All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to

reproduce or translate its publications, in part or in full.

The designations employed and the presentation of the material in this publication do not imply the expression of any

opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city

or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or

recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors

and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this

publication. However, the published material is being distributed without warranty of any kind, either express or implied.

The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health

Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not

necessarily represent the decisions or the stated policy of the World Health Organization.

This book outlines important suggestions by international experts to improve the health of those in prison and to reduce

both the health risks and risks to society of imprisonment. In particular, it aims to facilitate better prison health practices

in the fields of: (i) human rights and medical ethics, (ii) communicable diseases, (iii) noncommunicable diseases, (iv) oral

health, (v) risk factors, (vi) vulnerable groups and (vii) prison health management. It is aimed at professional staff at all

levels of responsibility for the health and well-being of detainees and at people with political responsibility. The term

“prison” covers all institutions where a state holds people deprived of their liberty.

HEALTHCARE SYSTEMS

HUMAN RIGHTS

MEDICAL ETHICS

PREVENTION

PRISONERS

PRISONS

VIOLENCE

Address requests about publications of the WHO Regional Office for Europe to:

Publications

WHO Regional Office for Europe

UN City, Marmorvej 51

DK-2100 Copenhagen O, Denmark

Alternatively, complete an online request form for documentation, health information, or for permission to

quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest).

ISBN: 978 92 890 5059 3

Cover: Photo by Maxim Dondyuk, www.maximdondyuk.com

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

The duty of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Why prison health is important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Difficulties with isolation of services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Essential components of a prison health service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Good governance for prison health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Basic principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Relationship between the prisoner and health care staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Organization of prison health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

European Prison Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Health care staff in prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Disciplinary measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Physical restraint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Intimate body searches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Prisoners who stop eating or go on hunger strikes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Torture and inhumane or degrading treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Definitions of violence in prison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Violence in prisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Sexual violence in prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Torture and ill-treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Prevention of violence in prisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Prisons and health

The role of the prison health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

What is solitary confinement?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

How does solitary confinement affect health and well-being. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Particularly vulnerable groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Long-term effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

When and why is solitary confinement used in contemporary penal systems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

How do international law and human rights bodies view solitary confinement?. . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Defining pre-trial detention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Challenges of pre-trial detention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Improving health conditions at the pre-trial stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Bloodborne viruses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

The issues or challenges within the prison environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

A comprehensive approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

The evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Nutrition support and diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Continuity of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Palliative care/compassionate release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Quality assurance and monitoring of, and interventions for, HIV and hepatitis C and D . . . . . . . . . . . . . . . . . . . . . .54

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Transmission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Case-finding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Contents

Screening strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Clinical features of TB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

MDR-TB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

TB/HIV co-infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

TB infection control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

Advocacy, communication and social mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

Continuum of care for released prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

Measles, mumps and rubella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Viral hepatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Tetanus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Diphtheria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

Sexually transmitted infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

Ectoparasites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

Vaccination, quarantine and personal hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Burden of disease and risk factors for NCDs in prisoners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Challenges in providing appropriate prevention and care to prisoners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

Human and prisoners’ rights and basic needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

Equivalence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Prevalence of poor mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Complexity and multiple needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Illness and social focus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89

The impact of prison on mental health and well-being. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89

Prisoners’ views of their needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89

Prisoners’ views on what constitutes a good mental health service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

Mental health awareness in the prison system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

Prisoners and their families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

Diagnosis and assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Screening and assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Treatment in prison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

Personality disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Continuity of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

Meeting the needs of different groups in the prison population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

The recovery approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

The roles of peers and mentors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

Diversion and liaison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Oral health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

General impact of general health on oral health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Utilization of the prison dental service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Provision of prison dental services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100

Accessibility of dental services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100

Good clinical practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Oral health promotion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

The dental team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102

Commissioning prison dental services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107

Drug use among the prison population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107

The social characteristics of drug treatment clients in prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

Health problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

Methodological limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Prevention, treatment, harm reduction and aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115

What works?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116

Contents

Psychosocial drug treatment and pharmacological approaches as complementary measures

in a comprehensive package of drug services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117

Opioid substitution treatment in custodial settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119

Harm reduction programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134

Alcohol in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134

Alcohol and crime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134

Alcohol problems in prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135

Effective detection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135

Effective interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135

Integrated care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135

Issues and challenges with alcohol problems in prisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

Main issues: prevalence and exposure to SHS in prison settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

WHO Framework Convention on Tobacco Control (WHO FCTC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139

Reasons for the high prevalence of tobacco use in prisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139

Significance of tobacco use in prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139

Tobacco use by prison staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140

Addressing the smoking issue in prisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Outline of a tobacco control policy in German prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151

International standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151

General principles of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152

Treatment in prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152

A suitable prison or place of detention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

A proper manner of detention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152

Some important messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152

Prisoners with physical disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Ethnic minorities and indigenous peoples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

Foreign prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

Prisons and health

Lesbian, gay, bisexual and transgender prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155

Older prisoners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159

Violence and abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159

Substance use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160

Mental health issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160

Infectious diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161

Dental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162

Children of women in prison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162

Organization of health care for women in prison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165

Accelerated ageing: who is old in prison?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

Geriatric medicine and the multimorbidity model of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166

Polypharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166

Geriatric syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167

Functional status and environmental mismatch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168

Mental health issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168

End of life care and death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168

Ageing and re-entry into the community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173

The purpose of health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173

The experience of prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174

The components of primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174

The primary care journey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174

Prison health care resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175

Common problems encountered in primary care practice in prisons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175

Building blocks for primary care in prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176

Measuring performance in health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176

Competencies of and support for prison clinical staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179

Contents

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180

Challenges and opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180

The health promotion needs of prisoners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

A whole-prison approach: a vision for creating a health-promoting prison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183

Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185

Health and the prison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185

The stressful workplace. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185

Risk factors and stress among prison employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186

Health risk factors for prison staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

Health promotion programmes to support employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187

Health awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187

Prison staff training in health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188

Managers, leaders and decision-making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188

Maintaining professional standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Clinical governance and performance monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189

Prisons and health

viii

The WHO Regional Office for Europe gratefully

acknowledges the work of the authors in writing this guide

to the most essential areas of prison health. Thanks are

also given to Dr Alex Gatherer and Dr Robert Greifinger

for reviewing the guide and for their valuable comments.

The document was edited by Mr Stefan Enggist,

Technical Officer, Health in Prisons, Dr Lars Moller,

Programme Manager, Dr Gauden Galea, Director, and

Ms Caroline Udesen, WHO consultant in the Division

of Noncommunicable Diseases and Life-course, WHO

Regional Office for Europe.

A special thanks to Ms Brenda van den Bergh for her

assistance at the start of the project.

The Regional Office is grateful to the Swiss Federal Office

for Public Health, the International Committee of the Red

Cross, the Pompidou Group of the Council of Europe and

the United Nations Office on Drugs and Crime for their

conceptual and financial support in the production of this

document.

ix

About the authors

Health, WHO Regional Office for Europe, Copenhagen,

Denmark

California San Francisco, San Francisco, United States of

America

Justice Reform, London, United Kingdom

Lead and Research & Development Officer, Healthy

Settings Unit, University of Central Lancashire, Preston,

United Kingdom

STIs and Viral Hepatitis, WHO Regional Office for Europe,

Copenhagen, Denmark

Committee of the Red Cross, Geneva, Switzerland

Tuberculosis and M/XDR-TB, WHO Regional Office for

Europe, Copenhagen, Denmark

London, London, United Kingdom

Programme, Open Society Foundations, London, United

Kingdom

M/XDR-TB, WHO Regional Office for Europe, Copenhagen,

Denmark

Sustainability, Director, Healthy Settings Unit, University

of Central Lancashire, Preston, United Kingdom

Programme, Centre for Mental Health, London, United

Kingdom

WHO Regional Office for Europe, Copenhagen, Denmark

NHS Health Scotland, United Kingdom

General Secretariat of Penitentiary Institutions, Ministry

of the Interior, Madrid, Spain

(deceased)

Centre for Drugs and Drug Addiction, Lisbon, Portugal

and Offender Health, Information Services Division, NHS

National Services Scotland, United Kingdom

Prison, Belfast, Northern Ireland

Health England, London, United Kingdom

New York, United States of America

Nations Office on Drugs and Crime, Vienna, Austria

Collaborating Centre for Health and Prisons, Public Health

England, United Kingdom

Program, Open Society Foundations, New York, United

States of America

Treatment of Drug Addiction, University Psychiatric

Hospital, Ljubljana, Slovenia, President, South Eastern

European Adriatic Addiction Treatment Network

Collaborating Centre for Prison Health and Education,

Vancouver, Canada

– Danish Institute Against Torture, Copenhagen, Denmark

Prisons and health

x

Drugs, WHO Regional Office for Europe, Copenhagen,

Denmark

Monitoring Centre for Drug and Drug Addiction, Lisbon,

Portugal

Monitoring Centre for Drug and Drug Addiction, Lisbon,

Portugal

University of Oxford, Oxford, United Kingdom

for the Prevention of Torture, Berne, Switzerland

Universitaire Hospitalier Vaudois, Lausanne, Switzerland

Switzerland

Centre for Drugs and Drug Addiction, Lisbon, Portugal

Confinement [website] and Research Fellow, Centre for

Criminology, University of Oxford, Oxford, United Kingdom

ADL activites of daily living

ART antiretroviral therapy

ARV antiretroviral

CPT European Committee for the Prevention of

Torture and Inhuman or Degrading Treatment

or Punishment

DOTS directly observed treatment, short-course

DST drug susceptibility testing

EMCDDA European Monitoring Centre for Drugs and

Drug Addiction

EU European Union

HBsAg hepatitis B surface antigen

HBV hepatitis B virus

HCV hepatitis C virus

HIPP Health in Prisons Programme

IADL instrumental activities of daily living

IGRA interferon gamma release assay

Research, University of Applied Sciences in Frankfurt,

Frankfurt, Germany

Belgium

International Harm Reduction Program, Open Society

Foundations, New York, United States of America

Patterns of Drug Use and Data Management, European

Monitoring Centre on Drugs and Drug Addiction, Lisbon,

Portugal

European Monitoring Centre for Drugs and Drug Addiction,

Lisbon, Portugal

Geriatrics, University of California San Francisco, San

Francisco, United States of America

National Institute of Forensic Psychiatry and Psychology,

Utrecht, Netherlands

IPT isoniazid preventive therapy

LGBT lesbian, gay, bisexual and transgender

MDR multidrug-resistant TB

NCD noncommunicable diseases

NTP national TB programme

OST opioid substitution therapy

RNA ribonucleic acid

SHS second-hand smoke

SIZO sledstvennyj izoljator [Russian pre-trial

detention centre]

STIs sexually-transmitted infections

TB tuberculosis

UNAIDS Joint United National Programme on HIV/

AIDS

UNODC United Nations Office on Drugs and Crime

XDR extensively drug-resistant TB

xi

Foreword

Zsuzsanna Jakab

WHO Regional Director for Europe

14

Prisons and health

15

1

• The state has a special duty of care for those in places

of detention which should cover safety, basic needs

and recognition of human rights, including the right to

health.

• A primary health care service in prisons must be

provided with staff, resources and facilities of at least

the same standard as those available in the community.

This principle of equivalence is an important measure

of the adequacy of health care provision in places of detention.

• All health staff should have complete professional

independence and should preferably be employed by a

health authority. Their right to practise their profession

within their professional codes of conduct and ethical

rules should be clearly understood and accepted.

• It is important that all staff working in prisons accept

that to the health team, prisoners are patients and

must be treated as such. The duty of care placed on

professional staff is the same whether the patient is

at liberty or in prison.

• The prisoner as patient has the right to confidentiality

and to treatment and care that is subject to informed consent.

• The importance of initial health screening and

evaluation must be recognized and the best possible

service should be provided. All staff involved should be

aware of the benefits of diversion to other institutions

for those prisoners who need to be in special facilities.

• Continuity of care is a crucial element of a sustainable

prison health service. Prison health staff should

make arrangements for continuous access to care on

transfer or on release, which should be facilitated by

prison management.

• Prison services have a responsibility to ensure that

prisoners are not exposed to hazards likely to injure their health.

• Health in prisons is too important to be left solely to

the health team. All staff working in prisons should

have further training in health issues so that they

have a better understanding of what the health team

is doing and can support those efforts through their

duties concerning the prison environment and regimes.

• Health resilience is an important aim of prison health

care and an important contribution towards successful

resettlement after discharge and to the reduction of

health inequalities.

• A prison health service should be seen as helping

to build a healthier society. An element of this is to

support, where possible, the work of the prison staff

in encouraging changes in attitude and behaviour with

the objective of a crime-free society.

• Prison health services should not be isolated but

should be integrated into regional and national health systems.

In 1994, when it was first suggested to the WHO Regional

Office for Europe that special attention should be given to

the health of those in prisons and other places of detention,

the Regional Director was Dr Jo E. Asvall, whose special

enthusiasm was for health for all. Research at that time

was drawing attention to tuberculosis (TB) and HIV/AIDS

in prisons. It was clear that prisoners were a vulnerable

group drawn from those parts of society which were hard

to reach as regards health. The Region was leading the

world in the settings approach to promoting health, and

there was a strong case being made that prisons were

a suitable setting, different from health-promoting cities

and schools but open to the same holistic approaches that

were so successful in daily living settings. Furthermore, in

most countries, prison health was the responsibility of the

ministry of justice or the ministry of the interior and was

thus excluded from any influence from WHO working with

the ministry of health.

In 1995, WHO and the United Kingdom organized a pilot

meeting of some eight countries and various experts

to discuss the proposal to establish a network for the

exchange of experience in tackling health problems in

prisons. The network, known as the WHO Health in Prisons

Programme (HIPP), which developed from that pilot now

includes most of the Member States in the Region. The

purpose of the network is to exchange experience in

tackling the health issues facing prisoners and prisons

and to produce consensual statements of advice. The

absence of a single publication drawing together advice

from experts and members of HIPP led, in 2007, to the

publication of the first edition of this guide.

There are several unique factors pertaining to people

remanded in custody by a judicial authority or deprived

of their liberty following conviction. The first is that

2

Prisons and health

the detaining authority has to assume a duty of care

for them, that is, a comprehensive obligation to meet

at least their basic needs. The second is that prisoners

are entirely dependent on the staff of prisons and

detention centres for all aspects of their daily lives,

as well as for protection and safety. This dependence

must be understood by the staff since they share the

duty of care with their employing authority, which should

influence their attitude and approach. The third factor is

that detainees retain all human rights other than their

freedom. Their right to health is in no way diminished by

their detention.

