Prison Health
Doctor Patient and Society 410
6th Feb, 2013
Ruth Elwood Martin
Larry Howett
1
Acknowledgements and Disclaimers
Public Health
Agency of Canada
2
What are the goals for today’s DPAS410
readings, discussions and presentations?
1. To understand the health disparities of
incarcerated populations;
2. To discuss the public health implications of lack
of ‘through care’;
3. To listen to narratives of prison health
experiences in Canada;
4. To appreciate ways that social exclusion impacts
the health of an individual over their lifespan.
3
Outline of today’s learning activities
1. My presentation
•
•
•
•
•
•
International context
My own story
Numbers of Canadian prisoners and their demographics
Health care of Canadian prisoners
Prevalence of disease burden among incarcerated people
How do we respond?
2. Larry Howett’s story
3. Announcements
•
•
How do we respond to ‘Determinants of Health’?
Plenary Quest RFP results
4. Volunteer guests will share their stories with you in
in your discussion group
‘One can measure the quality of a society by the
quality of its prisons’
…..attributed to Dostoevsky
Nelson
2
Mandela
Robben Island and Pollsmoor Prison
1962-1990
‘The Long Road to Freedom’
1. The Lancet, 2011. The health of prisoners.3
2. American Journal of Public Health, 2005.
Public health implications of substandard
correctional health care.4
3. American Journal of Public Health, 2005.
The World Health Organization European
Health in Prisons Project after 10 years:
Persistent barriers and achievements.5
4. Annals of Internal Medicine, 1993.
Correctional Health Care: A public health
opportunity.6
5. Canadian Medical Association Journal, 2000.
Health care problems in prisons.7
7
World Health Organization (Europe)
Health in Prisons Programme (HIPP)8
• Initiated in 1995 – academics – mental health
• 44 member European countries
• WHO International Policy Declarations:
– Prisons, drugs and society (2001)
– Prison health as part of public health (2003)
– Prisons, drugs and harm reduction (2005)
– Prisons and mental health (2007)
– Women’s health in prison (2009)
– Drug overdose in prisons (2010)
WHO Health in Prisons Programme (HIPP)
• Countries should provide prison health care that
demonstrates:
1. Community equivalence
2. Integration with a country’s public and primary
health care services
• Prison health care transferred from Ministry of
Justice to Ministry of Health: England, France,
Norway, Australia9 and Italy; and, Nova Scotia!
Back in 1994.....
10
Incarceration provides
a public health opportunity
to access and to serve
a high-risk population
otherwise inaccessible
to health care providers10
“the value of having prison health as
part of medical school is that it
exposes you to more or less every
population (determinant of health)
you could imagine. It’s immigrants,
it’s women, it’s homelessness, it’s
aboriginal, it’s drug dependency ….”
—medical student11
Numbers of Canadian prisoners and demographics
• Federal offenders: sentenced>2 years
• Provincial inmates: sentenced<2 years
• Remanded to custody: awaiting sentencing…may
be overnight or many months
• Canadian custodial admissions 262,067(2010)12
Correctional Service Canada
• 53 federal penitentiaries
• 8,323 federal custodial admissions (2010)12
–11% female
–27% Aboriginal
• 15,055 ‘count’-> institution Webpages (2011)
• 8,016 federal community admissions (2010)
Provincial Correctional System
• 8 adult correctional centres
• 23,837 BC custodial admissions (2008)12
– 11% women
– 25% Aboriginal (4% gen popn)
• 2100 ‘count’->institution Webpages (2011)
• Mean sentence length 45 days
• Recidivism 34% returned within 2 yrs of
release (2008/9)13  effectiveness
16
Health Care of Canadian Prisoners
Health care of federal prisoners
• The Correction Service Canada shall provide
every inmate with
– essential health care; and
– reasonable access to non-essential mental
health care that will contribute to the inmate’s
rehabilitation and successful integration into
the community14
• The provision of health care shall conform to
professionally accepted standards
Health care of provincial prisoners
• Nova Scotia – Ministry of Health
• BC - Ministry of Justice -> private health contractor
• Health Care Services Manual15, Corrections Branch,
BC
– First aid
– Emergency care
– Primary care
– Provisions for 24-hour nursing care if required
– Isolation care capability
What is the prevalence of ill health among
the Canadian prison population?
