China) and Australia, the policy is for HIV positive prisoners to be housed with the mainstream population. In part, this policy reflects the need for confidentiality of medical records in those jurisdictions. A prisoner's HIV status is known only to medical personnel and, possibly, to senior managers.

This leads on to another point of discussion, highlighted by the representative from Thailand namely, the health and safety of prison staff as well as prisoners. The paper from China made a similar point. In those jurisdictions where there is no segregation of HIV prisoners, the focus has been on preventive education and "universal precaution"; for example, all prisoners are to be searched using appropriate precautions. Staff in all countries are given regular education in disease control and management and are provided with screening and tests as required.

Mental Health Services

Mental health issues are a matter of ongoing and growing concern in all parts of the region. One problem to which the Australian report drew attention is that community supports tend to be adequate for psychiatric conditions, but are often lacking for other conditions such as personality disorders and attention deficit disorder : "the relative paucity of services for these conditions in the general community is a barrier to their effective management both within the prison system and after release."

The delegation from Hong Kong (China) addressed these problems in some detail, outlining the facilities which currently exist. An interesting development has been the establishment of special "Rehabilitation Units" within existing prisons for those prisoners who experience mental health problems but who do not require placement in a specialist psychiatric centre.

Clearly, mental health issues will continue to be a matter of great concern to prison administrators and there was clear agreement at the conference that this is an area in which further research, evaluation and service provision will be required. It was also clearly acknowledged that this is an area in which an integrated approach is required and that it is essential that appropriate supports are in place for prisoners upon release. If they are not, the danger is that ex-prisoners will commit further offences and return to prison; and that prisons will become "warehouses" for people with mental problems.

Managing Drug Offenders

A large number of the country papers drew attention to the medical difficulties associated with the management of drug offenders in prison. This is a large topic in its own right but some key themes can be briefly noted.

First, there are different views about the use of "substitute drugs" such as Methadone for heroin addicts. In some jurisdictions, including parts of Australia, methadone is used, and Canada is conducting a pilot Methadone program. Hong Kong (China) does not follow such programs but focuses on the treatment of symptoms of withdrawal and a policy of abstinence from drug use. Singapore appears to have gone further than other jurisdictions in the use of Naltrexone. Rather than being a "substitute drug", Naltrexone blocks receptor sites in the brain, reducing cravings for heroin. Naltrexone trials are also being conducted in Western Australia.

Secondly, a harm reduction strategy is pursued, within limits. It does not appear that any of the jurisdictions has a needle exchange program in prisons, as public and political opinion is unlikely to accept such a development. However, bleach is, in practice, available in a number of countries (including Australia, Canada and New Zealand) to permit some cleaning of needles.

Thirdly, there is an increasing focus on the provision of counselling programs for substance abuse. These programs may well need to address the use and abuse of legal substances such as alcohol as well as illegal drugs.

Smoking Policies

Smoking is generally identified as a health risk. However, prisons have traditionally allowed smoking; indeed, tobacco has historically been an item of prison "currency". The Conference Chairman noted that an attempt to establish a smoke-free prison in Queensland had been a failure; within a short time of opening, the prison had witnessed a serious disturbance - one of the underlying factors being that smoking was not allowed. However, a representative of Singapore stated that smoke-free prisons had operated there for several years.

Conclusion

The issues of inmate and staff health are inter-related and fundamental to effective and safe prison management. Correctional Services owe a duty of care to both parties and as prison systems develop during the first part of this century, health-related problems are likely to become increasingly complex. Clearly, there are no easy solutions to such problems and this summary has identified a number of areas in which practices diverge across the region. However, there is a clear and universal commitment to health issues and all nations can learn from developments elsewhere, including evaluations of new mental health or drug treatment strategies.