The prison service is still failing inmates’ healthcare needs
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m724 (Published 26 February 2020) Cite this as: BMJ 2020;368:m724Linked Commentary
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Stephen Armstrong reported the poorer healthcare in prison.[1] Improving the health service in prison is important, and it is urgent during epidemics, especially the current COVID-19.
On 20th February 2020, a surge in confirmed more than 500 COVID-19 cases within five prisons ended 16 days of continuous declines in new cases in China excluding Hubei Province.[2] Over half of the cases were in Hubei, the epicentre of the epidemic, including 230 at Wuhan Women’s Prison and 41 at Shayang Hanjin Prison. 207 cases, including seven prison guards, were diagnosed at Rencheng Prison in Shandong, and a further 34 at Shilifen Prison in Zhejiang. Several officials have been sacked for mismanagement over the infections. As the largest recent clusters of infection, prisons are becoming the new battleground in China’s fight against COVID-19.
The spread of infectious diseases results from interactions between agents and hosts. Prisoners, particularly older prisoners, pregnant women, and juveniles, are at higher risk of infectious diseases than communities outside.[3] The highly infectious environment in prisons is fuelled by overcrowding, poor health services, high risk behaviours, security vs public health concerns and lack of public empathy for prisoners.[4]
More than 10 million people are incarcerated worldwide.[5] The UN Basic Principles for the Treatment of Prisoners states that prisoners “shall have access to the health services available in the country without discrimination on the grounds of their legal situation”.[6] However, due to burgeoning prison populations and increasing epidemics, prison healthcare services have become increasingly strained. In China, there were 1.65 million prisoners in September 2018.[5] The 2003 severe acute respiratory syndrome (SARS) epidemic was a catalyst to reform China’s health system. There are approximately 16 000 health workers work in the nation’s prisons [7], but this is still insufficient. Infectious diseases are responsible for around 17.5% of prison mortality. For example, the prison tuberculosis infection rate of about 1 250 / 1000 000 is 3.4 times China’s national average.
COVID-19 has been a Public Health Emergency of International Concern. It is vital to fight the cluster infection globally. In the UK, to stop the possible spread in prisons, two inmates in Oxfordshire, England, were tested for coronavirus on 11th February.
The eruption of COVID-19 in Chinese prisons highlights the need to address prison healthcare.[3] Although attention has been focussed on Hepatitis C (HCV), human immunodeficiency virus (HIV) and tuberculosis (TB) within prisons, urgent research is required on Emerging Infectious Diseases including COVID-19. Health education for both inmates and prison staff must be intensified whilst increased funding should be allocated to medical treatment and prevention measures. Prison overcrowding is a significant factor that contributes to the spread of diseases such as COVID-19. More non-custodial sentences would decongest prisons reducing the potential for the flare-ups recently witnessed in China. Linkages between prison health and national health services should also be further strengthened.
Competing interests: None declared.
*Hong Yang [1], Julian R. Thompson [2]
h.yang4@reading.ac.uk
1 University of Reading, Reading RG6 6AB, UK; 2 UCL University College London, London, WC1E 6BT, UK
1. Armstrong S. The prison service is still failing inmates’ healthcare needs. BMJ 2020;368:m724. 10.1136/bmj.m724
2. China Central Government. Report of COVID-19 on 21 February 2020. 2020. http://www.gov.cn/xinwen/gwylflkjz25/wzsl.htm
3. Fazel S, Baillargeon J. The health of prisoners. Lancet 2011;377(9769):956-65. 10.1016/S0140-6736(10)61053-7
4. Simooya OO. Infections in prison in low and middle income countries: prevalence and prevention strategies. Open Infect Dis 2010;4(1):33-37. 10.2174/1874279301004010033
5. Walmsley R. World prison population list (Twelfth Edition). 2018. https://www.prisonstudies.org/sites/default/files/resources/downloads/wp...
6. United Nations. Basic principles for the treatment of prisoners, Adopted and proclaimed by General Assembly resolution 45/111 of 14 December 1990. New York: United Nations, 1990.
7. Li Y. Progress of prisoner's life and sanitation in China. Res Crime Reforma 2014(1):57-59.
Competing interests: No competing interests
The BMJ contacted the Ministry of Justice for comment on this story, and received the comment too late to include in the original copy.
The statement read: “Prisoners are able to access a range of healthcare services in custody including GP appointments, mental health and substance misuse support. Every effort is made to ensure inmates get to any necessary external appointments, while our capacity to escort prisoners has been boosted by the recruitment of 4,400 additional prison officers since 2016.”
Competing interests: No competing interests
Re: The prison service is still failing inmates’ healthcare needs
Dear Editor
In 2010, while working as a consultant colorectal surgeon in a private hospital in Harrow, I was unfairly convicted of the manslaughter of a patient who died under my care. I was sentenced to two and half years in prison and served half of this time behind bars in three of the toughest jails in this country. This conviction was overturned on appeal after I served the sentence. Earlier in my career, as a consultant surgeon in Hammersmith Hospital in west London, I had looked after patients from the nearby notorious HMP Wormwood Scrubs prison. I have therefore seen the care of prisoners from both aspects.
While I was in prison my left leg swelled spontaneously up to my knee and I was petrified I had a deep vein thrombosis (DVT). It took nearly a week for me to see someone in the prison health centre, despite daily visits to the unit office. The doctor refused to see me and after a long wait, I was passed over to a nurse. Even when I finally convinced her the matter was serious, I was not rushed to hospital but had to go through a series of searches to make sure I was not taking drugs or other contraband out of the prison.
When I was finally taken to the local A&E department, the two prison officers, in whose charge I was, paraded me in humiliating fashion in handcuffs through all the departments I attended and allowed me no privacy. The prison warders insisted on being present throughout all the examinations I underwent, including the ones where my genitals were exposed. Fortunately, I did not have a DVT, a life-threatening condition, but it took two weeks from when I first reported my symptoms for me to get that answer.
I had other encounters with the health service in all the prisons where I served, as I also suffered from hypertension. I agree with Stephen Armstrong (Health and Justice, 29 February) that prison healthcare is poor and even the Care Quality Commission has expressed concern about it. In my view one factor that contributes to this is the attitude of staff towards prisoners. I must say that I encountered some doctors and nurses who were polite and compassionate but this was not always the case. Some staff were rude to me and hurt my feelings when I was at my most vulnerable. In my first encounter with the nurse who saw me for my suspected DVT, the first question she asked me was: “Have been struck off the GMC register yet?”, once she realised that I was a doctor.
Such uncaring attitudes, I believe, are a major deterrent to the use of the service by prisoners. Prison is meant to take away the individual’s freedom, not their dignity or humanity. I have documented the entire experience in my memoir, “Did He Save Lives? A Surgeon’s Story” published by Sweetcroft Publishing and available from Amazon.
Competing interests: No competing interests