There are two other compelling reasons for providing

health care in prisons. First is the importance of prison

health to public health in general. Prison populations

contain a high prevalence of people with serious and often

life-threatening conditions. Sooner or later most prisoners

will return to the community, carrying back with them new

diseases and untreated conditions that may pose a threat

to community health and add to the burden of disease in

the community. Thus there is a compelling interest on the

part of society that this vulnerable group receive health

protection and treatment for any ill health.

The second reason is society’s commitment to social

justice. Healthy societies have a strong sense of fair

play: those involved in the provision of health care are

committed to reducing health inequalities as a significant

contribution to health for all. It is a fact that the majority

of prisoners come from the poorest parts of society, with

deficiencies in education and employment experience.

Their admission to prison can be the first time they have

had a settled life with adequate nutrition and a chance to

reduce their vulnerability to ill health and social failure.

Prison health care can play an important role in reducing

health inequalities.

All this underlines the need for governments to give a

degree of priority to health in prisons. First, they should

meet their duty of care for those deprived of their liberty.

Second, they should respect prisoners’ human rights, aid

the protection of their health and contribute to public

health as a whole, thus making a major contribution

towards reducing health inequalities in a vulnerable part

of the population while society awaits the effects of

action on the broader social determinants of health.

It is not, however, easy to provide health care in prisons

which by their nature are designed for safe custody and

provided with regimes that have necessarily developed

around questions of security.

One of the early and important lessons learned by

the network is that prison health services cannot be

adequately provided in isolation from other health

and social services. In 2003, the network agreed, and

WHO published, the Moscow Declaration, which called

attention to the need for prison health services to be

integrated or work closely with public health services

has been further developed as part of WHO’s work with

health systems. It is now realized that prison health has

important implications for health governance as a whole.

A modern prison health service takes as its working

method the “health in all policies” approach, in which

effective and systematic action for the improvement of

health genuinely uses all available measures in all policy

fields. In 2013, WHO and the United Nations Office on

Drugs and Crime (UNODC) published a policy brief on the

as other people;

• prisoners generally come from socially disadvantaged

segments of the community and carry a higher burden

of communicable and noncommunicable diseases

compared with the general population;

• prisons are settings with high risks of disease;

because their inhabitants continuously exchange

with outside communities, they present a complex

and difficult challenge for public health, especially

where communicable diseases such as HIV or TB are

concerned;

• states have a special, sovereign duty of care for

prisoners: they are accountable for all avoidable health

impairments to prisoners caused by inadequate health

care measures or inadequate prison conditions with

regard to hygiene, catering, space, heating, lighting,

ventilation, physical activity and social contacts;

• prison health services should work to at least

the equivalent professional, ethical and technical

standards to those applying to public health services

in the community;

• prison health services should be provided exclusively

to care for prisoners and must never be involved in the

punishment of prisoners;

• prison health services should be fully independent

of prison administrations and liaise effectively with them;

• prison health services should be integrated into

national health policies and systems, including the

training and professional development of health care staff.

3

The essentials about prisons and health

Each of these aspects features strongly throughout this

guide, as they underpin the objectives of a prison health

service and support the motivation of the staff. This

overview aims to give a brief outline of prison health

services and their main features.

The prison service is the least known and understood of

all the public services despite its importance for society.

Where health is concerned, a lack of prison health care

can threaten public health and add to the health burden

on communities. By helping to build healthy communities,

a prison health service can help to avoid an increase in the

general burden of disease. Good prison health care will

also contribute to a reduction in reoffending after release.

The essential points can be summarized under four

headings:

• medical care

• health protection

• health promotion

• health resilience.

The first essential is the provision of medical care for

prisoners in need of it, which requires access to fully

trained doctors and nurses with a supply of modern

medicines and appropriate facilities, such as consultation

rooms, treatment rooms and short-stay beds with some

nursing supervision. The recruitment, retention and

continuing professional training of health care staff should

be arranged so as to create a dedicated and specialized

health service for people in detention. It is important to

maintain the professional interest of health staff, which is

more easily done when the prison service is not isolated

from the community health services and has good links to

specialist health services.

Health care should include the continuance of any

treatment started before admission, so the second

essential is a full assessment of a prisoner’s health and

related needs as soon as possible after admission. This

is important to ensure that the prisoner does not have a

medical condition that could affect the health of others,

such as TB, and that he/she is not a danger or threat

to him/herself or others. The initial health screening is

recognized as an extremely important phase in prison

health. It ensures that a good assessment of the health

status of the prisoner and other needs are noted so that

a personalized treatment and care programme can be

established with the health team and others. Importantly,

it draws attention to prisoners whose health needs are

too complex to be managed in that prison, so that steps

can be taken to move the prisoner to a more appropriate

institution. This is of great value to those with serious

mental illness and/or substance abuse problems, who

need to be transferred to a facility with specialized

expertise. Furthermore, as it offers the possibility to

establish evidence of ill-treatment, the initial health

screening constitutes a basic safeguard against torture

and any other kind of ill-treatment.

The core of prison health is a primary care service, along

the lines of primary care in the community. It is not easy

to provide such a service within prisons, as easy access

to health clinics is usually not possible. What is possible

is for a service to be designed, with the agreement of

the staff and the prisoners kept fully informed, to provide

prompt access to an appropriate level of care. This

includes training and retraining for prison staff in first aid

and the management of acute mental illness, and training

for non-health staff on how to access acute care when the

health care staff are not on site.

The prison health services must also have good access

to specialist and diagnostic health services, including

hospitals, since prison hospitals are often unable to meet

the standards of hospitals serving the population outside.

Access has to be carefully planned with prison staff. Plans

to meet this need must be made in advance and made

known to all staff. These will vary with national policies

and local circumstances. The arrangements should be

known to the prisoners.

Finally, for health care provision in prison to be

sustainable, prison health services should do their best

to make arrangements for continuity of care on the

transfer or release of prisoners. This requires continuing

communication between the health team and the

management of prisoners so that all steps can be planned

in time and all necessary information can be transferred

with the prisoner.

Governments have a responsibility to ensure health

protection, meaning that prisoners in their care are

not exposed to serious threats to their health. Many

prisons are old and often overcrowded, so this is quite a

challenge. Health training for all staff (as recommended

in Chapter 22) should include the social determinants of

health, the causes of disease and the determinants and

mechanisms of ill health. This should greatly increase their

understanding of what should be done for the maintenance

and protection of good health. The aim is for all prison staff

to work with the health care team so that prisoners are

discharged with better health and health resilience than

they had on admission to prison. A clear understanding of

4

Prisons and health

the expected roles of the health team and those of other

prison staff is important for good collaboration.

The key steps in protecting health include: a reduction

of hazards in the environment, a good health screening

service, attention to immediate health needs, proper

nutrition, exercise in the fresh air if possible, and two

important additions to the prison service: where possible,

a method of using peer groups in what some prisons have

developed as a listening service for drawing attention to

prisoners in need, and a good complaints service.

Health promotion is now regarded as an essential part of

primary health care. The provision of health information

in a manner that prisoners can understand remains an

important part of promoting health. But this is not enough

not on its own. Prisoners’ attitudes to health should be

assessed and encouraged, and help given to change

unhealthy behaviour such as tobacco use, substance

abuse and alcohol abuse.

Prison authorities should ensure that health promotion

services are available and that deficiencies, such as any

necessary immunizations, can be rectified in prison.

It is well recognized that admission to prison can create

considerable pain and distress. Nearly all prisoners are

challenged by their loss of freedom. Prison regimes leave

scant room for self-determination. This is one of the

greatest challenges in prisons, and one which should be

the subject of regular staff development and continuing

training. It is assumed that all prisoners with serious

mental illness are diverted to specialist care, but there

may be periods when such prisoners have to remain in

their prison. Staff need to be trained in the management

of these patients.

Prison authorities should be aware of the pressure on

staff from prisoners with special needs. Support for staff

and opportunities to discuss particular issues should be

part of the service provided. It is critically important to

maintain confidentiality in all prison health work; this

poses a particular challenge to prison staff, who often

feel they have a right to know.

All prisoners need assistance to cope with and

control the effects of imprisonment. They also need

better preparation for life after discharge. This latter

challenge involves the whole prison programme, so that

educational deficiencies are at least partially met, work

experience has been made available and social skills

have been greatly enhanced.

Health resilience can be an important part of the

rehabilitation and resettlement process. Only in this way,

with health teams working collaboratively with other staff

in the prison, can prison health care play a part in reducing

inequalities, reducing recidivism and helping to produce a

better and healthier community.

The management of prisons and places of detention has

become a difficult and challenging task. This is often

not recognized in government and society. The complex

and widely ranging needs of prisoners, combined with

their increasing awareness of their rights and greater

expectations as well as (in some countries) access to a

good complaints system and to legal assistance, play a

considerable part in how best to provide prison health

services.

The expert group advising the Regional Office on

the policy brief on the organization of prison health

concluded that:

• the management and coordination of all relevant

agencies and resources contributing to the health

and well-being of prisoners is a whole-of-government

responsibility;

• health ministries should provide and be accountable

for health care services in prisons and advocate

healthy prison conditions.

A whole-of-government approach to prison health in the

longer term will have beneficial effects such as:

• lower health risks and improved health protection in

prisons;

• better health for prisoners;

• improved performance of national health systems;

• better health in deprived communities;

• better public health in the whole community;

• better integration of prisoners into society on release;

• lower rates of reoffending and reincarceration and a

reduction in the size of the prison population; and

• increased governmental credibility based on greater

efforts to protect human rights and reduce health

inequalities.

Regional Office for Europe, 2003 (http://www.euro.

who.int/__data/assets/pdf_file/0007/98971/E94242.

pdf, accessed 7 November 2013).

Copenhagen, WHO Regional Office for Europe, 2013

5

The essentials about prisons and health

(http://www.euro.who.int/__data/assets/pdf_file/0017/

231506/Good-governance-for-prison-health-in-the-

21st-century.pdf, accessed 9 November 2013).

6

• People who are in prison have the same right to health

care as everyone else.

• Prison administrations have a responsibility to ensure

that prisoners receive proper health care and that

prison conditions promote the well-being of both

prisoners and prison staff.

• Health care staff must deal with prisoners primarily as

patients and not prisoners.

• Health care staff must have the same professional

independence as their professional colleagues

working in the community.

• Health policy in prisons should be integrated into

national health policy, and the administration of public

health should be closely linked to the health services

administered in prisons.

• This applies to all health matters but is particularly

important for communicable diseases.

• The European Prison Rules of the Council of Europe

provide important standards for prison health care.

Several international standards define the quality of

health care that should be provided to prisoners. A

provision in Article 12 of the International Covenant on

Economic, Social and Cultural Rights establishes “the right

of everyone to the enjoyment of the highest attainable

to prisoners just as it does to every other human being.

Those who are imprisoned retain their fundamental right

to enjoy good health, both physical and mental, and

retain their entitlement to a standard of health care that

is at least the equivalent of that provided in the wider

community.

The United Nations Basic Principles for the Treatment of

to the highest attainable standard of health care should

be delivered: “Prisoners shall have access to the health

services available in the country without discrimination

on the grounds of their legal situation” (Principle 9). In

other words, the fact that people are in prison does not

mean that they have any reduced right to appropriate

health care. Rather, the opposite is the case. When a state

deprives people of their liberty, it takes on a responsibility

to look after their health in terms both of the conditions

under which it detains them and of the individual

treatment that may be necessary. Prison administrations

have a responsibility not simply to provide health care

but also to establish conditions that promote the wellbeing

of both prisoners and prison staff. Prisoners should

not leave prison in a worse condition than when they

entered. This principle is reinforced by Recommendation

No. R (98) 7 of the Committee of Ministers of the Council

aspects of health care in prison and by the European

Committee for the Prevention of Torture and Inhuman or

Degrading Treatment or Punishment (CPT), particularly in

Rights is also producing an increasing body of case law

confirming the obligation of states to safeguard the health

The argument is sometimes advanced that states cannot

provide adequate health care for prisoners because of

shortage of resources. In the 11th general report on

its activities, the CPT underlined the obligations state

governments have to prisoners even in times of economic

The CPT is aware that in periods of economic difficulty

sacrifices have to be made, including in penitentiary

establishments. However, regardless of the difficulties

faced at any given time, the act of depriving a person of

his liberty always entails a duty of care which calls for

effective methods of prevention, screening, and treatment.

Compliance with this duty by public authorities is all the

more important when it is a question of care required to

treat life-threatening diseases. In respect of the obligation

to provide adequate health care to prisoners, there are two

fundamental considerations. One concerns the relationship

between the prisoner and the health care staff and the other

concerns how prison health care is organized.

All health care staff working in prisons must always

remember that their first duty to any prisoner who is their

patient is clinical. This is underlined in the first of the

United Nations Principles of Medical Ethics relevant to

the Role of Health Personnel, particularly Physicians, in

the Protection of Prisoners and Detainees against Torture

7

Standards in prison health: the prisoner as a patient

and Other Cruel, Inhuman or Degrading Treatment or

Health personnel, particularly physicians, charged with

the medical care of prisoners and detainees have a duty to

provide them with protection of their physical and mental

health and treatment of disease of the same quality and

standard as is afforded to those who are not imprisoned or

detained.

The International Council of Prison Medical Services

confirmed this principle when it agreed on the Oath of

We, the health professionals who are working in prison

settings, meeting in Athens on September 10, 1979, hereby

pledge, in keeping with the spirit of the Oath of Hippocrates,

that we shall endeavour to provide the best possible health

care for those who are incarcerated in prisons for whatever

reasons, without prejudice and within our respective

professional ethics.

This principle is particularly important for physicians. In

some countries, full-time physicians can spend their whole

careers working in the prison environment. It is virtually

inevitable in such situations that these physicians will

form a close relationship with the prison management

and indeed may be members of the senior management

team of the prison. One consequence of this may be

that the director of the prison will occasionally expect

the physician to assist in managing prisoners who are

causing difficulty. For example, the security staff may

ask the physician to sedate prisoners who are violent

to themselves, to other prisoners or to staff. In some

jurisdictions, prison administrations may demand that

physicians provide them with confidential information

about a person’s HIV status. Physicians should never lose

sight of the fact that their relationship with every prisoner

should be first and foremost that between physician and

patient. A physician should never do anything to patients

or cause anything to be done to them that is not in their

best clinical interests. Similarly, as with all other patients,

physicians should always seek consent from the patient

before taking any clinical action, unless the patient is not

competent on clinical grounds to give this consent. An

behalf of the World Medical Association, focuses on many

of these issues. See also the World Medical Association

Declaration on Hunger Strikers adopted by the 43rd World

Medical Assembly, Malta, November 1991 and revised

by the World Medical Association General Assembly in

This primary duty to deal with prisoners as patients

applies equally to other health care staff. In many

countries nurses carry out a variety of basic health care

functions. These may include carrying out preliminary

health assessments of newly admitted prisoners, issuing

medicines or applying treatments prescribed by a physician

or being the first point of contact for prisoners concerned

about their health. The nurses who carry out these duties

should be properly qualified for what they do and should

treat people primarily as patients rather than as prisoners

when carrying out their duties. The International Council

of Nurses published a statement saying, among other

things, that national nursing associations should provide

access to confidential advice, counselling and support for

One method of ensuring that prisoners have access to an

appropriate quality of health care is by providing close

links between prison-administered health services and

public health. In recent years, some countries have begun

to create and strengthen such relationships. Many prison

and public health reformers argue, however, that a close

relationship is not enough and that prison health should

be part of the general health services of the country rather

than a specialist service under the government ministry

responsible for the prisons. There are strong arguments

for moving in this direction in terms of improving the

quality of health care provided to prisoners. In Norway,

for example, the process of giving local health authorities

responsibility for providing health care services in prison

was completed in the 1980s. In France, legislation was

introduced in 1994 placing prison health under the General

Health Directorate for Public Health Issues in the Ministry

of Health. In the United Kingdom (England and Wales),

responsibility and the budget for prison health care were

transferred to the National Health Service in 2002.

