- Email: [email protected]
The health of prisoners
Correspondence
Seena Fazel and Jacques Baillargeon (March 12, p 956)1 have produced a high-quality Review on the health needs of prisoners. After reading this paper, it is difficult to understand how the health of prisoners could not be a government priority. If prison is intended to punish and protect society, it also has the task of reintegration, including within the health-care system. The example of addiction is especially informative. Addictions largely affect the prison population, and the link between addiction and violence has been described.2,3 Treatment of addiction could help to promote reintegration and to fight against recidivism. Unfortunately, health professionals are too few to meet the needs of prisoners in this respect.4 Many reports increasingly show that the means fall short of the need. In France, a report by the Court of Auditors,5 which is known for its criticism of irrelevant government spending, recommended a “better budget for future health care costs of prisoners”. France has already been criticised by the European Court of Human Rights and the Committee for the Prevention of Torture of the Council of Europe for its detention conditions and poor access to health care in prison. Despite these reports, the horizon does not seem to brighten. Access to care in prison is a human right. Unfortunately, the health of prisoners is a public health priority confronted by the principles of realpolitik. I declare that I have no conflicts of interest.
Maxime Gignon [email protected] Public Health Department, Amiens University Hospital, 80054 Amiens, France 1 2
3
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. Lapham S. Screening and brief intervention in the criminal justice system. Alcohol Res Health 2004–05; 28: 85–93. Pihl RO, Sutton R. Drugs and aggression readily mix; so what now? Subst Use Misuse 2009; 44: 1188–203.
www.thelancet.com Vol 377 June 11, 2011
4
5
Farabee D, Prendergast M, Cartier J. Alcohol & drug abuse: alcohol, the “un-drug”. Psychiatr Serv 2002; 53: 1375–76. Cour des Comptes. Le service public pénitentiaire: “prévenir la récidive, gérer la vie carcérale”. Paris: La Documentation Française, 2010. http://www.ladocumentationfrancaise. fr/rapports-publics/104000386/index.shtml (accessed May 25, 2011).
Seena Fazel and Jacques Baillargeon,1 in their important Review on the health of prisoners, emphasise the increased prevalence, susceptibility to, and transmission of, various infectious diseases in prisoners. They focus on HIV infection, hepatitis B and C, and tuberculosis. Prisoners are also more susceptible to acute respiratory infections, sexually transmitted diseases, skin infections, and diarrhoeal diseases.2 The appalling prison conditions described by Fazel and Baillargeon are not restricted to resource-poor countries. They are prevalent in prisons in the UK, Europe, and the USA. In the UK today, the prevalence of tuberculosis in prisoners is 208 per 100 000, which is almost 14 times greater than the prevalence in the general population.3 Prisons in the countries of the former Soviet Union have the highest prevalence of tuberculosis anywhere in the world.4 Although crowded and poorly ventilated prison cells facilitate microbial transmission, it is the stress, poor nutrition, smoking, drugs, and HIV that have a profound effect on the immune system, resulting in high prisoner morbidity and mortality. As Louis Pasteur acknowledged on his deathbed, in reference to Claude Bernard’s belief that disease was not caused by microbes alone, but rather by an imbalance of the body’s “terrain”, “Le terrain est tout, le microbe n’est rien” (the terrain is everything, the microbe is nothing). Prisoners, by default, lose their dignity, liberty, autonomy, and privacy, and are commonly accorded inadequate accommodation and health care. Basic ethical practice requires observation of the UN charter on human rights5 for prisoners by
all governments. Urgent measures must be taken to rectify the prison conditions that underlie the disturbance of prisoners’ body “terrain” and homoeostatic mechanisms. We declare that we have no conflicts of interest.
Susannah Ireland/Rex Features
The health of prisoners
*Justin O’Grady, Peter Mwaba, Alimuddin Zumla [email protected] Department of Infection, University College London Medical School, London W1T 4JF, UK (JOG, AZ); and University of Zambia–University College London Medical School Research and Training Project, and Ministry of Health, Lusaka, Zambia (PM) 1 2
3
4
5
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. UNODC. HIV and prisons in sub-Saharan Africa: opportunities for action. Vienna: United Nations Office on Drugs and Crime, 2007. Story A, Murad S, Roberts W, Verheyen M, Hayward AC. Tuberculosis in London: the importance of homelessness, problem drug use and prison. Thorax 2007; 62: 667–71. Stern V. The house of the dead revisited: prisons, tuberculosis, and public health in the former Soviet bloc. In: Gandy M, Zumla A, eds. The return of the white plague: global poverty and the “new” tuberculosis. London: Verso, 2003. UN. The Universal Declaration of Human Rights. New York: United Nations, 1948.
