Let us get prison health care out of jail

Canada’s prison population is expected to grow because of government legislation to expand the number of crimes for which prison time is mandatory and to increase the mandatory minimum sentence for certain crimes. Overcrowding, double-bunking and an increase in incidence of self-harm, violence, mental health issues and use of intravenous drugs seem to be inevitable consequences that will, in turn, exacerbate the strain on the prison system. So why should we care about offenders who are serving their time?

In addition to the responsibility of providing adequate health care to prisoners, we have a responsibility to society. Most prisoners are released back into the community. To the extent that their blood-borne communicable diseases, depression and other mental disorders, and chronic, degenerative diseases are under poor control, their families and the community will bear the burden of the related health, social and economic costs of inadequate care.

Prisoners have poorer physical and mental health than the general population. Their incarceration as punishment for a crime is no excuse to punish them further by not addressing their health problems adequately. Rather, incarceration provides an opportunity to deliver care to people who have had no or limited access to health care and who often have difficulty staying in treatment programs in the community.

On any given day, there are about 38 000 adults in Canadian prisons: about 14 000 are in the 57 federal prisons and 24 000 in the provincial/territorial penitentiaries and remand centres.¹ Their health issues, if identified, are addressed by a patchwork of disconnected health services managed by prison executives. Management of chronic diseases and mental health disorders, preventive care, continuity of care, and transfer or release planning may often get neglected. Specialty care usually involves travel or transfer to the public system in an unplanned way. Transfers between prisons or from provincial to federal prisons are frequent and nearly always interrupt care. Lapses in curative or maintenance care for communicable diseases are particularly worrying. What we have at the moment is an ad hoc arrangement of some staffing by nurses and visits by doctors at intervals. This level of care is too patchy for the real health needs of prisoners and puts unwarranted strain on all of the staff.

The mandate of health care systems — disease management, and health promotion and maintenance — is distinct from that of incarceration. The current system of prison health care arguably constitutes cruel and unusual punishment, a contravention of the Canadian Charter of Rights and Freedom.

What is desperately needed is a well-organized and coordinated system of health care, one that follows the offender from the start of his or her incarceration to release and successful return to the community. Other countries have recognized the importance of prison health care and the need to reform their systems. Norway, France and the United Kingdom reviewed their prison care 15 to 25 years ago and now use their regular public system of medical care to serve their prisoners. What characterizes these approaches is that the responsibility and the budget for the health care needs of the prison population are transferred to a recognized health authority. The organization and administration of prison health services from outside the prison system means more autonomy with less conflict between health personnel and corrections authorities. Thus, health care professionals working in the prison system will have more regular exposure to the values and ethics that guide usual practice. The advent of the electronic health record should improve the current disconnect between in-prison care and that rendered outside, as well as smooth release planning and the transition back to civilian life.

That many of our prisons are located near medical schools and their research institutes provides an opportunity to challenge universities and professional colleges to develop and offer a curriculum focused on prison health. Were they to engage in this type of medicine, perhaps the pathetically small amount of research being done on the many special health problems in our prisons would yield to scientific enquiry.

Canada is falling behind. The fragmented patchwork of health services and programs in our correctional facilities is not acceptable. If other countries can reform their prison care, we ought to be capable of finding a way that satisfies the norms of the Canada Health Act and meets the needs of prisoners. A task force now examining discrepancies and deficiencies in the 57 federal prisons² needs a broader mandate that should include the possibility of changing who delivers the care, and where and when it is delivered. Ultimately, prison health care reform should include all jurisdictions involved in correctional services (federal, provincial and territorial) to bring a seamless approach and adequate health care to this population.

See also the analysis article by Iftene and Manson at www.cmaj.ca/lookup/doi/10.1503/cmaj.120222