The Committee of Ministers of the Council of Europe has

urged that “health policy in custody should be integrated

Committee points out that, as well as being in the interest

of prisoners, this integration is in the interest of the

health of the population at large, especially as concerns

policies relating to infectious diseases that can spread

from prisons to the wider community. The vast majority

of prisoners will return to civil society one day, often to

the communities from which they came. Some are in

prison for very short periods. When they are released, it is

important for the good of society that they return in good

health rather than needing more support from the public

health services or bringing infectious diseases with them.

Continuity of care between prisons and communities is a

public health imperative. Many other people go into and

8

Prisons and health

come out of prison on a daily basis: staff, lawyers, officials

and other visitors. This means that there is significant

potential for transmitting serious disease or infection. For

these reasons, prisons cannot be seen as separate health

sites from other institutions in society.

WHO strongly recommends that prison and public health

care be closely linked. The Moscow Declaration on Prison

of the reasons why close working relationships with

public health authorities are so important, as under:

• Penitentiary populations contain an overrepresentation

of members of the most marginalized groups in society,

people with poor health and chronic untreated conditions,

drug users, vulnerable people and those who engage in

risky activities such as injecting drugs and commercial

sex work.

• The movement of people already infected with or at high

risk of disease to penitentiary institutions and back into

civil society without effective treatment and follow-up

gives rise to the risk of the spread of communicable

diseases both within and beyond the penitentiary

system. Prevention and treatment responses must

be based on scientific evidence and on sound public

health principles, with the involvement of the private

sector, nongovernmental organizations and the affected

population.

• The living conditions in most prisons of the world are

unhealthy. Overcrowding, violence, lack of light, fresh

air and clean water, poor food and infection-spreading

activities such as tattooing are common. Rates of

infection with TB, HIV and hepatitis are much higher than

in the general population.

The Declaration makes a series of recommendations that

would form the basis for improving the health care of all

detained people, protecting the health of prison personnel

and contributing to the public health goals of every

Member State in the Region:

• Member governments are recommended to develop

close working links between the Ministry of Health and

the ministry responsible for the penitentiary system so

as to ensure high standards of treatment for detainees,

protection for personnel, joint training of professionals

in modern standards of disease control, high levels of

professionalism amongst penitentiary medical personnel,

continuity of treatment between the penitentiary and

outside society, and unification of statistics.

• Member governments are recommended to ensure that

all necessary health care for those deprived of their

liberty is provided to everyone free of charge.

• Public and penitentiary health systems are recommended

to work together to ensure that harm reduction becomes

the guiding principle of policy on the prevention of HIV/

AIDS and hepatitis transmission in penitentiary systems.

• Public and penitentiary health systems are recommended

to work together to ensure the early detection of

tuberculosis, its prompt and adequate treatment, and the

prevention of transmission in penitentiary systems.

• State authorities, civil and penitentiary medical services,

international organizations and the mass media are

recommended to consolidate their efforts to develop

and implement a complex approach to tackle the dual

infection of tuberculosis and HIV.

• Governmental organizations, civil and penitentiary

medical services and international organizations are

recommended to promote their activities and consolidate

their efforts in order to achieve quality improvements in

the provision of psychological and psychiatric treatments

to people who are imprisoned.

• Member governments are recommended to work to

improve prison conditions so that the minimum health

requirements for light, air, space, water and nutrition are

met.

• The WHO Regional Office for Europe is recommended

to ensure that all its specialist departments and country

officers take account in their work of the health care

needs and problems of penitentiary systems and develop

and coordinate activities to improve the health of

detainees.

All the countries that are members of the WHO Health in

Prisons Project are also members of the Council of Europe.

In 1973, the Committee of Ministers of the Council of

Europe adopted the European Standard Minimum Rules

modelled on the United Nations Standard Minimum Rules

of Europe had 15 members. At the beginning of 1987,

when it had expanded to 21 members, the Committee of

Ministers of the Council of Europe adopted a new set of

Ministers noted “that significant social trends and changes

in regard to prison treatment and management have made

it desirable to reformulate the Standard Minimum Rules

for the Treatment of Prisoners, drawn up by the Council of

Europe (Resolution (73) 5) so as to support and encourage

the best of these developments and offer scope for future

progress”. By 2005, the membership of the Council of

Europe expanded further to 46 states. For that reason, the

Council of Europe decided to revise the 1987 European

Prison Rules.

The revised European Prison Rules, adopted on 11 January

2006 by the Committee of Ministers of the Council of

9

Standards in prison health: the prisoner as a patient

health care in the prison setting. For the first time, the

European Prison Rules specifically refer to the obligation

of prison authorities to safeguard the health of all

prisoners (§39) and the need for prison medical services to

be organized in close relationship with the general public

health administration (§40).

Every prison is recommended to have the services of at

least one qualified general medical practitioner and to

have other personnel suitably trained in health care (§41).

Arrangements to safeguard health care begin at the point

of first admission, when prisoners are entitled to have

a medical examination (§42), and continue throughout

the course of detention (§43). The commentary to the

European Prison Rules refers to some recent developments

in imprisonment with implications for health care. One

is the increasing tendency for courts to impose very

long sentences, which increases the possibility that old

prisoners may die in prison. Related to this is the need

to give proper and humane treatment to any prisoner

who is terminally ill. The Committee of Ministers of the

Council of Europe has also made a recommendation on

to dealing with the health needs of individual prisoners,

those responsible for prison health are also recommended

to inspect the general conditions of detention, including

food, water, hygiene, sanitation, heating, lighting and

ventilation, as well as the suitability and cleanliness of

the prisoners’ clothing and bedding (§44). The European

Prison Rules also recommend that provision is made for

prisoners who require specialist treatment (§46) and

those who have mental health needs (§47).

One important change should be noted. The 1987 European

Prison Rules provided that prison authorities could only

impose “punishment by disciplinary confinement and any

other punishment which might have an adverse effect

on the physical or mental health of the prisoner” if the

medical officer certified in writing that the prisoner was

fit to undergo such punishment. This led to concerns that,

by providing this certification, the physician was in effect

authorizing the imposition of punishment, in contradiction

to the Hippocratic Oath. The revised European Prison

Rules remove this requirement.

High Commissioner for Human Rights, 1966 (http://

www.ohchr.org/EN/ProfessionalInterest/Pages/

CESCR.aspx, accessed 7 November 2013).

NY, United Nations, 1990 (http://www.ohchr.org/EN/

ProfessionalInterest/Pages/BasicPrinciplesTreatment

OfPrisoners.aspx, accessed 7 November 2013).

of Europe, 1998 (http://legislationline.org/documents/

action/popup/id/ 8069, accessed 7 November 2013).

4. European Committee for the Prevention of Torture

and Inhuman or Degrading Treatment or Punishment.

Council of Europe, 1993 (CPT/Inf (93) 12) (http:

//www.cpt.coe.int/en/annual/rep-03.htm, accessed

7 November 2013).

European Court of Human Rights, 14 November 2002

(application number 67263/010) (http://hudoc.echr.coe.int/

sites/eng-press/Pages/search.aspx#{“fulltext”:[“Mouisel

v. France”],”itemid”:[“003-651691-657425”]}, accessed

11 November 2013).

Strasbourg, European Court of Human Rights, 27 November

2003 (application number 65436/01) (http://hudoc.echr.coe.

int/sites/eng-press/Pages/search.aspx#{“fulltext”:[“Henaf

v. France”],”itemid”:[“003-885782-910233”]}, accessed

11 November 2013).

Court of Human Rights, 29 April 2003 (application

number 50390/99) (http://hudoc.echr.coe.int/sites/

eng-press/pages/search.aspx?i=003-741378-753326,

accessed 11 November 2013).

8. European Committee for the Prevention of Torture and

Council of Europe, 2001 (CPT/Inf (2001) 16) (http://

www.cpt.coe.int/en/annual/rep-11.htm, accessed

7 November 2013).

New York, NY, United Nations, 1982 (http://www.ohchr.org

/EN/ProfessionalInterest/Pages/BasicPrinciplesTreat

mentOfPrisoners.aspx, accessed 7 November 2013).

Practitioners, 1979 (http://www.medekspert.az/en/

chapter1/resources/The%20Oath%20of%20Athens.

pdf, accessed 7 November 2013).

2004 (http://www.wma.net/en/70education/10onlinecour

ses/20prison/, accessed 7 November 2013).

10

Prisons and health

Ferney-Voltaire, World Medical Association, 2013

(http://www.wma.net/en/30publications/10policies/

h31/, accessed 7 November 2013).

Geneva, International Council of Nurses, 1998 (http://

www.icn.ch/images/stories/documents/publications/

position_statements/A13_Nurses_Role_Detainees_

Prisoners.pdf, accessed 7 November 2013).

Regional Office for Europe, 2003 (http://www.euro.

who.int/__data/assets/pdf_file/0007/98971/E94242.

pdf, accessed 7 November 2013).

1973 (https://wcd.coe.int/com.instranet.Instra Servlet?

command=com.instranet.CmdBlobGet&InstranetIma

ge=588982&SecMode=1&DocId=645672&Usage=2,

accessed 7 November 2013).

New York, NY, United Nations, 1955 (http://www.

unhcr.org/refworld/docid/3ae6b36e8.html, accessed

10 November 2013).

coe.int/com.instranet.InstraServlet?command=com.

instranet.CmdBlobGet&InstranetImage=1977676&

SecMode=1&DocId=692778&Usage=2, accessed

7 November 2013).

wcd.coe.int/ViewDoc.jsp?id=955747, accessed

7 November 2013).

Coyle A, Stern V. Captive populations: prison health care.

Oxford University Press, 2004.

11

• Regardless of the circumstances, the ultimate goal of

health care staff in prisons must remain the welfare

and dignity of the patients.

• The results of medical examinations and tests

undertaken in prison with the patient’s consent as part

of clinical care must be treated with the same respect

for confidentiality as is normal according to medical

ethics in general medical practice.

• Prison physicians should avoid dual roles with the

same patient. To avoid as far as possible any confusion

about the role of the doctor in medical examinations

and treatment in the caregiving role and in other

functions (such as providing medical expertise for, for

example, forensic reports), the doctor should make it

clear to the patient at the outset of the consultation

that medical confidentiality will not apply to the results

of any medical examinations and tests undertaken for

forensic purposes.

• Regardless of security issues, health care staff should

have unrestricted access at any time and any place to

all prisoners, including those undergoing disciplinary

sanctions.

• Health care staff should under no circumstances

participate in enforcing any sanctions against

prisoners or in the underlying decision-making process,

as this will jeopardize any subsequent doctor–patient

relationship. This includes any medical examination to

determine if a prisoner is fit to undergo punishment.

• Medical staff should not carry out any medical acts

on prisoners who are restrained (including with

handcuffs). An exception may be considered when the

person concerned suffers from an acute mental illness

which may create an immediate serious risk for him/

herself or others.

• Prison doctors should not carry out any body searches

or examinations requested by an authority, except in

an emergency when no other doctor can be called in

or in cases where there is a lack of other qualified

health staff. In such cases doctors must explain to

the prisoner, before proceeding with the body search,

that they are intervening purely as experts, and that

their act does not have any diagnostic or therapeutic

purpose. Any such body search must have the informed

consent of the prisoner.

• During a hunger strike, doctors must avoid the risk

that prisoners, the prison or the judiciary authorities

manipulate medical decisions.

• Doctors have a duty to document physical signs and/

or mental symptoms compatible with a prisoner

having been subjected to torture or cruel, inhuman

and degrading treatment, and to report through the

appropriate channels any sign or indication that

prisoners may have been treated violently.

• The health service in a prison can potentially play an

important role in the prevention of ill-treatment within

the establishment and elsewhere. The physical and

psychological examinations carried out on admission

are particularly important in this respect.

• All health care staff working with prisoners on an

ongoing basis should have access to a specific training

programme. Training should address the specificities

and inner workings of different types of prison, the

handling of potentially dangerous or violent situations,

and the risks of ethical breaches specific to their

activities as health care providers in prisons.

Other chapters of this guide raise important issues relating

to equivalence of care, confidentiality and informed

consent of the patient detainee. This chapter will address

other highly specific and sensitive health problems faced

by health care staff (as well as the prison administration)

in the practice of prison medicine.

The role of a prison doctor is not limited to the provision of

care. As already noted, prison doctors should take part in

the general management of a prison establishment (such

as in control of food and hygiene). As far as possible,

a prison doctor should also have a say in the design of

various detention regimes as well as participating in the

promotion of alternatives to detention, while keeping in

mind that the role of the doctor is to promote prisoners’

health and social rehabilitation.

In practical terms, the doctor should submit a report to

the prison director whenever he/she considers that the

physical or mental health of a prisoner or the prison

population is at serious risk as a result of prolonged

imprisonment or of the conditions of detention, including

isolation. Further, the doctor should adopt a proactive

approach when the prisoner’s state of health is seriously

affected and release on medical grounds is required. If

the prison management does not accept the doctor’s

12

Prisons and health

recommendations, the doctor should ensure that his/her

The possible subordination of prison health care to the

ministry of health does not exempt doctors working

in prison from any functions specific to the practice of

medicine in a prison setting.

Doctors working in prisons are frequently torn between

various loyalties. Their primary duty is to protect and

promote the health of prisoners and to ensure that they

receive the best care possible. This duty may, however,

conflict with other priorities, notably those of the

prison management. In practice, the health care team

is frequently obliged, despite its reticence, to take into

account issues of order and security. Conversely, security

staff may find it difficult to accept attitudes, beliefs and

behaviour on the part of the health care staff that they

Although it is not recommended, the prison doctor

sometimes also acts as a treating doctor for security

staff (and occasionally even for their families). In such

a context, the position of prison doctors is extremely

complex since their duty is to take care of people who are

in opposition to each other, if not in conflict, at the same

time. The two types of doctor’s activity should preferably

be clearly distinguished physically. It should be stipulated

beforehand, for example, what percentage of the doctor’s

time is to be devoted to staff care and that two stocks of

medication (for prisoners and staff) will be kept separately.