We applaud Seena Fazel and Jacques Baillargeon1 for their excellent Review on prisoner health and the attention paid to post-release outcomes. We would only add that, in many countries, there are large racial and ethnic disparities in incarceration rates, raising concerns about how these disparities might translate to racial disparities in health. In the USA, for instance, African Americans are seven times more likely than whites to be imprisoned. Fazel and Baillargeon note that mortality rates are generally lower during incarceration, before skyrocketing in the weeks and months after release. Importantly, the negative health consequences of incarceration (which are related to the stress of imprisonment, exposure to infectious diseases while in prison, and numerous other factors before and after release) seem to outweigh the protective effects of incarceration on health.2 As a result, vast racial disparities in incarceration rates between African
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2001
Correspondence
For publications from the WHO Health in Prisons Project see http://www.euro.who.int/en/ what-we-do/health-topics/ health-determinants/prisonsand-health
Americans and whites in the USA have exacerbated racial health disparities.3,4 With growing correctional populations worldwide, the long-term health consequences of incarceration are taking an increasing toll not just on prisoners, but also on the communities to which they return. Mitigation of the collateral consequences of incarceration will require not only improvements in prison health-care services, but also attention to the social and political circumstances that have led to such unacceptable disparities. We declare that we have no conflicts of interest.
*Samuel L Dickman, Josiah D Rich [email protected] *Department of Medicine, Division of Infectious Diseases, Miriam Hospital and Brown Medical School, Providence, RI 02906, USA (SLD, JDR); and Center for Prisoner Health and Human Rights, Providence, RI, USA (SLD, JDR) 1 2
3
4
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. Massoglia M. Incarceration as exposure: the prison, infectious disease, and other stress-related illnesses. J Health Soc Behav 2008; 49: 56–71. Massoglia M. Incarceration, health, and racial disparities in health. Law Society Rev 2008; 42: 275–306. Johnson R, Raphael S. The effects of male incarceration dynamics on acquired immune deficiency syndrome infection rates among African American women and men. J Law Econ 2009; 52: 251–93.
The Review on the health of prisoners by Seena Fazel and Jacques Baillargeon1 draws attention to an important subject. We would like to show that some real achievements have been made during the period covered by their Review. Substantial work has been done in the past decade or so in terms of reducing the spread of HIV and tuberculosis in prisons.2,3 Additionally, data produced regularly by the European Monitoring Centre for Drugs and Drug Addiction are of central importance to the issue of drugs in prisons in Europe, and huge efforts have been made in reducing the harm from illicit drugs. The work of several organisations, such as WHO, the UN Office on Drugs and Crime, the International Harm Reduction Association, and AIDS Foundation 2002
East-West should be mentioned in this regard. Fazel and Baillargeon rightly draw attention to the 1998 Council of Europe recommendation on integration of prison health services into public health, but they do not mention the more recent and probably more influential Moscow Declaration of WHO in 2003.4 This declaration was one of the outcomes of the WHO Health in Prisons Project, which has produced authoritative and evidence-based publications on drugs, mental health, and communicable diseases in prisons. Up until as recently as the early 1990s, prison health was of little interest to prison authorities because such bodies were judged on security, and was of no interest to public health services because prison health was usually the responsibility of ministries of justice. This situation is now changing, and by 2009 three countries in Europe (Norway, France, and England and Wales) had passed the responsibility over to ministries of health. Many countries in Europe want to know more about this transfer and how best to achieve it. They have asked WHO to establish an expert group to give advice and support.5 We declare that we have no conflicts of interest.