Sexually transmitted infection:
• Chlamydia:
– 0.15% in general population
– 5.5% on admission testing to CSC
• Gonorrhea:
- 0.02% in general population
- 0.9% on admission testing to CSC16
Cervical Dysplasia and other neoplasia
• Prevalence of all types of cancer higher
among incarcerated populations17, 18
• BC provincial female prisoners:
High grade abnormalities 11x >
47% Pap in the previous 3 years,
Vs 87% age-matched population
(p<0.001)19
Designed a Pap screening intervention20
Psychiatric illness, death & suicide
• 267 new intakes in BC federal penitentiaries
• 31.7% current diagnosis mental disorder
• 12% serious mood/psychotic disorder.21
• Review of deaths all causes of incarcerated
men, CMAJ (2002)22
• OD deaths- fed 50 x: prov 10 x
• Strangulation- fed 10 x: prov 4.5 x
• Rate of death all causes/100,000420 fed: 211 prov: 187 gen. male popn.
Yvonne Johnson
Stolen Life
The Journey of a Cree Woman23
1990’s
Ashley Smith
Inquest24
CBC Fifth Estate25
Substance Use, HIV and HCV
• 10 Quebec penitentiaries, survey (N=317), (1999)26
16 % alcohol, 29% drugs, 17% heroin
• 9 women’s federal facilities, qualitative interviews,
(2000/1)27
20/105 (19%) of participants engaging in IDU
• BC Corrections, women surveyed (N=104, 83%
response rate) (2001)28
21% women reported IDU while incarcerated
Substance Use, HIV and HCV, cont’d
• CSC, self reported, 200729
31% HCV men; 37% HCV women
5% HIV men; 8% HIV women
22% men IDU; 29% women IDU
• CSC, 200530
2.84% HIV women
1.63% HIV men
(0.2% prevalence in general Canadian popn)
• Ontario correctional centres, 199831
2% HIV men
• BC provincial corrections,199432
1% HIV men
3.3% HIV women
....from a poem….
Grey Cocoon
Substance Use
74% of BC female prisoners surveyed33
“My current prison sentence
is because of crime
directly related to my
drug use”
Leanne’s letter to the Parole Board
Methadone
• CSC
1998, Phase l: maintain methadone if accessing
methadone prior to incarceration
2002, Phase 2, ‘expanded access to MMT’
• BC Correctional Centres
1996, continued on the program
Initiation if person meets requirements of
College of Physicians and Surgeons and if a MD
available in the community for continuity of
care
34
Prisons
Action on HIV/AIDS in
Too Little, Too Late
- A Report Card (2002) -
Scoring System
Pts
Condoms, dental dams, lubricant available
2
Condoms, dental dams, lubricant accessible 4
Bleach available
2
Bleach accessible
4
Methadone treatment continuation provided 6
Methadone treatment initiation provided
6
Needle exchange or distribution available
6
Harm reduction report card
BC
CSC (Federal)
Quebec
Saskatchewan
Newfoundland & Labrador
Yukon, Ont, NWT, Man, NB, NS
Alberta
Nunavut, PEI
Score
Grade
22
21
14
10
9
5-8
3
0
B
BF
F
D*
F
F*
F*
Prison Needle Exchange Programs
• Review of Prison Syringe-exchange programs, 200335
- feasible, no negative events
- drug use reduced or stable
- syringe sharing reduced dramatically
- no new cases of HIV, HCV, HBV
• Ontario Medical Association, position paper, 200336
– Why is Canada lagging behind in establishing needle
exchange programs in prisons?