Two separate consultation rooms would be best.

This permanent state of tension can only be dealt with

through regular meetings between the prison director and

the medical director to make any necessary adjustments.

The exchanges during such meetings are even more

essential as, in a large proportion of establishments,

the acute lack of health care staff can force the prison

management to delegate certain tasks related to health

care to the security staff.

Regardless of the circumstances, the ultimate goal of

health care staff must remain the welfare and dignity

of the patients. It should be made clear to the patients,

prison staff and the prison director that the primary task of

the prison health care staff is the health care of prisoners,

and that all work is based on the strict medical and ethical

principles of health care professionalism: independence,

equivalence and confidentiality of care.

A doctor working in a prison may be called upon to play

two somewhat opposing roles: that of a care provider

to the prisoner as a patient, and that of an independent

medical expert providing medical evidence concerning a

patient to a court or other official body. While the careprovider

is concerned with the well-being of the individual

patient, the doctor acting as a medical expert is asked

to reveal medical information that would otherwise be

confidential, in the interests of justice and in the service

of the community. The latter role may not be in the doctor’s

patient’s interest. According to common ethical rules, a

doctor should be one or the other. Only in an emergency

is it tolerated for a doctor to combine these two functions

without the formal consent of the patient.

In practice, however, the reality of prison life frequently

obliges doctors to go beyond their role as care providers.

For instance, the judiciary or prison authorities may ask

doctors to establish a person’s fitness to be detained or

to prepare forensic reports in cases of allegations of illtreatment.

Ideally, such tasks should be performed by an

independent doctor from outside the prison system. If,

however, a prison doctor has to perform such a task, the

doctor charged with examining a prisoner as a medical

expert should clearly inform the patient at the outset of

the consultation that medical secrecy will not apply to the

results of the medical examination and tests, to avoid a

confusion of the two roles.

A prison doctor may be asked to evaluate the threat

to society posed by a prisoner in connection with, for

example, a request for parole or leave of absence. In

such situations, the doctor must respond with extreme

caution and clearly establish that his/her opinion can only

be based on a current assessment of physical and mental

function and must not predict future criminal conduct.

Doctors are neither trained nor qualified to predict

criminal behaviour. In such cases, since the prisoner may

see the prison doctor as effectively playing a role in his/

her release or continued detention, this has the potential

to affect the doctor–atient relationship. Thus again,

it is best for an independent opinion to be given by a

professional qualified to make judgments on criminality.

The multiple parameters affecting the work of prison

doctors may run contrary to their personal convictions. It is,

therefore, highly preferable to employ prison health care

staff who choose to work in prisons and to provide them

with focused training. In countries where prison health

care services have been integrated with the community

health services, patients inside the prison are considered

as simply another group within the wider community and

the health staff are expected to deliver services at the

same level as in the wider community.

13

Prison-specific ethical and clinical problems

In attempting to carry out their duties according to the

usual professional and ethical standards, doctors may

face conflicts not only with the decisions of the prison

administration but also with local regulations and even

national laws. In such cases, doctors should ask their

national professional organization (national medical

association) for advice and, if needed, ask the opinion

of colleagues working in other countries in the same

field, including seeking the support of the World Medical

Association. Another possibility is to contact the national

prevention organization, if one exists in the country.

In any prison, access to health care facilities may be

difficult because of security practices. This is particularly

the case in disciplinary and maximum security units. The

prison authorities often want to limit contact with certain

prisoners to a strict minimum.

Regardless of the security issues, health care staff should

have unrestricted access at any time and any place to

all prisoners, including those subject to disciplinary

measures. The doctor in charge is responsible for ensuring

that each prisoner can, in practice, exert his/her right of

access to health care at any time.

When the prison authorities decide to punish a prisoner

for breach of regulations, sanctions may take different

forms. Health care staff should never participate in the

initiation or enforcement of any sanctions, as this is not

a medical act and thus to participate will jeopardize any

subsequent doctor–patient relationship with this prisoner

and with all prisoners.

Doctors may frequently be approached when the sanction

considered is solitary confinement. Solitary confinement

cases where it is enforced, its use should be limited to the

shortest time possible. Thus, doctors should not collude in

moves to segregate or restrict the movement of prisoners

except on purely medical grounds, and they should not

certify a prisoner as being fit for solitary confinement or

any other form of punishment. Prisoners who are placed

in isolation should be evaluated initially and periodically

for acute mental illness, drug or alcohol withdrawal and

injuries. If these are identified, prisoners should have

access to prompt and effective treatment. Doctors should

not certify fitness for isolation.

Once a sanction is enforced, however, doctors must follow

the prisoner being punished with extreme vigilance. It is

well-established that solitary confinement constitutes an

important stressor and risk, notably of suicide. Doctors

must pay particular attention to such prisoners and

visit them regularly on their own initiative, as soon as

possible after an isolation order has taken effect and

daily thereafter, to assess their physical and mental

state and determine any deterioration in their well-being.

Furthermore, doctors must immediately inform the prison

management if a prisoner presents a health problem.

In prison, situations of extreme tension can occur. In such

cases, the prison authorities can decide to use physical

restraints on one or more prisoners for the purpose of

preventing self-harm or harm to other prisoners and staff.

Restraints must only be applied for the shortest time

possible to achieve these purposes and should never be

used as a form of punishment. Since the decision to use

restraints in situations of violence is not a medical act, the

doctor must have no role in the process.

There may, however, be instances where some form of

restraint must be applied for medical reasons, such as

acute mental disturbance in which the patient is at high

risk of injuring him/herself or others. The decision to use

restraints or to move a prisoner to a cell for such purposes

must be confirmed in each case by health care staff, based

purely upon clinical criteria.

Medical personnel should never carry out medical acts on

prisoners who are under restraint (including handcuffed),

except for patients suffering from an acute mental illness

or delirium with potential for immediate serious risk for

themselves or others. Moreover, doctors should never

agree to examine a blindfolded prisoner.

For security reasons, it may be necessary to search a

prisoner to ensure that he/she is not hiding anything in a

natural body cavity. In many cases it may suffice to keep

the prisoner under close surveillance and wait for the illicit

object to be naturally expelled. Prison doctors and nurses

should not carry out body searches, blood or urine tests

for drug metabolites or any other examinations except

on medical grounds and with the consent of the patient.

Vaginal, anal and other intrusive bodily inspections are

primarily a security rather than a medical procedure, and

thus should not form part of the duties of prison health care

staff. On the rare occasions when intimate body searches

are deemed necessary, they should be performed by doctors

who are, as far as possible, external to the prison.

It is vital to understand why a prisoner stops eating since

the medical care will differ completely depending on the

reason for refusing food. Prisoners may stop eating:

14

Prisons and health

• for religious reasons, as a part of specific religious

festivals or if food is served that is not prepared

in accordance with religious precepts; the prison

administration should deal with such issues and

ensure that religious considerations are taken into

account in the preparation of food for prisoners;

• because of somatic problems such as dental problems,

ulcers, obstructions of the digestive tract, very poor

general health and fever; the appropriate treatment

should be provided;

• because of mental disorders such as psychosis,

poisoning, delusion, major depressive disorders and

anorexia nervosa; such prisoners should benefit from

health care support of the kind they would receive in

open society;

• with the intention of protesting to achieve some

change in their regime or to obtain perceived or actual

rights.

In the last case, two sets of values clash:

• the duty of the state to preserve the physical integrity

and life of those directly under its charge, notably

people it has deprived of liberty; and

• the right of every individual to dispose freely of his/her

own body.

Such situations are challenging for prison health care

staff. Pressure is often brought to bear on the doctor, who

should avoid the risk that the prisoner, prison or judiciary

authorities manipulate medical decisions.

The most important guidance for prison doctors regarding

hunger strikes is the World Medical Association’s

below and some important issues are discussed.

• Physicians have the duty to act ethically. Whatever

their role, they must try to prevent coercion or

maltreatment.

• The autonomy of the patient must be respected.

In order to do so, the physician must assess an

individual’s mental capacity. Getting a second opinion

from an independent psychiatrist as to soundness of

mind is always wise in every case of food refusal.

• A thorough examination of the patient should be made

and the physician should make sure that the patient

fully understands the consequences of his/her hunger

strike. It is important to recognize that the refusal of

certain treatments must not prejudice any other aspect

of medical care, such as treatment of infection or pain.

• The wish to continue the strike must be ascertained

on a daily basis, and the physician should talk to the

prisoner concerned in private.

The physician must visit patients regularly and, if they

agree, conduct regular follow-up examinations. These

consultations should be held in a positive, personalized

climate, and the physician should inform the patient of

the progressive decline in his/her health. In this way,

hunger strikers can freely change their mind at any time

and abandon the strike, having been duly informed of

the worsening nature of the risks to which they are

exposing themselves. The doctor must evaluate each

prisoner individually and should be particularly careful

in case of a collective hunger strike, as prisoners are

often subjected to external pressure.

Physicians should offer detainees the possibility to

access a special diet whenever this is possible. It is

widely accepted that liquids, vitamins, sugar and trace

nutrients protect the striker’s health from irreversible

allow both the prisoner and the authorities to propose

a mutually acceptable solution in order to avoid lethal

deadlock.

• Confidentiality must be respected, unless it is

necessary to share information in order to prevent a

serious threat to the patient or to others.

• The doctor must keep the prison and judicial authorities

informed of the evolution of the health condition of the

patient through regular and successive health reports.

These carefully established and strictly objective

health reports are part of the medical care for a person

in danger and allow the authorities to take more

adequate decisions.

• If no discussion is possible with the patient (for example

because he/she has already lost mental capacity), the

physician must respect the patient’s wish, but has to

consider very carefully the instructions given by the

patient as the situation might have changed or the

instructions may have been written under pressure. In

case of doubt, the physician must act in the patient’s

best interest.

• In a case of conflict between loyalty to the authorities

and to the patient, the physician’s primary obligation

is to the patient.

• Forcible feeding of prisoners is never ethically

acceptable.

Such a procedure can only be justified if a serious

mental disorder affects the decision-making capacity

of the patient (see Differential diagnosis above). In

such a case, this constitutes artificial nutrition and not

force-feeding, and must be carried out in a hospital

setting.

If there is no obvious alteration in the prisoner’s

decision-making capacity, the doctor must carefully

consider a course of action, keeping in mind that, in

the vast majority of cases, the prisoners do not want

to die. On the contrary, they want to enjoy better

conditions. Patients frequently expect that the doctor,

15

Prison-specific ethical and clinical problems

who will invariably be called in if a hunger strike is

kept up, will act as an intermediary and may act to

protect them in this struggle.

In these situations, the medical approach should

sometimes be frankly paternalistic. It should entail

a discussion with the patients on hunger strike to

try and persuade them to accept at least a minimal

calorie intake. Faced with a firm medical attitude, the

prisoner may recover some hope and accept a normal

healthy diet later. Some patients do not consider

dying as part of their struggle and may even accept

artificial feeding, but will not indicate this explicitly.

The evaluation of the real volition of the detainee in

these situations is very difficult.

Patients may ask for hospitalization to give their

case more weight. In this situation, hospitalization

unwarranted by clinical status should not appear as an

indirect support to achieve their aims. Nevertheless,

early hospitalization may allow better follow-up of

biological parameters. Further, a radical change of

atmosphere could lead to a situation in which the

prisoner may choose to interrupt the hunger strike

without losing face in front of his/her comrades.

• If the patient’s position remains firm, based on his/

her free will to exert pressure through his/her body to

modify his/her prison situation or to conduct a political

struggle, doctors should limit interventions to warning

of the dangers to which strikers expose themselves by

refusing to eat.

The capacity of the human body to survive starvation or

water deprivation is not yet fully understood. Obviously,

data in this area tend to be anecdotal rather than

interventional studies.

In dry fasting, the person refuses all solid or fluid intake.

Death occurs in 4 to 10 days, depending on factors such as

ambient temperature and humidity and the striker’s level

of stress and physical activity.

Severe electrolytic imbalance can rapidly cause death

due to cardiac arrhythmia or damage to the central

nervous system. A hypovolemic state causes multiorgan

dysfunction and acute renal insufficiency, worsening an

In total fasting, the individual only consumes clear water,

with no other intake of nutrients.

The usual clinical evolution of a hunger strike in a healthy,

young patient who continues to drink water is as follows:

• first week: sensation of hunger and fatigue; possible

occasional abdominal cramping;

• second and third weeks: increasing weakness

accompanied by dizziness, making the upright position

difficult to maintain; progressive disappearance of the

feelings of hunger and thirst; permanent sensation of

chilliness;

• third and fourth weeks: progressive worsening of

the symptoms mentioned above; slowing down of

intellectual faculties;

• fifth week: alteration of consciousness from mild

confusion to stupor and sleepiness, apathy and

anosognosia, followed by anomalies of ocular

movements (initially uncontrollable movements

followed by paralysis); generalized lack of motor

coordination with notable difficulty in swallowing;

diminished vision and hearing, leading to loss of vision

and hearing; sometimes diffuse haemorrhaging.

Death can occur abruptly either due to cardiac rhythm

alterations, sepsis or several hours after the induction of

In theory, the reserves of the human body should allow

a person to survive for 75–80 days without absorbing a

single calorie.

In practice, it is usually accepted that there is little risk of

dying within the first six weeks of a fast for a previously

serious, sometimes deadly, clinical disorders may appear

after a few weeks of complete fasting, mainly because

of susceptibility to infection due to decreased immunity

and impaired wound healing. As with dry fasting, renal

It should be noted that death is not usually due to tissue

loss per se but to organ failure or infection. The limit of a

body mass index compatible with life itself is thus not the

only parameter that should be taken into account.

It is vital to recognize that certain medical factors can

predispose to the rapidly fatal evolution of a fast. The

major factors include heart disease, renal insufficiency and

diabetes, especially if the patient is insulin-dependent.

Gastric or duodenal ulcers can manifest as problems as

early as one week after the start of the fast.

Today most hunger-strikers follow dietary fasts with the

absorption of certain vitamins, trace minerals and some

food (sweet drinks, candy or small amounts of various

foods). This type of hunger strike allows them to hold on

for several months. Prisoners going on a fast should have

access to this diet because the risk of permanent damage

16

Prisons and health

to the nervous system is significantly reduced. However,

a prolonged hunger strike poses a substantial risk of

Wernicke syndrome), and it should be emphasized that

glucose intake without vitamin B1 accelerates the process

of neurological damage.

In practice, because many different factors affect a fast, such

as the type of fast, conditions of detention (temperature,

humidity) and mental stressors, it is virtually impossible to

determine medically the risk and timing of death.