Andrew Fraser, *Lars Møller, Brenda van den Bergh [email protected] WHO Collaborating Centre for Alcohol, Illicit Drugs and Prison Health, Department of Health, London, UK (AF); and WHO Regional Office for Europe, 2100 Copenhagen Ø, Denmark (LM, BvdB) 1 2
3
4
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. United Nations Office on Drugs and Crime, UNAIDS, World Health Organization. HIV testing and counselling in prisons and other closed settings. http://www.who.int/hiv/pub/idu/tc_ prison_tech_paper.pdf (accessed Dec 14, 2010). Tuberculosis Coalition for Technical Assistance and International Committee of the red Cross. Guidelines for control of tuberculosis in prisons. http://www.scribd.com/doc/28734882/ Guidelines-for-Control-of-TB-in-Prisons (accessed May 25, 2011). World Health Organization Regional Office for Europe. Moscow Declaration: prison health as part of public health. Copenhagen: WHO Regional Office for Europe, 2003. http://www. euro.who.int/__data/assets/pdf_file/0007/ 98971/E94242.pdf (accessed Dec 14, 2010).
5
World Health Organization Regional Office for Europe. Final report of the WHO national counterpart meeting on prison health. http:// www.euro.who.int/__data/assets/pdf_file/0004/ 127759/e94508.pdf (accessed Dec 14, 2010).
Mediator: who’s to blame? Asher Mullard’s World Report summarising the story of Mediator (benfluorex; March 12, p 890)1 shows that there are important lessons to be learned about dealing with old drugs. We do not wish to defend the drug, the manufacturer, or the French regulatory system, but to focus on the scapegoating to which Mullard alludes. The regulatory body AFSSAPS has removed Anne Castot and Carmen Kreft-Jais, its most senior pharmacovigilance personnel. It is clearly wrong to blame them personally for wider system failings: such people have to work within legal and bureaucratic frameworks and resource limits set by others—ie, politicians and senior executives. It is very easy with hindsight to say that the drug should have been withdrawn in 1999 on the basis of just two cases, but the major problem then was a lack of capacity to undertake rapid pharmacoepidemiological research in France to confirm and measure the risk. Also, desire to protect data privacy worked against the availability of suitable data resources. Pharmacovigilance personnel, who have to monitor the safety of thousands of substances, should not be expected to remove ineffective drugs—the regulator should put in place a separate unit for that purpose. Castot and Kreft-Jais are respected worldwide as competent professionals, with an exemplary commitment to public health. Removing them is pure political expediency. The loss of their experience will not only reduce the likelihood of improvements being made to the French system, but also serve to discourage able people from entering the field. www.thelancet.com Vol 377 June 11, 2011
Seena Fazel and Jacques Baillargeon (March 12, p 956)1 have produced a high-quality Review on the health needs of prisoners. After reading this paper, it is difficult to understand how the health of prisoners could not be a government priority. If prison is intended to punish and protect society, it also has the task of reintegration, including within the health-care system. The example of addiction is especially informative. Addictions largely affect the prison population, and the link between addiction and violence has been described.2,3 Treatment of addiction could help to promote reintegration and to fight against recidivism. Unfortunately, health professionals are too few to meet the needs of prisoners in this respect.4 Many reports increasingly show that the means fall short of the need. In France, a report by the Court of Auditors,5 which is known for its criticism of irrelevant government spending, recommended a “better budget for future health care costs of prisoners”. France has already been criticised by the European Court of Human Rights and the Committee for the Prevention of Torture of the Council of Europe for its detention conditions and poor access to health care in prison. Despite these reports, the horizon does not seem to brighten. Access to care in prison is a human right. Unfortunately, the health of prisoners is a public health priority confronted by the principles of realpolitik. I declare that I have no conflicts of interest.
Maxime Gignon [email protected] Public Health Department, Amiens University Hospital, 80054 Amiens, France 1 2
3
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. Lapham S. Screening and brief intervention in the criminal justice system. Alcohol Res Health 2004–05; 28: 85–93. Pihl RO, Sutton R. Drugs and aggression readily mix; so what now? Subst Use Misuse 2009; 44: 1188–203.
www.thelancet.com Vol 377 June 11, 2011
4
5
Farabee D, Prendergast M, Cartier J. Alcohol & drug abuse: alcohol, the “un-drug”. Psychiatr Serv 2002; 53: 1375–76. Cour des Comptes. Le service public pénitentiaire: “prévenir la récidive, gérer la vie carcérale”. Paris: La Documentation Française, 2010. http://www.ladocumentationfrancaise. fr/rapports-publics/104000386/index.shtml (accessed May 25, 2011).