• CSC, Ottawa, October 1999
– Study Group on Needle Exchange Programs; Final
Report remains internal
Paradox……
Providing health care
for my patient (the prisoner)
within a
correctional system
How should prison health care clinicians
respond?
1. Witnesses and observers of our patients’ lives
2. Conscientious and compassionate medical care
3. Prison-based clinical quality improvement
activities
4. Advocacy role……..
Collaborating Centre For Prison Health
and Education (CCPHE)
Thank you for listening!
Collaborating Centre for Prison Health and Education
300 - 5950 University Boulevard
Vancouver, BC V6T 1Z3
Tel: (604) 827-4976
Fax: (604) 827-4184
Email: prison.health@familymed.ubc.ca
CCPHE banners paintings: Artist Mo Korchinski lives in Maple Ridge, BC, and is a mother and
grandmother. Mo paints with acrylics on canvas to portray images that inspired her during
her incarceration and during her (re)integration into the community. Mo is also communitybased researcher with Women in2 Healing and is passionate about working to improve the
health and education of women inside and outside of prison.
References
1Dostoevsky,
Fyodor. The House of the Dead (1862)
Nelson. Long Walk to Freedom: The Autobiography of Nelson Mandela
3Fazel S, Baillargeon J. The health of prisoners. The Lancet 2011; 377(9769):956-965.
4Restum ZG. Public health implications of substandard correctional health care. Am J Public Health 2005; 95(10):16891691.
5Gatherer A, Moller L, Hayton P. The World Health Organization European Health in Prisons Project after 10 years:
Persistent barriers and achievements. Am J Public Health 2005; 95(10):1696.
6Glaser JB, Greifinger RB. Correctional Health Care: A public health opportunity. Ann Intern Med. 1993; 118:139-145
7Ford PM, Wobeser, WL. Health care problems in prisons. CMAJ 2000; 162(5):664-665
8 World Health Organization (Europe), Health in Prisons Programme (HIPP)
http://www.euro.who.int/en/what-we-do/health-topics/health-determinants/prisons-and-health/who-healthin-prisons-programme-hipp
9Prison Health and Public Health: the integration of prison health services (report from a conference). International
Centre for Prison Studies. April 2004. http://www.prisonstudies.org/info/downloads/health_service_integration.pdf
10Glaser JB, Greifinger RB. Correctional Health Care: A public health opportunity. Ann Intern Med. 1993; 118:139-145
11Filek H, Buxton J, Harris J, Pang H, Sharif, N. Martin RE. Medical Students and Residents go to Prison. American Public
Health Association, 140th Annual Meeting and Exposition, San Francisco, USA, Oct 2012
12Canada Statistics. Correctional Services. Adult correctional services, admissions to provincial, territorial and federal
programs . [Internet]. Available from: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/legal30beng.htm
13Ministry of Public Safety and Solicitor General, 2010/11 – 2012/13 SERVICE PLAN , March 2010
14Health Care, Corrections and Conditional Release Act (S.C. 1992, c. 20). Available from: http://lawslois.justice.gc.ca/eng/acts/C-44.6/page-24.html#h-33
15Health Care Services Manual, Corrections Branch, Ministry of Justice, BC
16Zakaria D, Thompson JM, Jarvis A, Borgatta F. Research Reports [Internet]. Summary of Emerging Findings from the
2007 National Inmate Infectious Diseases and Risk-Behaviours Survey. 2007 [cited 2012 Mar 13]. Available from:
http://www.csc-scc.gc.ca/text/rsrch/reports/r211/r211-eng.shtml
2Mandela,
References, continued
17Davies
EA, Sehgal A, Linklater KM, Heaps K, Moren C, Walford C, Cook R, Møller H. Cancer in the London prison
population, 1986–2005. 2010. Journal of Public Health. pp. 1–6. doi:10.1093/pubmed/fdq009
18Harzke AJ, Baillargeon JG, Kelley MF, Pruitt SL, Pulvino JS, Paar DP. Leading medical causes of mortality among male
prisoners in Texas, 1992--2003. J Correct Health Care. 2011 Jul;17(3):241-53. doi: 10.1177/1078345811401362.