The major electrolytes and vitamin depletion in people

suffering from malnutrition cause serious threats when

it comes to re-feeding. Indeed, glycaemia triggers

insulin secretion, which in turns starts the movement of

electrolytes and fluids across cellular membranes (mainly

of phosphates and potassium). These very rapid changes

can lead to lethal consequences, such as cardiac arrest.

As mentioned above, glucose intake in a case of vitamin

depletion can also precipitate Wernicke syndrome. In

consequence, re-feeding should be considered very

carefully in people at risk, that is, those who have had no

food intake for more than 10 days (5 days if the body mass

Medical personnel seriously violate the rules of medical

ethics if they:

• in any way assist in (even by merely being present)

sessions of torture or inhumane and degrading

treatment or advise the torturers or those inflicting

such treatment;

• provide facilities, instruments or substances to that

effect;

• certify that a prisoner is able to withstand a torture or

inhumane treatment session; or

• weaken the resistance of the victim to torture or

inhumane treatment.

The health service in a prison can, however, potentially

play a very important role in the fight against ill-treatment

within prisons and elsewhere, specifically police stations.

In the context of medical consultations, people sometimes

show physical signs or mental symptoms compatible with

having been subjected to torture or other forms of cruel,

inhumane or degrading treatment.

In view of this, the physical and mental examinations

carried out on admission of a prisoner are particularly

important.

During a physical examination (most specifically, the one

carried out on arrival), any trace of violence compatible

with torture or inhumane treatment must be duly noted

and registered (photos are desirable) both in the prisoner’s

personal file and in any general register of traumatic

injuries. Likewise, any psychological or psychiatric

disturbances that may indicate that a person has been

subjected to ill-treatment must be recorded. Such

information must be automatically transmitted without

delay to the supervising authorities. Prisoners should be

entitled to obtain a copy of the medical report concerning

them at any time.

However, the simple fact of being identified by the health

care services as bearing traces of traumatic lesions or

mental symptoms compatible with torture or inhumane

treatment can trigger reprisal measures against the

victim. To protect patients from this risk of retaliation,

doctors must formally inform them that they are going to

report to the competent authority the evidence they have

gathered during the consultation. If the patients fear that

they will be subjected to reprisal, they may decide not to

divulge how the lesions were inflicted and even lie about

them.

In their reports, doctors must clearly distinguish between

the patient’s allegations (circumstances of the physical or

mental trauma as described by the patient) and complaints

(subjective sensations experienced by the patient), and

the clinical and para-clinical objective findings (such

as mental state; size, location, aspect of the lesions;

X-rays and laboratory results). If the doctors’ training

and/or experience allow, they must indicate whether

the patients’ allegations are compatible with their own

clinical findings.

Health professionals should never be complicit in any

way (even by their presence) with capital punishment,

and should not be involved in examining the detainee

immediately before the execution nor in confirming death

or issuing the death certificate. The donation of organs

after an execution associates the medical profession with

1. Linder JF, Meyers FJ. Palliative care for prison inmates:

2. Augestad LB, Levander S. Personality, health and job

stress among employees in a Norwegian penitentiary

1992 6:65–79.

17

Prison-specific ethical and clinical problems

3. Whitehead J, Lindquist C. Correctional officer job

4. Metzner JL, Fellner J. Solitary confinement and mental

illness in U.S. prisons: a challenge for medical ethics.

Ferney-Voltaire, World Medical Association, 2013

(http://www.wma.net/en/30publications/10policies/

h31/, accessed 7 November 2013).

6. Kirbas D et al. The impact of prolonged hunger

strike: clinical and laboratory aspects of twenty-five

7. Chaari A et al. [Acute renal failure and rhabdomyolysis

secondary to prolonged hunger strike. A case report].

8. van der Helm-van Mil AH et al. Hypernatremia from

a hunger strike as a cause of osmotic myelinolysis.

10. Gorsane I et al. [Acute renal failure in a prisoner after

11. Altun G et al. Deaths due to hunger strike: postmortem

146(1):35–38.

13. Mehanna HM, Moledina J, Travis J. Refeeding

syndrome: what it is, and how to prevent and treat it.

14. Caplan A. The use of prisoners as sources of organs

Bass, 1979.

“Gesundheitsforderung im Justizvollzug”, Band 10), 2004.

Prison Studies, 2002.

Medical Association, 2013 (http://www.wma.net/

en/30publications/10policies/c18/, accessed 8 November

2013).

European Committee for the Prevention of Torture and

Europe, 1993 (CPT/Inf (93) 12) (http://www.cpt.coe.int/

en/annual/rep-03.htm, accessed 7 November 2013).

European Committee for the Prevention of Torture and

Europe, 2001 (CPT/Inf (2001) 16) (http://www.cpt.coe.int/

en/annual/rep-11.htm, accessed 7 November 2013).

European Committee for the Prevention of Torture and

Europe, 2011 (CPT/Inf (2011) 28) (http://www.cpt.coe.int/

en/annual/rep-21.pdf, accessed 8 November 2013).

Strasbourg, Council of Europe, 1998.

Gerstein L, Topp H, Correl G. The role of the environment

and person when predicting burnout among correctional

369.

Penguin, 1961.

www.globallawyersandphysicians.org/storage/UK%20

Protocol.pdf, accessed 8 November 2011).

United Nations High Commissioner for Human Rights, 1999

(Professional Training Series No. 8/Rev.1) (http://www.

18

Prisons and health

ohchr.org/Documents/Publications/training8Rev1en.pdf,

accessed 8 November 2013).

Practice. Chene-Bourg, World Psychiatric Association, 1996

(http://www.rewi.uni-jena.de/rewimedia/Downloads/

LS_Ruffert/Ethical+Codes/WPA_Madrid+Declaration

+on+Ethical+Standards+for+Psychiatric+Practice.pdf,

accessed 8 November 2013).

Mental health promotion in prisons: a consensus

Europe, 1999 (http://www.euro.who.int/__data/assets/

pdf_file/0007/99016/E64328.pdf, accessed 8 November

2013).

Hague, Penal Reform International, 1995.

York, United Nations, 1982 (http://www.ohchr.org/

EN/ProfessionalInterest/Pages/MedicalEthics.aspx,

accessed 7 November 2013).

Strasbourg, Council of Europe, 2006 (https://wcd.coe.int/

ViewDoc.jsp?id=955747, accessed 7 November 2013).

Regional Office for Europe, 2010 (http://www.euro.who.

int/__data/assets/pdf_file/0012/111360/E93574.pdf,

accessed 8 November 2013).

Copenhagen, WHO Regional Office for Europe, 2007 (http://

www.euro.who.int/__data/assets/pdf_file/0006/99006/

E91402.pdf, accessed 8 November 2013).

Wakai S et al. Conducting research in corrections:

2009, 27(5):743–752.

2009 (http://www.euro.who.int/__data/assets/pdf_file/

0004/76513/E92347.pdf, accessed 8 November 2013).

19

• Violence in prisons is often clandestine because of the

fear of reprisal when it is reported.

• Because violence is not brought into the open, it is

easily overlooked or underestimated.

• Authorities are obliged to protect prisoners against

violence, which must not constitute an additional

punishment on top of deprivation of liberty.

• Violence begets violence, so prison violence inhibits

rehabilitation for normal life.

• Violence occurs mostly in high-security facilities and

prisons with coercive practices, even though the

security measures have been established to minimize

the violence.

• A key performance indicator for the prevention of

violence is that prisoners feel safe and secure.

• About 25% of prisoners are victimized by violence

each year while 4–5% experience sexual violence and

1–2% are raped.

• Prevention may focus on the prisoners by identifying

groups with special needs who are at risk of being

victimized.

• Prevention may focus on creating a positive prison

climate to encourage respect, humanity and fairness.

Prisons are violent places compared to the community.

United States government statistics demonstrate that

rates of physical assault for male inmates are more than

18 times higher than the equivalent rates for males in

the general population. For female inmates, the rates are

Violence in prisons is and should be a prison management

and prison health service priority issue for several reasons.

First, violence begets violence, that is, exposure to violence

during adolescence increases the risk of later violent and

non-violent crime, drug use and intimate violence against

dimension of imprisonment is undermined if prisoners are

placed in an environment that makes them more violent

and more criminal than before.

Second, in international law, prisoners are entitled to

protection against violence such as assault, rape and

torture. According to principle 5 of the United Nations

Basic Principles for the Treatment of Prisoners: “Except

for those limitations that are demonstrably necessitated

by the fact of incarceration, all prisoners shall retain the

human rights and fundamental freedoms set out in the

Thus, state authorities have an obligation to ensure

that prisoners enjoy protection against all human rights

violations.

Third, a violent institution is more difficult and expensive to

manage than a secure and safe institution with a positive

climate, including a positive working environment.

Violence is difficult to address and assess precisely

because it is surrounded by silence and, therefore,

often underreported. Violence is – except for a justified

proportionate use of force by staff – illegal and punishable.

For this reason, reporting of violence committed by

prisoners or by staff may lead to reprisals and retaliation

(“snitches get stitches”). While this may also be the

case in the world outside the prison, the deprivation

of liberty means that a victim who reports the violence

has no possibility of escape from the retaliation by the

perpetrator. A study found that 25% of respondents who

had not reported their most recent experiences of assault

said that they did not believe that reporting victimization

would make a difference. An additional 20% did not

Comparisons of official violence and disorder statistics

with unofficial statistics indeed reveal that the official

WHO has defined violence as “The intentional use of physical

force or power, threatened or actual, against oneself,

another person, or against a group or community, that either

results in or has a high likelihood of resulting in injury, death,

It is noteworthy that the definition includes threats such as

the potential use of force, and that the defining outcome

is not only injury or death but also psychological harm,

maldevelopment and deprivation.

Violence may further be categorized as self-directed,

interpersonal or collective when directed towards:

(i) oneself; (ii) one’s family, intimate partner or unrelated

person; and (iii) specifically defined groups for reasons of

20

Prisons and health

a social, political or economic agenda. Organized groups

or states may perpetrate collective violence. The nature

of the violence may be physical, psychological, sexual or

In a prison context, the prison authorities have a general

obligation to protect inmates against any type of violence,

including excessive use of force. This chapter will address

how prison authorities, including prison health services,

may address the issue of violence.

Except for a proportionate use of force required for

security procedures (which is outside the scope of this

chapter), the many types of violence that may occur in

prisons include:

• suicides, suicide attempts and self-harm;

• physical violence (beatings, fights) among prisoners;

• psychological violence such as threats, bullying or

humiliation;

• sexual assaults of prisoners by other prisoners or by

prison staff;

• excessive violence committed by prison staff towards

prisoners amounting to torture or ill-treatment;

• violence by prisoners against prison staff, from single

events to prison riots.

Suicide attempts and self-harm are outside the scope

of this chapter. The following discussion will deal with

violence more generally between prisoners, between

prisoners and staff, sexual violence, torture and illtreatment.

The occurrence of the violence and underlying

risk factors will be addressed and the final section will

discuss the prevention of prison violence, both among

inmates and perpetrated by prison staff.

On a technical note, the measures of violence used in the

studies reviewed include the proportion of all prisoners

exposed to violence, whether victimized once or several

times (sometimes called the prevalence rate). This

measure reflects the proportion of all prisoners surveyed

as to their exposure to violence in the period of interest.

This might be their lifetime prevalence or those who were

exposed during a current or recent period of incarceration,

for example, in the previous 6 or 12 months.

The studies of violence in prisons do not have uniform

measures of frequency, although United States studies

tend to focus on the most recent six months. In some

studies, the reference period is not explicit. The

differences between the estimates may be rather small,

especially if the average period in prison was between 6

and 12 months, exposed prisoners were typically exposed

more than once, and the prisoner had been in prison only

once or twice before.

A recent study found a six-month male prevalence rate

of 205 per 1000 for prisoner-on-prisoner physical violence

In other words, 20% of the prisoners had been subjected

to physical violence by other prisoners and 25% to

violence by prison staff during the preceding six months.

For females, the prisoner-on-prisoner rate was the same

whereas the staff-on-prisoner rate was 8%, that is, male

prisoners experience more staff-on-inmate violence than

female prisoners do.

Small to medium-sized facilities had higher prevalence

rates of inmate-on-inmate physical violence, whereas

medium-sized and large facilities had higher staff-oninmate

rates of physical violence. For comparison, the sixmonth

sexual violence victimization rates for both sexes

were 42 per 1000 for any sexual victimization and 15 for

Fairly consistent with the American study, a recent

Australian study reported that 34% of the male inmates and

24% of the female inmates reported having been physically

assaulted at any time during their imprisonment, and 7% of

Juveniles seem to be involved in prison misconduct and

violence more frequently than slightly older prisoners and

Obviously, violence in prisons makes prisons a violent

workplace for the staff. A study of direct, injury-producing

violence using workers’ compensation claims in a random

sample of 807 correctional officers in an urban prison

revealed that 25.9% reported one episode and 20.3%

reported two or more violent episodes during an average

Thus, at least half of the prison staff suffered injury due

to violence during a 10-year employment period. The

main risk factors for male employees being exposed to

workplace violence were long-term substance-abuse,

whereas female employees seem to have a violencereducing

effect on the inmate population.

against staff occurred in the detention/high security

areas, during the day shift, predominantly directed

towards trainees with little experience and committed by

young inmates aged 25 years or less.

Sexual violence is particularly difficult to study and assess

21

Violence, sexual abuse and torture in prisons

because of the stigma associated with being raped or

abused and also because of the risk of reprisals from the

perpetrator. Sexual violence may be defined as behaviour

that leads a person to feel that he/she is the target of

pressure. In a recent study, sexual victimization was

viewed more narrowly as non-consensual sexual acts with

oral, vaginal or anal penetration as well as abusive sexual

contacts (touching or grabbing in a sexually threatening

Estimates of sexual assault victimization have varied

between 1% and 41%, depending on what was included.

The annual rate in United States prisons seems to converge

of studies of prison rape proper concluded that

1.9% of inmates have experienced a completed episode

of sexual victimization during their entire period(s) of

and 22% of female inmates reported that they had been

subject to prisoner-on-prisoner sexual victimization

(most often abusive sexual contact such as inappropriate

touching) during the previous six months. At least one type

of staff-on-prisoner sexual victimization was reported by

7% of male inmates and 8% of female inmates. Nonconsensual

prisoner-on-prisoner sexual acts amounted

to less than 2% over six months, while staff-on-prisoner

non-consensual sexual acts were less than 1.1%.

In 2007, the United States Department of Justice

conducted a national inmate survey of 60 500 prisoners

using an audio computer-assisted self-interview. The

survey showed that 2.1% of the prisoners reported

inmate-on-inmate victimization and 2.9% reported staffon-

inmate victimization. Of the latter, about half was

A study in a juvenile correctional centre in South Africa,

comprising interviews with 439 offenders, revealed that

29% said that they had been assaulted, attacked or

physically hurt while in the facility. Of these, 68% had

been beaten, pushed, stamped on or the like, 21% had

Of a random sample of current prisoners in California,

4% had experienced sexual violence (rape, other sexual

assault) and 59% of transgender prisoners reported that

British study found, by interviewing ex-prisoners, that 1%

of prisoners had been sexually coerced involving sexual

intimacy and 4% had been subjected to forced drug

searches.

