Prison tattoo program wasn't given enough time

A federal pilot project aimed at controlling the spread of infectious diseases within prisons by offering inmates sanitary tattooing wasn't given enough time to demonstrate its worth, Chief Public Health Officer of Canada Dr. David Butler-Jones says.

Public Safety Minister Stockwell Day last month axed the $600 000 sterile tattooing pilot as a waste of tax dollars that wasn't “demonstrably effective.”

“A relatively short space of time,” like the 1 year given for this pilot, isn't adequate to conclusively establish whether a program affects the prevalence rate of HIV, hepatitis C and other infectious diseases, Butler-Jones told CMAJ.

“When you have multiple inputs and factors, it's very difficult to do that in 1 year. In general, the best you could probably hope to see would be some change in behaviours that serve as a surrogate to, you would anticipate, lower rates of infection. But you need to do the research in a rigorous enough way, for long enough, to determine whether that behaviour is sustained.”

Butler-Jones wasn't consulted about the potential consequences of kiboshing the program, but believes harm reduction measures like safe tattooing are an integral element of any comprehensive strategy (which would also include health promotion, education, illness prevention, surveillance testing and treatment) to reduce infectious diseases in prisons.

“This was one method that, from a public health perspective, makes sense as one of the initiatives of a broader strategy or program. But governments and communities have the right to make decisions about such programs based on a range of factors, not just public health considerations, and about which elements of a comprehensive strategy should receive more emphasis. In this case, the government has decided to put its efforts more on the prevention/education elements.”

Although the consequences of axing the pilot can't be conclusively proven, it's legitimate to surmise that “you run the risk of increasing the risk of infection,” Butler-Jones added. “But in terms of [the government's] overall strategy, if you reduce the risk in other ways, you end up with a ‚disease-neutral outcome.' It's too soon to tell exactly what's going to happen.”

Anything other than a disease-neutral outcome could have staggering consequences, given the prevalence of infectious diseases within Canada's prisons, and the cost of treating inmates.

According to Corrections Canada, 3303 inmates in Canada's 54 prisons had hepatitis C in 2004; an overall prevalence of 25.2% (women: 37.4%; men: 24.8%). That same year, 2472 HCV positive inmates were released. As well, 188 inmates were infected with HIV, for a prevalence of 1.43% (women: 3.44%; men: 1.37%), while 235 HIV-positive inmates were released.

Corrections Canada pegs the annual cost of providing HIV treatment for an inmate at $29 000, and for hepatitis C treatment at $26 000. Those costs of roughly $90 million absorb the bulk of a burgeoning $100-million or so annual Corrections Canada health care budget.

Meanwhile, a national survey indicates tattooing has become such an inherent part of prison culture that 45% of inmates receive tattoos and 17% have body piercing, often using dirty needles.

Day declined to release an evaluation of the pilot undertaken by Corrections Canada's audit branch, saying it's in the final stages of translation and unavailable. It remained so, as of CMAJ's Jan. 10 press deadline.

Day's spokesperson Melissa Leclerc rejected suggestions the evaluation indicated the program was reducing risky behaviour. “The minister hasn't seen any evidence, or any way, or any reasons to support continuing this program,” Leclerc said. “From his perspective, on what was presented in the evaluation, this was not where we wanted to put the money…. We believe the taxpayer's money should be put where it counts most. That means tackling crime, keeping drugs off our streets.”

Canadian HIV/AIDS Legal Network Deputy Director Richard Elliott countered that discontinuing the program is nothing short of “public health folly” and “fiscally irresponsible.” He argues the $100 000 per prison cost of the pilot completely offsets health care costs if just 4 cases of infection are prevented annually. “It's a sensible investment in public health.”

Moreover, kiboshing the program violates human rights law and international obligations to safeguard prisoners, Elliott added. “We sentence people to be in prison. We don't sentence them to a greater risk of bloodborne diseases like HIV or hepatitis C while performing a perfectly legal act like obtaining a tattoo.”

The pilot, launched in August 2005, with funding from the $85-million Federal AIDS Initiative, was overseen by the Public Health Agency of Canada, which had representation on the steering committee overseeing its development.

Corrections Canada Director General of Health Services Dr. Francoise Bouchard says the program targeted 6 prisons, including a women's site. An inmate at each institution was trained in infectious disease prevention and began providing tattoos under supervision of correctional staff.

Bouchard declined comment on the public health consequences of discontinuing the program. Demonstrating a reduction in transmission would require a huge, long-term study, she added. “The objective was to see if such a project could contribute to minimize the risk in terms of high-risk behaviours, and also to look at minimizing the risk of staff injuries, and to educate inmates about infectious disease, as well as promoting health and wellness, while maintaining security.” — Wayne Kondro, CMAJ

Figure. About 45% of Canada's 13 000 or so inmates receive unsterile tattoos while in jail. Photo by: Canapress