The spread of infectious diseases is a serious problem in prison systems worldwide, with prisoners often many times more likely to be living with Tuberculosis, HIV or hepatitis than a person in the broader community. Alongside the generally poor and unsanitary conditions prevalent in prisons, one major route to infection is unsafe injecting drug use. Yet very few jurisdictions permit or provide harm reduction services (such as clean needles) in prisons. In this blog, Gen Sander, Human Rights Research Analyst at Harm Reduction International, says that states have both a public health duty and a human rights obligation to tackle spread of infectious disease in closed settings.
The spread of infectious diseases affects the population at large, but global data reveal it is an especially acute problem in prison systems worldwide. Tuberculosis (TB) rates, for example, can be up to 81 times higher in prisons than in the general population, while global human immunodeficiency virus (HIV) prevalence is up to 50 times higher among the prison population in some countries. At the same time, one in four detainees worldwide have been found to be living with hepatitis C (HCV), a figure that becomes even more unsettling when compared to, for example, the rate of HCV in the broader community in the WHO Europe region, which is one in every 50.
Prisons represent high-risk environments for the transmission of these diseases for a number of reasons. For one, members of poor and marginalised groups are overrepresented in the prison population worldwide. Many of the factors that make these groups more likely to be incarcerated, including poverty and discrimination, also mean that they tend to carry a disproportionately high burden of disease and ill-health, including higher rates of TB, HIV and HCV.
Punitive approaches to drugs have also led to the mass incarceration of people who use drugs. According to global figures, 10-48% of male and 30-60% of female prisoners are using or dependent on illicit drugs on entry to prison, and every sixth prisoner is thought to be a so-called ‘problem drug user’. In Europe, crimes related to the use, possession or supply of illicit drugs are the main reason for incarceration of between 10% and 25% of all sentenced prisoners.
Despite being prohibited, drugs always find their way into prisons. With people who inject drugs comprising about one third to one half of prison populations, and because needles and syringes are so scarce, levels of unsafe injecting drug use are high. Prisoners are often forced to make their own injecting equipment, and sharing or reusing occurs out of basic necessity. There are reports of up to 15 or 20 individuals injecting with the same equipment in prison, which is the easiest and most effective way of transmitting HIV and HCV.
Intensifying the risk of disease transmission or health decline are the substandard prison conditions in which prisoners are all too often accommodated. Overcrowding, poor sanitary conditions, inadequate ventilation, extreme temperatures, inadequate means for maintaining personal hygiene, lack of access to clean drinking water, and nutritionally inadequate food are common in prisons and contribute to high rates of morbidity and mortality. Furthermore, these poor conditions generally exist within a climate of hostility, humiliation and discrimination that creates obstacles to accessing necessary health care services, which are more often than not weak, inadequate or simply absent.
There is mounting evidence that one of the most effective ways of preventing the spread of infectious diseases in prisons in through the provision of harm reduction services, such as needle and syringe programmes (NSPs) and opioid substitution therapy (OST). Yet the availability of these life-saving services remains extremely limited in comparison to what is available in the community. For example, while 90 and 80 countries or territories implement NSPs and OST respectively in the broader community, only seven and 43 implement them in at least one prison.
Because the vast majority of prisoners eventually return to the broader community, prison health is intimately connected to public health. There is no question that in order to reach global targets on HIV, TB and HCV, harm reduction services will need to be significantly scaled up in prisons.
But preventing the spread of infectious diseases in prisons isn’t just a public health concern, it’s also a human rights imperative. Prisoners retain their human rights during incarceration, including the right to health, the right to life, freedom from torture and ill treatment, and freedom from discrimination. These rights impose a legal duty of care on states to protect the lives, health and well being of persons deprived of their liberty.
Holding authorities to account for their human rights and public health obligations, however, is always more challenging when it comes to closed settings. This is where the work of prison monitoring bodies – such as the UN Subcommittee for Prevention of Torture, the European Committee for the Prevention of Torture and National Preventive Mechanisms (NPMs) – is so crucial. Armed with the most extensive mandates to prevent ill treatment and granted unrestricted access, prison monitoring bodies are in a unique position to help promote and protect prisoners’ health and human rights through consistent monitoring of issues relating to infectious diseases.
Harm Reduction International (HRI) is currently undertaking a European Commission co-funded project that aims to strengthen infectious disease monitoring in prisons. This is the first of two posts on the topic. For more information, please visit HRI’s website.
About the author
Gen Sander joined Harm Reduction International as a human rights analyst in 2014. Prior to that, she was a senior researcher at the University of Essex Human Rights Centre, where she taught a module on human rights and worked with Prof. Paul Hunt, former UN Special Rapporteur on the right to health, on issues relating to health and human rights. She has also been a consultant for the WHO and the Independent Expert Review Group (iERG) on right to health issues, and has worked with various human rights NGOs in Canada, Europe and the Middle East.
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