Sexual coercion in United States female facilities

showed rates almost as high as male rates: up to 27%

of female prisoners had experienced sexual coercion at

some point in any prison in the state. Of these, about

of 7–8%.

Sexual victimization during imprisonment is experienced

by between 1% and 40% of the inmates, while physical

victimization is experienced by between 10% and 25%

obviously depend on the investigation methodology,

including the sample and the phrasing of the question

posed to the interviewees. Wolff and colleagues found

that when they used the same questions, 0.2% of women

in a community sample reported being raped (attempted

or completed) during a 12-month period compared to 4.6%

of women during a 6-month period in prison. The rates

of physical assault on men were 0.9% in a community

sample over a 12-month period and 32.9% in prison during

the emotional consequences of their worst incidents of

sexual victimization. The majority of the targets reported at

least one consequence – most frequently feeling distrust,

nervousness, social apprehension, and worry about

recurrence and depression. Also, sexual victimization

within the previous six months was associated with

prison sexual assault finds it difficult to reintegrate into

society and tends to become more violent. Many prisoners

worry about their sexual identity.

Torture is a subgroup of collective violence, defined

specifically by the severity of the pain, the intentionality,

the purpose and the perpetrator. In the United Nations

Convention Against Torture and other Cruel, Inhuman

(i) severe pain or suffering, physical or mental; (ii) inflicted

intentionally; (iii) with a specific purpose such as to obtain

a confession or to punish; and (iv) by a person acting in a

public capacity. In contrast, cruel, inhuman or degrading

treatment (also called ill-treatment) may involve less but

still substantial pain or suffering and not necessarily be

committed for a specific purpose.

Torture is prohibited according to international law, and

there are no circumstances that justify an exception to

this prohibition. Nevertheless, according to human rights

reports, torture is practised in about 130 countries and is

widespread and systematically used in 80–100 countries

22

Prisons and health

Hostilities facilitate torture, for example, between the

warring parties in an armed conflict or between religious,

sexual or political majorities and minorities. Such

hostility may develop into de-individualization and dehumanization.

Torture may be interpreted as socialized

obedience in an environment where the perpetrators see

themselves as performing a great service by punishing a

this reason, minorities (of a sexual, political or religious

nature) are at increased risk of being victims of torture

and may be in need of stronger protection measures.

Pre-trial detainees are at special risk of torture because

their investigation is ongoing. Obtaining a coerced

confession may be viewed as attractive by law enforcement

authorities. In addition to coercing a confession by use of

torture or other types of excessive use of force, isolation

is particularly sensitive for pre-trial detainees. The mental

of solitary confinement on an accused pre-trial detainee

may cause suffering and pressure to force confession to

a crime that the detainee might not have committed or

admitted.

In some torture settings, the signs of torture may serve a

political purpose as a show-case, to scare the opposition

or dissidents from being politically active. Here, methods

leaving physical marks (unsystematic and systematic

beatings, electrical torture, cuts and amputations) indeed

serve their purpose. In other settings, the regime pretends

to comply with human rights and applies torture methods

which leave no marks so that international missions do

not detect them. Torture that leaves no visible marks

can include psychological torture, such as deprivation,

induced desperation, threats, sexual humiliation or

Documentation of torture, both the torture methods

used and the medical documentation of the health

consequences of torture, is best made according to

an internationally recognized standard procedure: the

of detention often takes place in connection with national

or international external monitoring mechanisms.

Torture leaves severe marks on the body and mind. A

recent review of 181 studies demonstrates that posttraumatic

stress disorder and depression are frequent

The main approach to the prevention of torture is

the independent monitoring of prisons. Monitoring

mechanisms, which represent the outside world looking

at what goes on behind bars, can contribute to prevention

through making recommendations to the authorities and/

or by making the findings known to the public.

National monitoring mechanisms include:

• prison inspectorate/police inspectorate;

• parliamentary committees;

• lay monitoring committees;

• national preventive mechanisms established or

appointed according to the Optional Protocol to the

United Nations Convention against Torture – often an

ombudsman or national human rights institutes;

• national nongovernmental organizations.

International mechanisms include:

• the United Nations Sub-Committee for the Prevention

of Torture;

• the United Nations Special Rapporteur for Torture;

• the International Committee for the Red Cross;

• the Council of Europe Committee for the Prevention

of Torture and Inhuman or Degrading Treatment or

Punishment;

Many intergovernmental monitoring bodies operate with a

mandate based on confidentiality, and publication of their

findings may only take place if the host state party agrees.

Thus documentation of the occurrence of torture rarely

originates publicly from these bodies, but rather from

national and international nongovernmental organizations

(such as Amnesty International and Human Rights Watch)

in their country or annual reports.

To address the prevention of violence, the starting point

is in the explanation of models of violence. To understand

their violence-prone behaviour to the institutions through

their histories, personal attributes and links to criminal

groups, for example. This model would direct prevention

efforts toward addressing the individual prisoners’

proneness to violence through initiatives such as anger

management programmes.

and loss of freedom cause psychological trauma so that,

for self-preservation, prisoners create an oppositional

prison subculture promoting violence. This model would

direct prevention efforts towards the environmental

factors and general prison climate, which need to be

addressed by prison management.

23

Violence, sexual abuse and torture in prisons

Recent literature has predominantly focused on the details

of prison organization, interactions between people and

situational factors of considerable significance for prison

violence.

Individual risk factors for committing violence range from

potential violence to assaults with serious injuries. Youth

and short sentences are associated with higher levels of

violent misconduct, while older age, drug convictions and

a higher educational attainment indicate reduced violent

offences, violent victimization and psychiatric treatment

were associated with increased risk of injuries. Work

assignments reduced violence-related risks but increased

the possibility of accident-related risks.

prison for inmates with and without mental disorders, and

found that the rates were approximately 2.5 times higher

for inmates with a mental disorder and three times higher

among female inmates compared to males.

Other special needs groups are likely to be at risk of

victimization, such as inmates suffering from chronic

diseases, minorities (ethnic, sexual, religious) and inmates

with substance abuse. Also the rising population of older

the health problems and functional deficits prevailing

among older prisoners, it is likely that such victimization

has a considerable impact on their quality of life and

feelings of safety and security.

Studies have found a greater risk of violent incidents in

because high-security facilities host more violenceprone

prisoners. However, it might also be expected that

security measures serve to manage the risk of violence

and thereby prevent it. An explanation put forward by

Gadon and colleagues is that increased surveillance

creates greater levels of violence through a self-fulfilling

prophecy.

There is also evidence that mixing the ages of prisoners

may be associated with lower levels of violence than

those found among groups of younger prisoners.

A study including 371 American prisons revealed that

poor prison management is associated with assaults on

included the guard–inmate ratio, guard turnover rate,

ratio of white–black correctional staff, involvement in

educational, vocational or industrial programmes and size

of institution. Violence between inmates and violence

against staff are correlated because staff are often injured

Most violent episodes occur at the weekends, which could

be a consequence of the lack of vocational and educational

to be a risk factor for violence, but the evidence for this is

In conclusion, risk factors for violence in prison settings

involve factors related to the level of security, mix

of prisoners, staff experience, days of the week and

management approaches and relationships between

It is also a plausible assumption that fights among

inmates are often triggered by disagreements about

underground economy issues such as money, drugs,

phenomenon in survey data from 208 recently released

inmates in a midwestern state (United States) and

concluded that participation in the prison economy (being

in debt, borrowing money and having too little money to

buy goods) is predictive of victimization through violence:

Although the picture is complex, and some inconsistent

findings have emerged, generally the literature supports the

notion that the more coercive the prison environment the

greater potential for violence. This is especially so where

prison management and treatment of prisoners are perceived

by prisoners as unfair or illegitimate, as this strengthens

The joint efforts of ombudsmen, prison inspectorates

and independent monitoring bodies have not managed

Inspection standards developed in a monitoring context

may, however, serve as standards for further quality

assurance. One example is the healthy prison concept

developed by Her Majesty’s Prison Inspectorate in the

• held in safety

• treated with respect for their human rights

• offered purposeful activity

• prepared for re-settlement into the community.

Recently, performance indicators have emerged as a

way of measuring institutional development. In terms of

violence prevention, an example of a key performance

indicator may be the proportion (say, 90%) of prisoners who

felt safe the first night in prison and generally thereafter.

Measuring the status of this indicator empirically (through

24

Prisons and health

surveys) and comparing actual performance to the target

performance will provide an indication of the need for

further measures.

On a more holistic note, the concept of the moral

performance of prisons has been developed by Liebling

point of view of inmates. This is a conceptual framework

that is related to the overall social climate and respect

for prisoners in general, and to the occurrence of violence

and abuses specifically. The overall values included in this

concept are:

• respect

• humanity

• staff–prisoner relationships

• trust

• support

• power/authority

• social relations

• fairness

• order

• safety

• well-being

• personal development

• family contact

• decency

• meaning

• quality of life.

A tool has been developed (Measuring Quality of Prison

Life) to measure the compliance of prisons with this

conceptual framework. This tool has been included in

the routine assessments made by Her Majesty’s Prison

Inspectorate in the United Kingdom.

While the prison management, including security

measures and prison climate, has been identified above as

the key factor in preventing violence, the health services

have the potential to make an important contribution

to the prevention of violence. Access to health care is

associated with the prison climate: a positive prison

climate facilitates interactions between correctional and

health care staff and prisoners, while in negative climates

correctional staff act as a filter or barrier between inmates

When violence leads to injuries or to psychological

consequences, the prison health service is frequently

involved in attending to the victims. In delicate cases (cases

of sexual violence, torture, or staff-on-prisoner violence),

the health services may be involved under a false pretext,

such as accidents, fights between prisoners or “falls”. They

may even be pressured to make a false report on the causes

of the injury. However, it is important to develop a precise

health information registry of the causes and circumstances

of the injury, that is, violence between prisoners or between

staff and prisoner. With an injury registry in place, the

injury data can provide indispensable information on how

to prevent violence through the examination of such factors

as the place, time and day, circumstances, persons involved

and the nature of the violence.

Of particular importance for the prevention of violence is

the initial medical examination carried out on arrival in the

alia, identification of indications (report, signs, symptoms)

of violence or even torture experienced prior to arrival at

the institution. A careful record should be made of such

signs and symptoms and made available to the prisoner

for potential subsequent complaint or legal remedy.

In addition to the health information registry of episodes of

violence for internal consumption and quality development,

the health services need to have a reporting mechanism

to independent authorities, such as the ministry of health

or an independent human rights body, to ensure that the

delicate and punishable cases of violence, torture or

sexual abuse may be evaluated neutrally, according to

international standards such as the Istanbul Protocol.

The integrity of the health services, that is, the ability

to operate professionally independent of the prison

management, is at stake here, as is the technical capacity

to document sensitive cases of violence, torture and

sexual abuse for future documentation and legal remedy.

As mentioned above, many special needs groups (ethnic,

sexual and religious minorities, minors) are at increased

risk of being victimized by violence, sexual abuse and

even torture. This also applies to prisoners with mental

health disorders.

The initial medical examination may serve to identify

prisoners with such special needs at an early stage. This

allows the prison health service – with the consent of

the prisoners – to put forward recommendations for their

protection, often through meeting the special needs that

apply to each group.

1. Wolff N, Blitz CL, Shi J. Rates of sexual victimization in

prison for inmates with and without mental disorders.

2. Fagan AA. The relationship between adolescent

physical abuse and criminal offending: support for an

25

Violence, sexual abuse and torture in prisons

York, United Nations, 1990 (http://www.ohchr.org/

EN/ProfessionalInterest/Pages/BasicPrinciplesTreat

mentOfPrisoners.aspx, accessed 7 November 2013).

Centre for the Study of Violence and Reconciliation,

2007 (Briefing Report No 2).

5. Byrne JM, Hummer D. Myths and realities of prison

Organization, 1996 (WHO/EHA/SPI.POA.2).

8. Wolff N, Shi J, Blitz CL. Racial and ethnic disparities

9. Schneider K et al. Psychological distress and experience

of sexual and physical assault among Australian

2011, 21(5):333.

10. Kuanliang A, Sorensen JR, Cunningham MD. Juvenile

inmates in an adult prison system: rates of disciplinary

2008, 35:1186.

11. Safran DA, Tartaglini AJ. Workplace violence in an

urban jail setting. In: VandenBos GR, Bulatao EQ, eds.

Association, 1996.

12. Kratcoski PC. The implications of research explaining

52(1):27–32.

Elsevier, 1980.

14. Wolff N, Shi J. Patterns of victimization and feelings

of safety inside prison: the experience of male and

Justice, 2004.

DC, U.S. Department of Justice, 2007 (Report No. NCJ

219414).

Irvine, CA, University of California, Center for Evidence-

Based Corrections, 2007.

18. Banbury S. Coercive sexual behaviour in British

19. Struckman-Johnson C, Struckman-Johnson D. Sexual

coercion reported by women in three midwestern

227.

20. Wolff N, Shi J, Bachman R. Measuring victimization

Nations, 1987 (Treaty Series. Vol. 1465) (http://

treaties.un.org/doc/Publication/UNTS/Volume%20

1465/volume-1465-I-24841-English.pdf, accessed 9

November 2013).

22. Modvig J, Jaranson J. A global perspective of torture,

political violence, and health. In: Wilson JP, Drozdek B,

Brunner-Routledge Press, 2004.

23. Fiske ST, Harris LT, Cuddy AJC. Why ordinary people

1483.

24. Andersen HS et al. A longitudinal study of prisoners on

remand: repeated measures of psychopathology in the

initial phase of solitary versus nonsolitary confinement.

26(2):165–177.

25. Ojeda AE. What is psychological torture? In: Ojeda

Barbara, CA, Praeger, 2008.

26. McCulloch J, George A. Naked power. Strip searching

in womens’ prisons. In: Scraton P, McCulloch J,

Routledge, 2009.

of the United Nations High Commissioner for Human

Rights, 1999 (Professional Training Series No. 8/Rev.1)

(http://www.ohchr.org/Documents/Publications/

training8Rev1en.pdf, accessed 8 November 2013).

28. Steel Z et al. Association of torture and other potentially

traumatic events with mental health outcomes among

populations exposed to mass conflict and displacement.

29. Homel R, Thomson C. Causes and prevention of

violence in prisons. In: O’Toole S, Eyland S, eds.

Press, 2005.

26

Prisons and health

30. Cunningham MD, Sorensen JR. Actuarial models

for assessing prison violence risk: revisions and

extensions of the risk assessment scale for prison

31. Sung H-E. Prevalence and risk factors of violencerelated

and accident-related injuries among state

16(3):178–187.