19Martin RE. A review of a prison cervical cancer screening program in British Columbia. Can J Public Health. 1998; 89.6:
382 - 386.
20Martin RE, Hislop GT, Grams GD, Calam B, Jones E, Moravan V. Evaluation of a cervical cancer screening intervention
for prison inmates. Can J Public Health. 2003; 95.4: 285 - 289.
21Brink, J.H., Doherty, D., & Boer, A. (2001). Mental disorder in federal offenders: A Canadian prevalence study.
International Journal of Law and Psychiatry 2, 330- 356. doi:10.1016/S0160-2527(01)00071-1.
22Wobeser WL, Datema J, Bechard B, Ford P. Causes of death among people in custody in Ontario, 1990-1999. CMAJ.
2002 Nov 12;167(10):1109-13.
23Wiebe R, Johnson Y. Stolen Life: The Journey of a Cree Woman. Vintage Canada. ISBN-10: 0676971962.
24See daily postmedia news reports written byChristie Blatchford. For example, Guard cries at Ashley Smith inquest over
‘what we were reduced to’, Feb 6, 2013.
http://www.canada.com/Guard+cries+Ashley+Smith+inquest+over+what+were+reduced/7928857/story.html
25CBC Fifth Estate documentaries, Behind the Wall http://www.cbc.ca/fifth/2010-2011/behindthewall/ and Out of
Control http://www.cbc.ca/fifth/2009-2010/out_of_control/
26 Poulin C, Michel A, Gilles L, Gaston G, et al. Prevalence of HIV and hepatitis C virus infections among inmates of
Quebec provincial prisons. CMAJ .2007;177(3): 252-256.DOI: 10.1503/cmaj.060760
27DiCenso AM, Dias G, Gahagan J. Unlocking our Futures: A National Study on Women, Prisons, HIV, and Hepatitis C.
2003. Prisoners' HIV/AIDS Support Action Network (PASAN).
http://www.pasan.org/Publications/Unlocking_Our_Futures.pdf
28Martin RE, Gold F, Murphy W, Remple V, Berkowitz J, Money D. Drug use and risk of bloodborne infections: a survey of
female prisoners in British Columbia. Can J Public Health. 2005; 96.2: 97 – 101.
29 Calzavara L, Ramuscak N, Burchell AN, et al.Prevalence of HIV and hepatitis C virus infections among inmates of
Ontario remand facilities. CMAJ.2007; 177.3: 257
30Correction Service Canada Infectious Disease Surveillance System (2005). Available at http://www.cscscc.gc.ca/text/pblct/infdscfp-2005-06/p6-eng.shtml#l31
References, continued
31 Ford,
P. et al. HIV and Hep C Seroprevalence and Associated Risk Behaviours in a Canadian Prison.Canadian HIV/AIDS
Policy and Law Newsletter (Volume 4, Number 2/3, Spring 1999).
32Rothon D, Mathias R, Schechter M. Prevalence of HIV infection in provincial prisons in British Columbia. CMAJ. 1994;
151.6: 781-786.
33 Martin RE, Gold F, Murphy W, Remple V, Berkowitz J, Money D. Drug use and risk of bloodborne infections: a survey of
female prisoners in British Columbia. Can J Public Health. 2005; 96.2: 97 – 101.
34Lines, Rick. Action on HIV/AIDS in Prisons, Too Little, Too Late - A Report Card.
http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=179
35Dolan K, Rutter S, Wodak AD.Prison-based syringe exchange programmes: a review of international research and
development. Addiction. 2003 Feb;98(2):153-8.
36Improving our health. Why is Canada lagging behind in establishing needle exchange programs? Position paper,
Ontario Medical Association. 2004. http://www.iprt.ie/files/oma_pnep_doc.pdf
37Study Group on Needle Exchange Programs (October 1999). Final Report of the Study Group on Needle Exchange
Programs. Correctional Service of Canada: Ottawa.