Seena Fazel and Jacques Baillargeon,1 in their important Review on the health of prisoners, emphasise the increased prevalence, susceptibility to, and transmission of, various infectious diseases in prisoners. They focus on HIV infection, hepatitis B and C, and tuberculosis. Prisoners are also more susceptible to acute respiratory infections, sexually transmitted diseases, skin infections, and diarrhoeal diseases.2 The appalling prison conditions described by Fazel and Baillargeon are not restricted to resource-poor countries. They are prevalent in prisons in the UK, Europe, and the USA. In the UK today, the prevalence of tuberculosis in prisoners is 208 per 100 000, which is almost 14 times greater than the prevalence in the general population.3 Prisons in the countries of the former Soviet Union have the highest prevalence of tuberculosis anywhere in the world.4 Although crowded and poorly ventilated prison cells facilitate microbial transmission, it is the stress, poor nutrition, smoking, drugs, and HIV that have a profound effect on the immune system, resulting in high prisoner morbidity and mortality. As Louis Pasteur acknowledged on his deathbed, in reference to Claude Bernard’s belief that disease was not caused by microbes alone, but rather by an imbalance of the body’s “terrain”, “Le terrain est tout, le microbe n’est rien” (the terrain is everything, the microbe is nothing). Prisoners, by default, lose their dignity, liberty, autonomy, and privacy, and are commonly accorded inadequate accommodation and health care. Basic ethical practice requires observation of the UN charter on human rights5 for prisoners by
all governments. Urgent measures must be taken to rectify the prison conditions that underlie the disturbance of prisoners’ body “terrain” and homoeostatic mechanisms. We declare that we have no conflicts of interest.
Susannah Ireland/Rex Features
The health of prisoners
*Justin O’Grady, Peter Mwaba, Alimuddin Zumla [email protected] Department of Infection, University College London Medical School, London W1T 4JF, UK (JOG, AZ); and University of Zambia–University College London Medical School Research and Training Project, and Ministry of Health, Lusaka, Zambia (PM) 1 2
3
4
5
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. UNODC. HIV and prisons in sub-Saharan Africa: opportunities for action. Vienna: United Nations Office on Drugs and Crime, 2007. Story A, Murad S, Roberts W, Verheyen M, Hayward AC. Tuberculosis in London: the importance of homelessness, problem drug use and prison. Thorax 2007; 62: 667–71. Stern V. The house of the dead revisited: prisons, tuberculosis, and public health in the former Soviet bloc. In: Gandy M, Zumla A, eds. The return of the white plague: global poverty and the “new” tuberculosis. London: Verso, 2003. UN. The Universal Declaration of Human Rights. New York: United Nations, 1948.
We applaud Seena Fazel and Jacques Baillargeon1 for their excellent Review on prisoner health and the attention paid to post-release outcomes. We would only add that, in many countries, there are large racial and ethnic disparities in incarceration rates, raising concerns about how these disparities might translate to racial disparities in health. In the USA, for instance, African Americans are seven times more likely than whites to be imprisoned. Fazel and Baillargeon note that mortality rates are generally lower during incarceration, before skyrocketing in the weeks and months after release. Importantly, the negative health consequences of incarceration (which are related to the stress of imprisonment, exposure to infectious diseases while in prison, and numerous other factors before and after release) seem to outweigh the protective effects of incarceration on health.2 As a result, vast racial disparities in incarceration rates between African
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2001
Correspondence
For publications from the WHO Health in Prisons Project see http://www.euro.who.int/en/ what-we-do/health-topics/ health-determinants/prisonsand-health
Americans and whites in the USA have exacerbated racial health disparities.3,4 With growing correctional populations worldwide, the long-term health consequences of incarceration are taking an increasing toll not just on prisoners, but also on the communities to which they return. Mitigation of the collateral consequences of incarceration will require not only improvements in prison health-care services, but also attention to the social and political circumstances that have led to such unacceptable disparities. We declare that we have no conflicts of interest.
*Samuel L Dickman, Josiah D Rich [email protected] *Department of Medicine, Division of Infectious Diseases, Miriam Hospital and Brown Medical School, Providence, RI 02906, USA (SLD, JDR); and Center for Prisoner Health and Human Rights, Providence, RI, USA (SLD, JDR) 1 2
3
4
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. Massoglia M. Incarceration as exposure: the prison, infectious disease, and other stress-related illnesses. J Health Soc Behav 2008; 49: 56–71. Massoglia M. Incarceration, health, and racial disparities in health. Law Society Rev 2008; 42: 275–306. Johnson R, Raphael S. The effects of male incarceration dynamics on acquired immune deficiency syndrome infection rates among African American women and men. J Law Econ 2009; 52: 251–93.
