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The vilest deeds, like poison weeds,
Bloom well in prison air;
Oscar Wilde, "The Ballad of Reading Gaol", 1896
More than two years ago, an editorial in this Journal stated: "Prison
authorities and governments must realise that the responsibility
for the infection of a prisoner with a bloodborne virus, because means
for prevention were not available within the prison, rests with
them."1
Sadly, there is little improvement to report. Bleach, for cleaning
injecting equipment, has been made available since 1995 in most
custodial systems. Condoms and dental dams were first introduced
into New South Wales prisons in 1997, but are currently provided to
prison inmates in only three jurisdictions. The methadone
maintenance program began in New South Wales in 1986 and will soon
expand through trials in Queensland and South Australian prisons.
Methadone withdrawal regimens are provided in Victorian prisons.
Three articles in this issue of the Journal highlight some of the
continuing health risks faced by inmates in Australian
prisons.2-4 These reports raise
concerns that inmates are still placed at unnecessary risk by not
being offered opportunities to minimise infection with bloodborne
viruses, and complement reports of transmission of a wide range of
contagious diseases from custodial systems in other
countries.5,6 McDonald et al report that control of HIV transmission in the community has
protected prisoners, with sustained low levels of identified
HIV-antibody-positive individuals entering Australian
prisons.2
The evidence for transmission in prison of HIV presented by Dolan and
Wodak3 and of
hepatitis C by Haber et al4 indicate
that custodial authorities' commitment to zero tolerance would be
better applied to the transmission of these viruses rather than to
illicit drugs and injecting equipment within prison. Despite
universal support for zero tolerance among Australian custodial
authorities, drug use continues after reception into prison. In New
South Wales, in 1996, 21% of men and 32% of women reported that they had
injected drugs in prison; 18% of men and 11% of women did so in the week
before interview. Of those who had injected in prison, 69% of men and
64% of women reported that they had shared needles.7
Zero tolerance is not protecting the lives of prison inmates. Between
1980 and 1998, there were 86 deaths in custody in Australian prisons
that were classified as accidents -- overwhelmingly drug
related.8 The fear of having illicit
drugs confiscated leads to "binge" use. Irregular use and
inexperience in assessing dosage and drug purity readily lead to
overdosing. Needles and syringes have a higher probability of being
infectious in the prison environment, as the prevalence of
bloodborne viruses is so high. An environment that inadvertently
encourages sharing of equipment actually promotes transmission of
bloodborne viruses.
Consider the ability of zero tolerance in providing prison workers
with a safe work environment. It might be argued that the restrictions
on needles and syringes make prisons a safer workplace, but the
evidence for this is not compelling. The malicious stabbing of a
prison officer with a syringe filled with HIV-contaminated blood in
1990 occurred when needles and syringes were prohibited items.
The principle of harm minimisation guides public health efforts to
control bloodborne viruses in the community. Why should this not also
be applied in the prison environment?
No measures should be spared to provide a safer environment for prison
inmates, and health and custodial staff. A full range of options need
to be available for custodial and health authorities to offer
inmates, including drug-free prisons, methadone maintenance and
consideration of therapeutic prescription of injectable drugs.
With controlled heroin prescribing and provision of syringes and
needles, the trafficking of contaminated equipment should
decrease. In Switzerland and Germany, programs for therapeutic
heroin prescription in a few prisons are currently being
evaluated.9
These initiatives will require strong advocates for the health of
prison inmates and the general community. For this to occur, prison
health services must be brought into the mainstream of clinical
medicine and public health.10 This can be accomplished
by granting autonomy to prison health authorities, by fostering ties
between correctional health programs and academic and public health
departments, and by funding research that addresses public policy
questions peculiar to the prison environment.11
To accelerate the uniform introduction of health protective
measures throughout Australian prison systems, correctional
health programs need standards against which their performance can
be monitored. Australian prison authorities have devised uniform
guidelines of operation, but they are not health standards, and they
are not enforceable.12
There are currently over 19 000 inmates in Australian prisons, and the
number is increasing by more than 7% each year.13 The importance of the
health of prisoners and its impact on the general community can only
grow. Since March 1999, the Australian Red Cross has identified
imprisonment in the previous 12 months as an unacceptable risk factor
for blood donation.14
Two years have been squandered. The evidence mounts that prisons pose
a health risk to inmates, to workers within prisons, and to the general
community. The statement by Crofts bears repeating: "Prison
authorities and governments must realise that the responsibility . .
. rests with them."1
Michael H Levy
Director, Population Health, Corrections Health Service
Matraville, NSW, and Department of Public Health and Community
Medicine
University of Sydney
- Crofts N. A cruel and unusual punishment. Med J Aust 1997;
166: 116.
-
McDonald AM, Ryan J, Brown PR, et al. HIV prevalence at reception
into Australian prisons, 1991-1997. Med J Aust 1999; 171:
18-21.
-
Dolan K, Wodak A. HIV transmission in a prison system in an
Australian State. Med J Aust 1999; 171: 14-17.
-
Haber PS, Parsons SJ, Harper SE, et al. Transmission of hepatitis C
within Australian prisons. Med J Aust 1999; 171: 31-33.
-
Taylor A, Goldberg D, Emslie J, et al. Outbreak of HIV infection in a
Scottish prison. BMJ 1995; 310: 289-292.
-
Valway SE, Richards SB, Kovacovich J, et al. Outbreak of
multi-drug-resistant tuberculosis in a New York State prison, 1991.
Am J Epidemiol 1994; 140: 113-122.
-
Preliminary findings of the Inmate Health Survey. Sydney:
Corrections Health Service, 1997.
-
Dalton V. Prison homicide in Australia: 1980 to 1998. Trends and
issues in crime and criminal justice. No. 103. Canberra: Australian
Institute of Criminology, 1999.
-
Vumbuca G. Finding a better way. Canberra: The Winston Churchill
Memorial Trust of Australia, 1999.
-
Prisoners: an end to second class health care? BMJ 1999;
318: 954-955.
-
Correction of attitudes to prison medicine [editorial].
Lancet 1998; 351: 1371.
-
Standard Guidelines for Corrections in Australia 1996. The
Corrective Services Ministers' Conference. 1995.
-
Australian Bureau of Statistics. Corrective Services,
Australia. Canberra: ABS, 1998. (Catalogue no. 4512.0.)
-
Australian Red Cross Blood Service. Donor Questionnaire. March
1999.
©MJA 1999
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