32. Wolff N, Blitz CL, Shi J. Physical violence inside

2012 (http://www.hrw.org/sites/default/files/reports/

usprisons0112webwcover_0.pdf, accessed 9 November

2013).

34. Gadon L, Johnstone L, Cooke D. Situational variables

and institutional violence: a systematic review of the

534.

35. McGorkle RC, Miethe TD, Drass KA. The roots of prison

violence: a test of the deprivation, management and

1995, 41(3):317–331.

36. Copes H et al. Participation in the prison economy

37. Medlicott D. Preventing torture and casual cruelty in

prisons through independent monitoring. In: Scraton P,

York, NY, Routledge, 2009.

Downing College, 2011 (http://www.cepprobation.

org/uploaded_files/Pres%20STARR%20Cam%2010%

20Liebling.pdf, accessed 9 November 2013).

39. Ross MW, Liebling A, Tait S. The relationships of prison

climate to health service in correctional environments:

inmate health care measurement, satisfaction and

Strasbourg, Council of Europe, 2010 (CPT/Inf/E (2002)

1 – Rev. 2010) (http://www.cpt.coe.int/en/documents/

eng-standards.pdf, accessed 9 November 2013).

New York, NY, Routledge, 2009.

27

• Solitary confinement is used in prison systems across

the world.

• Research demonstrates that solitary confinement has

a negative impact on the health and well-being of

those subjected to it, especially for a prolonged time.

• Those with pre-existing mental illness are particularly

vulnerable to the effects of solitary confinement.

• Solitary confinement can affect rehabilitation efforts

and former prisoners’ chances of successful reintegration

into society following their release.

• International human rights law requires that the use

of solitary confinement must be kept to a minimum

and reserved for the few cases where it is absolutely

necessary, and that it should be used for as short a

time as possible.

WHO defines health as a “state of complete physical,

mental and social wellbeing, not merely the absence

of disease or infirmity”, affirming that health, as

confinement negatively affects all these aspects of

health. It is an extreme form of confinement whose

deleterious physical, mental and social health

effects have long been observed and documented

by practitioners and researchers alike. Yet solitary

confinement is a common and universal feature of

prison systems worldwide, used throughout the

various stages of the criminal justice process and for a

variety of reasons including punishment, containment

and protection. This chapter offers a brief overview

of the practice, with a particular focus on key issues

relevant to prison health care staff.

The term “solitary confinement” refers to the physical

and social isolation of an individual in a single cell

for 22.5 to 24 hours a day, with the remaining time

Different jurisdictions may use other terms to describe

what is essentially a regime of solitary confinement as

defined above, including segregation, isolation, closed

confinement, 23/7 regime, cellular confinement and

The deprivation of human contact inherent in solitary

confinement is usually accompanied by additional

restrictions and controls applied to the prisoner. The exact

nature of these will of course vary from one jurisdiction

to another. But in most, isolated prisoners will have very

limited, if any, access to educational, vocational and

recreational activities, all conducted in isolation from

others. The number and type of personal belongings

allowed in prisoners’ small, sometimes windowless cells

are highly restricted and closely regulated. Their cells

and few belongings are closely monitored and regularly

searched. Inside their cells, prisoners are monitored

either by closed circuit television or directly by guards.

Family visits, where allowed at all, may be held through

a glass barrier, preventing any physical contact between

the prisoner and others. On the few occasions prisoners

leave their cells, they are typically escorted by a minimum

of two guards and restrained with handcuffs and in some

cases placed in additional body restraints, such as legirons

and body-belts. Prior to being returned to their cells,

they will be body-searched and, in some jurisdictions,

subject to a full body-cavity search.

In short, isolated prisoners would typically spend a

minimum of 22.5 hours a day locked up alone in a small

cell with few personal belongings and little to do.

They are routinely subjected to body searches and the

application of physical restraints, as well as limits on their

communication with the outside world. This regime can

last for months or years, and can be of an indeterminate

duration.

The physical conditions in solitary cells range from

reasonably sized cells with windows and natural light,

self-contained with a toilet and a shower screened-off

from the rest of the cell to protect the prisoner’s privacy,

to small, windowless, filthy cells where prisoners have

to use a bucket to relieve themselves. Similarly, in some

2 The requirement to provide prisoners with a minimum of one hour of fresh air and exercise daily is enshrined in international law as well as in national laws in

many jurisdictions.

3 This should be distinguished from isolation (or seclusion) for medical purposes, which is not discussed here.

28

Prisons and health

prisons, isolated prisoners may have access to books,

television and a radio inside their cells, whereas in others

prisoners may only be allowed a copy of a religious text, if

any books at all. Finally, the degree and quality of human

contact prisoners enjoy varies greatly, from no human

contact other than with silent prison staff who deliver

food and medication to the prisoner inside his cell, to

regular contact with family, lawyers, religious personnel

and so on.

Three main factors are inherent in all solitary confinement

regimes: social isolation, reduced activity and

environmental input, and loss of autonomy and control

over almost all aspects of daily life. Each of these factors

is potentially distressing. Together they create a potent

and toxic mix, the effects of which were well summarized

as early as 1861 by the Chief Medical Officer at the

Fremantle Convict Establishment in Western Australia:

In a medical point of view I think there can be no question

but that separate or solitary confinement acts injuriously,

from first to last, on the health and constitution of anybody

subjected to it ... the symptoms of its pernicious constitutional

influence being consecutively pallor, depression, debility,

The rich body of literature that has accumulated since

that time on the effects on health of solitary confinement

largely echoes these observations and includes anxiety,

depression, anger, cognitive disturbances, perceptual

distortions, paranoia and psychosis among other

symptoms resulting from solitary confinement. Levels of

self-harm and suicide, which are already much higher

The effects on health of solitary confinement include

physiological signs and symptoms, such as:

Psychological symptoms occur in the following areas and

range from acute to chronic:

• anxiety, ranging from feelings of tension to full-blown

panic attacks:

− persistent low level of stress;

− irritability or anxiety;

− fear of impending death;

− panic attacks;

• depression, varying from low mood to clinical depression:

− emotional flatness/blunting;

− emotional liability (mood swings);

− hopelessness;

− social withdrawal, loss of initiation of activity or

ideas, apathy, lethargy;

− major depression;

• anger, ranging from irritability to rage:

− irritability and hostility;

− poor impulse control;

− outbursts of physical and verbal violence against

others, self and objects;

− unprovoked anger, sometimes manifesting as rage;

• cognitive disturbances, ranging from lack of

concentration to confused states:

− short attention span;

− poor concentration;

− poor memory;

− confused thought processes, disorientation;

• perceptual distortions, ranging from hypersensitivity

to hallucinations:

− hypersensitivity to noises and smells;

− distortions in time and space;

− depersonalization, detachment from reality;

− hallucinations affecting all five senses (for example,

hallucinations of objects or people appearing in the

cell, or hearing voices);

• paranoia and psychosis, ranging from obsessional

thoughts to full-blown psychosis:

− recurrent and persistent thoughts (ruminations)

often of a violent and vengeful character (for

example, directed against prison staff);

− paranoid ideas, often persecutory;

− psychotic episodes or states: psychotic depression,

schizophrenia;

• self-harm and suicide.

How individuals will react to the experience of being

isolated from the company of others depends on personal,

environmental and institutional factors, including their

individual histories, the conditions in which they are held,

the regime provisions which they can access, the degree

and form of human contact they can enjoy and the context

of their confinement. Research has also shown that both

the duration of solitary confinement and uncertainty as to

the length of time the individual can expect to spend in

solitary confinement promote a sense of helplessness and

determinants of the extent of adverse health effects

experienced.

• gastro-intestinal and

genito-urinary problems

• diaphoresis

• insomnia

• deterioration of

eyesight

• lethargy, weakness,

profound fatigue

• feeling cold

• heart palpitations

• migraine headaches

• back and other joint

pains

• poor appetite, weight

loss, diarrhoea

• tremulousness

• aggravation of

pre-existing medical

problems.

29

Solitary confinement as a prison health issue

The adverse effects of solitary confinement will thus vary,

depending on the pre-morbid adjustment of the individual

and the context, length and conditions of confinement.

The experience of previous trauma will render the person

more vulnerable, as will the involuntary nature of his/her

solitary confinement and confinement that persists over

a sustained period of time. Initial acute reactions may be

followed by chronic symptoms if the regime of solitary

confinement persists.

There is, however, and regardless of these variables and

among health practitioners and researchers that solitary

confinement adversely affects health and well-being

and prisoners’ chances of successful reintegration into

confinement are so consistent that Harvard psychiatrist

Stuart Grassian, a long-time researcher of and

commentator on solitary confinement, contends that the

constellation of these effects forms a unique syndrome,

which he terms the “isolation syndrome”:

… while this syndrome is strikingly atypical for the

functional psychiatric illnesses, it is quite characteristic of

an acute organic brain syndrome: delirium, characterized

by a decreased level of alertness, EEG abnormalities

... perceptual and cognitive disturbances, fearfulness,

paranoia, and agitation; and random, impulsive and selfdestructive

While the effects of solitary confinement vary from one

individual to another and depend on the factors listed

above, some individuals are particularly vulnerable to

the negative effects of isolation, including those with

pre-existing mental and learning disabilities, children

and young people and detainees held on remand. These

categories are briefly examined below.

People who suffer mental problems are grossly

overrepresented in prisons in general, and in

may be segregated for their own protection because

they are victimized by other prisoners, or they may end

up in isolation because they misunderstand the rules

and regulations that govern prison life. They may also

behave in ways that, in the context of high-security

confinement, are interpreted as violations of rules rather

than a manifestation of their mental problems. Where

prisoners’ progression through the system depends on

their behaviour and perceived adherence to prison rules,

this can “turn a minor incident into a serious situation”

prolonged stay in isolation, where these very conditions

make them worse and less able to abide by the rules

and regulations. Furthermore, placement in isolation, as

noted earlier, also limits prisoners’ access to privileges,

programmes and work release assignments and affects

Experts largely agree that individuals with pre-existing mental

illness are at a particularly high risk of worsening psychiatric

problems as a result of their isolation (for example, Grassian

being recognized by the courts on both sides of the Atlantic.

In a case involving the placement of a prisoner with known

mental health problems in punitive isolation for 45 days and

his subsequent suicide, for example, the European Court on

Human Rights reiterated that:

… the vulnerability of mentally ill persons calls for special

protection. This applies all the more where a prisoner

suffering from severe disturbance is placed, as in [this] case,

in solitary confinement or a punishment cell for a prolonged

period, which will inevitably have an impact on his mental

state, and where he has actually attempted to commit

In a class action lawsuit involving the Security Housing

Unit at Pelican Bay, California, federal judge Thelton

Henderson observed that conditions there may well “hover

on the edge of what is humanly tolerable for those with

normal resilience, particularly when endured for extended

prolonged isolation at the Unit were not tolerable. These

prisoners included, according to the court:

The already mentally ill, as well as persons with borderline

personality disorders, brain damage or mental retardation,

impulse-ridden personalities, or a history of prior psychiatric

problems or chronic depression. For these inmates, placing

them in the SHU is the mental equivalent of putting an

The particularly devastating effects that solitary

confinement has on the mentally ill were more recently

also recognized by the American Psychiatric Association,

compared to normative adult samples. However, elevations were present among the comparison groups too, suggesting that high degrees of psychological

disturbances are not unique to the [administrative segregation] environment”. The study also found that mentally ill prisoners were more aggravated by their

experiences of isolation than prisoners who were not (diagnosed as) mentally ill, but this was true whether they were in segregation or the general population. The

30

Prisons and health

which stated that: “Prolonged segregation of adult inmates

with serious mental illness, with rare exceptions, should be

Children and young adults are still developing physically,

mentally and socially. This makes them particularly

vulnerable to the negative effects of solitary confinement

which, as psychologist Craig Haney put it, is the

equivalent of placing them in a deep-freeze. Furthermore,

the prevalence of mental illness among young people in

prison is even higher than among adult prisoners, with as

many as 95% having at least one mental health problem

important to note that young people in prisons are 18

times more likely to commit suicide than their counterparts

the United States Attorney General to report on children

exposed to violence noted the following:

Nowhere is the damaging impact of incarceration on

vulnerable children more obvious than when it involves

solitary confinement .... Juveniles experience symptoms

of paranoia, anxiety, and depression even after very short

periods of isolation. Confined youth who spend extended

periods isolated are among the most likely to attempt or

actually commit suicide. One national study found that among

the suicides in juvenile facilities, half of the victims were in

isolation at the time they took their own lives, and 62 percent

The practice of isolating young people, both in juvenile

facilities and in adult prisons, either for their own

protection or as punishment is nonetheless common. In

Texas, for example, a 2012 survey found that “the majority

of jails held juveniles in solitary confinement for 6 months

physical restraint and solitary confinement of children in

England and Wales found that solitary confinement was

widely used in institutions for young offenders: during an

18-month period, for example, 519 children were placed in

Such practices and the particular vulnerability of

young people have led international bodies as well as

professional associations to call for a prohibition on the

use of solitary confinement for juveniles. Rule 67 of the

United Nations Rules for the Protection of Juveniles

confinement among a list of prohibited treatments:

All disciplinary measures constituting cruel, inhuman or

degrading treatment shall be strictly prohibited, including

corporal punishment, placement in a dark cell, closed or solitary

confinement or any other punishment that may compromise

the physical or mental health of the juvenile concerned. The

reduction of diet and the restriction or denial of contact with

family members should be prohibited for any purpose.

among others, all call for a complete ban on the use of

solitary confinement with juveniles and young people. The

American Academy of Child and Adolescent Psychiatry

has stated that where solitary confinement is used, the

young person should be evaluated by a mental health

Detainees held on remand are another particularly

vulnerable group, and research shows that their

vulnerability is made worse in solitary confinement. In

England and Wales, one study found that 54% of prison

suicides took place among detainees held on remand,

and that around half of these occurred within one month

detainees held on remand in Denmark, found that where

detainees were isolated for four weeks, “the probability

of being admitted to hospital for a psychiatric reason

was about 20 times as high as for a person remanded

in non-solitary confinement for the same period of time”

by the Swedish Prisons and Probation Service to

examine the health effects of restricted detention among

those held on remand (including solitary confinement)

found that such detention poses a “significant risk of

psychiatric contact, substance abuse, gender, parenting)

are controlled for. One in four of those detained with

restrictions suffered mental illness, compared to one

in five of those held without restrictions. A qualitative

study carried out in parallel to the main study found that

three factors are particularly harmful to mental wellbeing

and behaviour in prison: passivity, uncertainty and

feelings of impotence. These factors, which are present

to some degree in any form of confinement, are of course

magnified in isolation.

In sum, the literature shows that solitary confinement is

damaging across the board, with young people, detainees

held on remand and people with learning difficulties and

mental illness being particularly vulnerable to the damaging

7 In the United States, a jail is a city or county prison.

31

Solitary confinement as a prison health issue

effects of solitary confinement. The key negative health

effects of solitary confinement are listed above.