The Review on the health of prisoners by Seena Fazel and Jacques Baillargeon1 draws attention to an important subject. We would like to show that some real achievements have been made during the period covered by their Review. Substantial work has been done in the past decade or so in terms of reducing the spread of HIV and tuberculosis in prisons.2,3 Additionally, data produced regularly by the European Monitoring Centre for Drugs and Drug Addiction are of central importance to the issue of drugs in prisons in Europe, and huge efforts have been made in reducing the harm from illicit drugs. The work of several organisations, such as WHO, the UN Office on Drugs and Crime, the International Harm Reduction Association, and AIDS Foundation 2002
East-West should be mentioned in this regard. Fazel and Baillargeon rightly draw attention to the 1998 Council of Europe recommendation on integration of prison health services into public health, but they do not mention the more recent and probably more influential Moscow Declaration of WHO in 2003.4 This declaration was one of the outcomes of the WHO Health in Prisons Project, which has produced authoritative and evidence-based publications on drugs, mental health, and communicable diseases in prisons. Up until as recently as the early 1990s, prison health was of little interest to prison authorities because such bodies were judged on security, and was of no interest to public health services because prison health was usually the responsibility of ministries of justice. This situation is now changing, and by 2009 three countries in Europe (Norway, France, and England and Wales) had passed the responsibility over to ministries of health. Many countries in Europe want to know more about this transfer and how best to achieve it. They have asked WHO to establish an expert group to give advice and support.5 We declare that we have no conflicts of interest.
Andrew Fraser, *Lars Møller, Brenda van den Bergh [email protected] WHO Collaborating Centre for Alcohol, Illicit Drugs and Prison Health, Department of Health, London, UK (AF); and WHO Regional Office for Europe, 2100 Copenhagen Ø, Denmark (LM, BvdB) 1 2
3
4
Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. United Nations Office on Drugs and Crime, UNAIDS, World Health Organization. HIV testing and counselling in prisons and other closed settings. http://www.who.int/hiv/pub/idu/tc_ prison_tech_paper.pdf (accessed Dec 14, 2010). Tuberculosis Coalition for Technical Assistance and International Committee of the red Cross. Guidelines for control of tuberculosis in prisons. http://www.scribd.com/doc/28734882/ Guidelines-for-Control-of-TB-in-Prisons (accessed May 25, 2011). World Health Organization Regional Office for Europe. Moscow Declaration: prison health as part of public health. Copenhagen: WHO Regional Office for Europe, 2003. http://www. euro.who.int/__data/assets/pdf_file/0007/ 98971/E94242.pdf (accessed Dec 14, 2010).
5
World Health Organization Regional Office for Europe. Final report of the WHO national counterpart meeting on prison health. http:// www.euro.who.int/__data/assets/pdf_file/0004/ 127759/e94508.pdf (accessed Dec 14, 2010).
Mediator: who’s to blame? Asher Mullard’s World Report summarising the story of Mediator (benfluorex; March 12, p 890)1 shows that there are important lessons to be learned about dealing with old drugs. We do not wish to defend the drug, the manufacturer, or the French regulatory system, but to focus on the scapegoating to which Mullard alludes. The regulatory body AFSSAPS has removed Anne Castot and Carmen Kreft-Jais, its most senior pharmacovigilance personnel. It is clearly wrong to blame them personally for wider system failings: such people have to work within legal and bureaucratic frameworks and resource limits set by others—ie, politicians and senior executives. It is very easy with hindsight to say that the drug should have been withdrawn in 1999 on the basis of just two cases, but the major problem then was a lack of capacity to undertake rapid pharmacoepidemiological research in France to confirm and measure the risk. Also, desire to protect data privacy worked against the availability of suitable data resources. Pharmacovigilance personnel, who have to monitor the safety of thousands of substances, should not be expected to remove ineffective drugs—the regulator should put in place a separate unit for that purpose. Castot and Kreft-Jais are respected worldwide as competent professionals, with an exemplary commitment to public health. Removing them is pure political expediency. The loss of their experience will not only reduce the likelihood of improvements being made to the French system, but also serve to discourage able people from entering the field. www.thelancet.com Vol 377 June 11, 2011