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Places of care Interviews

The right to healthcare in prison

Amongst overcrowding, language barriers and gender medicine

Interview with Nerina Dirindin and Fabio Gui

National Forum for the Right to Health of Persons Deprived of Liberty

By May 2020July 17th, 2020No Comments
Photo by Lorenzo De Simone

The Italian Constitution states that prisoners and free citizens have equal rights to healthcare, but is this really the case?

The institution of the Italian National Healthcare Service (SSN, or Servizio Sanitario Nazionale) in 1978 integrated the text of the Italian Constitution, thus introducing a universal health service. It’s no small thing, even though we often forget that. However, this concept did not apply to prisons because the implementation of healthcare services in detention sites was left for a later time. The SSN effectively managed the healthcare system of the whole territory except for penitentiaries, while these remained under the authority of the Ministry of Justice. We should also consider that in 2000 the management of prevention and substance abuse services was transferred from the Ministry of Justice to the regions. This led to the provision of addiction support services and – whenever ASLs (or Agenzie Sanitarie Locali, Local Health Authorities) offered these – also prevention services inside prisons. Only after the 2008 DPCM (Prime Ministerial Decree) the SSN became indefinitely the body responsible for the provision of ASLs services in prisons. The goal of the reform was to offer prisoners healthcare services, as consistently as possible, and regional projects (screening, prevention etc.) led by the needs of the incarcerated. Frankly, the service consistency outlined by the DPCM around prevention, diagnosis, treatment and rehabilitation is yet to be reached, for many reasons, like insufficient budgets and because some regions were busy with restructuring plans or were organised differently. Furthermore, 2008 started with a tangibly critical context. For years the Ministry of Justice had been investing progressively less resources into prison healthcare so when the ASLs took over the services they were often faced with obsolete or unregulated healthcare facilities, complex staffing situations and most importantly the issue of prison overcrowding- conditions that speak of a started path that requires attentive monitoring.

An efficient prison system must consider the needs of prisoners with serious physical disabilities or pathologies. How much does this happen in reality?

The healthcare needs of prisoners- in the various legal settings- are dependent on the physicians and the relevant legal authorities. In some situations, the Court declares the incarceration incompatible with certain pathologies, but often this fair measure faces gaps in the social or family network of the individual so it does not offer continuity of care. We’ve also had ill prisoners that, according to both the Court and the physicians, could not access services because of homelessness, no right to reside or the lack of family support. Finally, what can also happen is that, despite the regional healthcare service declaring incarceration as incompatible, the Court considers the prisoner dangerous to the public, so he remains in prison anyway. In short, different interpretations, competencies, responsibilities and rights are at play when it comes to the prisoners’ health. That’s also the case because the prison is still isolated from the network of support services that often views it as a “social dumpster”. Those ending up in prison are frequently people that pose a low risk to society but create a great demand on support services.

What are the most common pathologies in prisons?

I would say that the most common condition in prisons is overcrowding, which favours the onset of all the other diseases, especially mental health issues. Then you have conditions linked with increased contact or poor hygiene- meaning personal hygiene and often of the poor cleanliness of the space. Think about the mattresses and bedding, the shower rooms and the lack of airflow, but also the prison infrastructure itself, the decay and the fact that just a few of them follow the directive around separating the healthcare spaces from the social areas. Additionally, a third of the prisoners suffers with some form of addiction, or pathologies connected with leading a “poor lifestyle”, so issues with tooth care, nutrition and liver disease. There are also conditions linked with age: for example, the prevalence of elderly prisoners led to an increase of illnesses impacting the cardiovascular and the digestive system. Finally, there are also issues around abuse of substances such as sleeping medication and tranquilisers. I would like to add that it’s challenging to provide continuity of care to those prisoners that, despite starting a diagnostic or treatment process, get transferred to another prison, due to displacement measures against overcrowding, or because of security or legal reasons.

The most common condition in prisons is overcrowding, which favours the onset of all the other diseases.

What are the challenges for the relationship between healthcare workers and prisoners? Whenever you are dealing with an immigrant prisoner is an interpreter present?

The primary issue is that patients cannot choose their doctor in prison as this is often imposed by the healthcare service present or by the legal authority. It is challenging to establish trust. Additionally, one third of prisoners are foreigners, so how can you establish a rapport of trust with a doctor when you have to overcome the language barrier as well? How can you take their medical history? Whenever the interpreter, normally required by regulations, is actually not available you have to seek alternative solutions. There are often situations where the first generation of prisoners helps with interpreting and cultural mediation. You can imagine how delicate such a setting can be, not to mention the issues around confidentiality.

How are medications managed inside prisons? Are there pharmaceutical distribution points?

