Australian prisons are still health risks

We must provide a safer environment for prison inmates and staff

MJA 1999; 171: 7-8

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 Make a comment Home | Issues | MJA shop | Terms of use | MJA Careers | More... | Contact | Topics | Search | RSS  mja.com.au | The Medical Journal of Australia   Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1999 Medical Journal of Australia. We appreciate your comments.