Regulations state that every penitentiary must offer a series of healthcare services including pharmacy distribution points with the same accessibility to over-the-counter drugs and general medication that free citizens benefit from. However, the reality is that there are differences among ASLs as well as prisons. Some penitentiaries have direct access to the hospital pharmacies due to the structure of their healthcare service, while others are connected to the pharmacies of the territory where sometimes provision can become a problem. The real issue is that many drugs need to be purchased – and often volunteers or the prison chaplaincy take care of that – for example dermatological medications, which are crucial for life in a community where it’s difficult to keep social distancing.

Is it feasible to take in consideration the healthcare services need of so-called gender medicine, which is linked to certain aspects of women’s health?

Women are a minority amongst prisoners (4-5%) and they present specific needs. Many are non-nationals, several are Roma and often their children are in the penitentiary with them. A lot of female prisoners suffer with extremely difficult mental health and social conditions, so the sole presence of the specialist is not sufficient. What’s missing is the correct management of specific needs that women have during certain times of their life. I think about, for example, prevention tests for women’s pathologies or physical and mental health issues resulting from menopause. The management of women’s conditions in prison requires more attention, all-round. I would also like to mention a very vulnerable group in the prison population: transsexual prisoners. They are detained in male penitentiaries and in addition to the more common prison issues they also suffer due to the lack of acknowledgment of their transition from one gender to the other. It is very relevant to consider the psychological impact of this: transsexual prisoners often express their internal struggle, resulting from being incarcerated, with self-harming behaviours, which often makes us fear for their life. I would say that the response to this is only partial and is given with great difficulty. What makes a difference is the sensitivity of the healthcare staff and the care they provide inside the walls of the prison.

What’s missing is the correct management of specific needs that women have during certain times of their life.

Does prevention and education work around healthy lifestyle choices take place in prisons?

Often, we work in situations of overcrowding, prison deterioration and with no separation between night and day areas, so the issue of smoking becomes secondary, not because it’s not relevant but because it’s viewed in the context of the general decay. If we wanted to discuss healthy lifestyle choices, we would have to close the prison and redesign it first. Sometimes the smoking ban creates an issue around access to healthcare services. For example, in Rome healthcare structures for prisoners have a smoking ban during the period of hospitalisation, in line with the European regulations. Whether that’s right or not we know about some prisoners who did not accept to be hospitalised because of this restriction.

A few years ago, the WHO introduced the phrase “healthy prison” to contrast the notion, proven by some studies, that it’s often the prison space itself to cause the illness. Do you agree with that?

Yes, we agree with that because the prison, just like any place designed for promiscuity, is a pathogenic element. It is so in daily life the moment you must ask for permission to make a phone call or to take a shower. Some say that incarceration could infantilise prisoners because it takes away all responsibilities and manages and directs everything. However, the paradox is that it can also have a useful role because it intercepts a more fragile, vulnerable and marginal population group and can then offer them health and treatment pathways. This group could become part of a new concept of public health and social care that includes reintegration and rehabilitation. Therefore, it all depends on how the prison is viewed. If it’s seen as a box to put people in that are having issues, then yes, it becomes a pathological element. Nevertheless, it could also become an opportunity. For example, some people could get an early diagnosis after their incarceration because they have tests done and they pay more attention to their health conditions. Then we go back to the 2008 reform that put at the centre prevention, diagnosis and treatment. Is it a cultural reform? If so, we would definitively need that because it means giving back to prisoners, at the end of their incarceration, newfound responsibilities and self-awareness.

The prison, just like any space designed for promiscuity, is a pathogenic element.

How is the coronavirus emergency being managed in prisons?

Initially the emergency was not well managed. Prisoners were asked to restrict their movements with self-isolation, as a containment and prevention strategy. It’s a plan that requires the adhesion, participation and awareness of citizens. However, the information that the family visits would be suspended came from the television news rather than the authorities. This triggered worry, panic and anxiety in most prisoners. It is challenging to maintain social distancing in prison given that there are 10,000 people more than the maximum capacity of the facilities. It’s difficult to empower people to take care of their health whenever they are sharing a cell with 6, 7 or 8 others who are in the conditions described above. How come they then decide that the only contact to avoid it’s solely with the family? It was decided that in order to deal with the issue the characteristics of the individual prisons would have to be considered. Even though the decisions management made were sensible they were not communicated to the prison workers. They also did not consider the necessary timelines to put the strategies in place, particularly the technical aspects, and they did not engage the prisoners and the associations. They were decisions that prisons were subjected to rather than being an active part of their making. Suspending prison visits is an important matter and it necessarily requires the adhesion, participation and awareness of the detained citizens- in this case requiring prisoners to hold a responsibility rather than infantilising them. Unfortunately, prisons were only talked about when riots and violence took place, just like the theme of substance abuse in prisons was just discussed when deaths by overdose happened. That’s unacceptable. You cannot put prisons in the spotlight solely during emergencies. We should remember that prisoners are first citizens and that they should benefit from the same right to health as all of the other citizens.