While some of the adverse health effects of solitary

confinement will subside on its termination, others

may persist. The lasting effects of solitary confinement

are perhaps most evident in social settings and with

interpersonal relationships:

Although many of the acute symptoms suffered by

inmates are likely to subside upon termination of solitary

confinement, many – including some who did not become

overtly psychiatrically ill during their confinement in solitary

– will likely suffer permanent harm as a result of such

confinement. This harm is most commonly manifested by a

continued intolerance of social interaction, a handicap which

often prevents the inmate from successfully readjusting

to the broader social environment of general population in

prison and … often severely impairs the inmate’s capacity

to reintegrate into the broader society upon release from

The transition from life in solitary confinement to coexistence

with others, whether in general prisons or in

free society, can be sharp and unsettling. Some of the very

survival skills adopted in reaction to the pains of isolation,

such as withdrawal and going mute, render the individual

dysfunctional upon release. Some become so dependent

on the structure and routines of the prison for controlling

their behaviour that they find it difficult to function

without them. This problem of becoming institutionalized

is experienced by many prisoners on their release, but it

takes on a much more acute form when the transition is

necessary social skills to lead a functioning social life,

some of those held in solitary confinement in prison may

continue to live in relative social isolation after their

release. In this sense, solitary confinement operates

against one of the main purposes of the prison, which is

to rehabilitate offenders and facilitate their reintegration

into society.

Each state has its own peculiarities but in most, solitary

confinement is used throughout the different stages of

the criminal process: pre-charge, pre-trial and following

conviction. The principle of isolation is common to all these

uses, but each entails slightly different arrangements and

has a different rationale and different official goals.

Solitary confinement can be used:

is also an interrogation technique, particularly for

people suspected of committing acts against state

security;

remand is to prevent collusion and to prevent them

from intimidating potential witnesses;

institution while the newly arrived prisoner is being

risk assessed.

Solitary confinement also has several roles or purposes

• as a short term-punishment for prisoners who break

prison rules;

• to prevent escape;

• for the prisoners’ own protection to prevent them from

harming themselves or being harmed by others;

• as a prison management tool for the safe management

of difficult and challenging prisoners, and for the

management of prisoners belonging to certain groups

(such as prison gang members);

• where capital punishment is still practised; death row

prisoners are typically held in solitary confinement,

and where the death penalty has been abolished it is

often substituted with a sentence of life in conditions

of solitary confinement, on the basis that prisoners

sentenced to death have nothing to lose and may

therefore commit serious crimes inside prison or

indeed attempt to escape;

• while awaiting transfer to another prison or to a

hospital, disciplinary or classification hearing, or a

bed; these are temporary measures, but in some cases

the prisoner may be isolated for many weeks and

sometimes months;

punishment can mean that prisoners are confined to

their cells for an entire day or for several days at a

time in what is commonly known as lockdown.

considered hidden forms of isolation.

Whatever the reason for placing a detainee or prisoner

in solitary confinement, its use in any one case must be

proportionate and reasonable and the decision taken by

the competent lawful authority. The prisoner must be

informed, in writing, of the reasons for his/her placement

in solitary confinement, its expected duration and the

appeal process. A record of the decision must be kept

on file, and it must be substantively reviewed at regular

intervals by a body different to that which took the initial

32

Prisons and health

The severity of solitary confinement and its potentially

devastating effects on the health and well-being of those

subjected to it are recognized under international law,

where the practice occupies a special place. The United

Nations has gone as far as calling for its abolition as

states: “Solitary confinement shall be imposed as a

punishment only in exceptional cases and for a specified

The courts and international monitoring bodies also pay

particular attention to the practice and, in the light of its

severity, have asserted that it is a practice which in some

circumstances constitutes a form of torture, inhuman

or degrading treatment (see, for example, the United

As far back as 1978, the former European Commission of

Human Rights stated the following:

Complete sensory isolation coupled with complete social

isolation can no doubt ultimately destroy the personality;

thus it constitutes a form of inhuman treatment which

cannot be justified by the requirements of security, the

prohibition on torture and inhuman treatment contained in

This position has since been affirmed and reaffirmed by

the European Court in numerous cases: see, for example,

isolation for more than three years of a prisoner labelled

as a persistent rule-breaker, the court reiterated that:

“... solitary confinement without appropriate mental and

physical stimulation is likely, in the long term, to have

damaging effects, resulting in deterioration of mental

To fall under the scope of Article 3, the prisoner’s treatment

must cause suffering which exceeds the unavoidable

level inherent in detention (Onoufriou v. Cyprus [2010]

circumstances of the case, such as the duration of the

treatment, its physical and mental effects and, in some

cases, the state of health of the victim (Kudł v. Poland

such treatment will be taken into account, in particular

the question of whether it was intended to humiliate or

debase the victim, but the absence of any such purpose

does not necessarily mean that Article 3 has not been

While solitary confinement has always been viewed

by international human rights law and bodies as an

undesirable, if legitimate, prison practice, it is only in

the last few years that a more concentrated and targeted

campaign against its use especially for prolonged

periods, has begun. In 2007, a group of international

experts adopted the Istanbul Statement on the Use and

Effects of Solitary Confinement, calling on states to

limit the use of solitary confinement to very exceptional

cases, for as short a time as possible, and only as a

Rapporteur on Torture, Manfred Nowak, endorsed these

recommendations and added that: “Regardless of the

specific circumstances of its use, effort is required to raise

the level of social contacts for prisoners: prisoner-prison

staff contact, allowing access to social activities with

other prisoners, allowing more visits and providing access

In August 2011, the then new United Nations Special

Rapporteur on Torture, Juan Mendez, focused his periodic

report to the United Nations General Assembly on the

practice of solitary confinement, stating that it is a “harsh

measure which may cause serious psychological and

physiological adverse effects on individuals” and which

can violate the international prohibition against torture

the Special Rapporteur called for the absolute prohibition

of prolonged solitary confinement, which he defined as a

period in excess of 15 days. Soon thereafter, in November

2011, the CPT also focused its annual report on solitary

confinement, stating that it is a practice which “can have

an extremely damaging effect on the mental, somatic and

social health of those concerned. This damaging effect

can be immediate and increases the longer the measure

on states to reduce the use of solitary confinement to an

absolute minimum and ensure that its use in any given

case meets what the CPT has termed the PLANN test: it

must be proportionate, lawful, accountable, necessary

Solitary confinement is a prison practice whose harmful

effects on health and well-being are well documented. The

extent of psychological damage varies and will depend on

individual factors (such as personal background and preexisting

health problems), environmental factors (physical

conditions and provisions), regime (time out of cell, degree

of human contact), context of the isolation (punishment,

33

Solitary confinement as a prison health issue

own protection, voluntary/non-voluntary, political/

criminal) and its duration. Notwithstanding variations in

individual tolerance and environmental and contextual

factors, there is remarkable consistency in research

findings on the health effects of solitary confinement

dating back to the 19th century. These have demonstrated

negative health effects, in particular psychological but

also physiological.

The best way to avoid such damage to health and wellbeing

is not to isolate prisoners. Where this is absolutely

necessary, it should only be done as a last resort and for as

short a time as possible. The decision to place a prisoner in

solitary confinement must always be made by a competent

body, transparently and in accordance with due process

requirements, and be subject to regular, independent and

substantive review. The prisoner must be kept in decent

physical conditions and have regular access to fresh air

and exercise. Educational, recreational and vocational

programmes must be provided to prisoners, ideally in

association with others, and prisoners should be allowed

to keep books, magazines, hobbies and craft materials

in their cells. They must be afforded regular, meaningful

human contact, ideally also with people from outside

the prison, but prison staff should also be encouraged to

communicate informally with prisoners who are held in

solitary confinement. Finally, isolated prisoners should be

allowed, and encouraged, to maintain contact with their

friends and family, through open (contact) visits, letters

and telephone communications. Crucially, prisoners must

always be treated with respect for their inherent dignity

as human beings.

Office for Europe, 1978 (http://www.euro.who.

int/__data/assets/pdf_file/0009/113877/E93944.pdf,

accessed 10 November 2013).

accessed 10 November 2013).

Mannheim Centre for Criminology, London School of

Economics, 2008 (http://www.solitaryconfinement.org/

sourcebook, accessed 10 November 2013).

2011 (DOC A/66/268).

5. Attfield GC. Surgeon at the Convict Establishment

Fremantle. Letter to AE Kennedy, Governor of Western

Australia, 30 April 186. In: House of Commons

Parliamentary Papers Online [website] (http://parli

papers.chadwyck.com/marketing/guide.jsp, accessed

22 April 2014).

6. Prisons and health: data and statistics [web site].

Copenhagen, WHO Regional Office for Europe, 2013

(http://www.euro.who.int/en/what-we-do/healthtopics/

health-determinants/prisons-and-health/factsand-

figures, accessed 13 January 2013).

7. Fazel S et al. Prison suicides in 12 countries: an ecological

Colorado Springs, CO, Colorado Department of

Corrections, 2010.

9. Casella J. ACLU and experts slam findings of Colorado

December 2010 (http://solitarywatch.com/ 2010/12/04/

aclu-and-experts-slam-findings-of-colorado-doc-reporton-

solitary-confinement/, accessed 10 November 2013).

10. Grassian S. Fatal flaws in the Colorado solitary

(http://solitarywatch.com/2010/11/15/fatal-flaws-inthe-

colorado-solitary-confinement-study/, accessed

10 November 2013).

nicic.gov/blogs/mentalhealth/archive/2011/06/21/oneyear-

longitudinal-study-of-the-psychological-effectsof-

administrative-segregation-introduction.aspx,

accessed 10 November 2013).

12. Scharff Smith P. The effects of solitary confinement

on prison inmates. A brief history and review of the

13. Grassian S. Psychiatric effects of solitary confinement.

law.wustl.edu/Journal/22/p325Grassian.pdf, accessed

11 February 2014).

Office of Juvenile Justice and Delinquency Prevention,

2004 (http://www.ncjrs.gov/pdffiles1/ojjdp/grants/

206354.pdf, accessed 13 January 2013).

Justice, National Institute of Corrections, May 2004.

16. Haney C. Mental health issues in long-term solitary

2003, 49(1):124–156.

Francisco, CA, Jossey-Bass, 1999.

34

Prisons and health

European Court of Human Rights, 2008 (http://hudoc.

echr.coe.int/sites/eng/pages/search.aspx?i=001-88972

#{“itemid”:[“001-88972”]}, accessed 13 November 2013).

20. The Civil Rights Litigation Clearing House. Madrid

v Gomez [web site]. Ann Arbor, MI, University of

Michigan, 1995 (http://www.clearinghouse.net/detail.

php?id=588, accessed 13 November 2013).

Association, 2012 (http://www.dhcs.ca.gov/services/

MH/Documents/2013_04_AC_06c_APA_ps2012_Priz

Seg.pdf, accessed 10 November 2013).

US Department of Justice, December 2012 (http://

www.justice.gov/defendingchildhood/cev-rpt-full.pdf,

accessed 10 November 2013).

London, The Howard League for Penal Reform, 2006.

1990 (A/RES/45/113) (http://www.un.org/documents/

ga/res/45/a45r113.htm, accessed 10 November 2013).

25. University of Essex and Penal Reform International.

Drugs and Crime, 2012 (UNODC/CCPCJ/EG.6/2012/

NGO/1) (http://www.unodc.org/documents/justice-andprison-

reform/EGM-Uploads/NGO-1_PRI-ESSEXUNI.

pdf, accessed 10 November 2013).

Washington, DC, American Academy of Child &

Adolescent Psychiatry, 2012 (http://www.aacap.org/

cs/root/policy_statements/solitary_confinement_of_

juvenile_offenders, accessed 10 November 2013).

27. Liebling A. Prison suicide and its prevention. In:

Willan, 2007.

28. Sestfot DM et al. Impact of solitary confinement on

hospitalisation among Danish prisoners in custody.

21(1):99–108.

29. Andersen HS et al. A longitudinal study of prisoners

on remand: repeated measures of psychopathology

in the initial phase of solitary versus non-solitary

Probation Service, 2011.

Heartland Alliance National Immigrant Justice Center

and Physicians for Human Rights, 2012 (https://

s3.amazonaws.com/PHR_Reports/Invisible-in-Isolation-

Sep2012-detention.pdf, accessed 10 November 2013).

Ombudsman of the Netherlands, 2012 (Report No.

2012/105) (http://www.nationaleombudsman.nl/sites/

default/files/report_2012105_immigration_detention.

pdf, accessed 10 November 2013).

of Europe, 2011 (CPT/Inf (2011) 28) (http://www.cpt.

coe.int/en/annual/rep-21.pdf, accessed 10 November

2013).

York, NY, United Nations, 1990 (A/RES/45/111)

(http://www.un.org/documents/ga/res/45/a45r111.

htm, accessed 10 November 2013).

(https://wcd.coe.int/ViewDoc.jsp?id=955747, accessed

7 November 2013).

(A/63/175) (http://unispal.un.org/UNISPAL.NSF/0/

707AC2611E22CE6B852574BB004F4C95, accessed

10 November 2013).

4 July 2006 (https://www.google.com/#q=Ramirez

+Sanchez%2C+v.+France+%5BGC%5D%2C+no.+594

50%2F00%2C+ECHR+2006-IX, accessed 10 November 2013).

Strasbourg, European Court of Human Rights, 3 October

2012 (http://hudoc.echr.coe.int/sites/eng/pages/search.

aspx?i=001-111837#{“itemid”:[“001-111837”]}, accessed

10 November 2013).

Strasbourg, European Court of Human Rights, 8 July

1978 (http://hudoc.echr.coe.int/sites/eng/pages/search.

35

Solitary confinement as a prison health issue

aspx?i=001-73445#{“itemid”:[“001-73445”]}, accessed

10 November 2013).

European Court of Human Rights, 12 May 2005 (http:// hudoc.

echr.coe.int/sites/eng/pages/search.aspx?i=001-69022

#{“itemid”:[“001-69022”]}, accessed 10 November 2013).

Rights, 24 September 2012 (http://hudoc. echr.coe.int/

sites/eng/pages/search.aspx?i=001-110267# {“itemid”:

[“001-110267”]}, accessed 10 November 2013).

Strasbourg, European Court of Human Rights, 7 April 2010

(http://www.google.com/url?sa=t&rct=j&q=&esrc=s&

frm=1&source=web&cd=2&ved=0CC4QFjAB&url=http

%3A%2F%2Fwww.law.gov.cy%2FLaw%2Flawoffice.

nsf%2F0%2FA25CA98D198CFF44C225742D002210

9E%2F%24file%2FOnoufriou%2520v%2520Cyprus.

Judgment.07.01.10.doc&ei=Ua9_UryZJqiY4gSv-YCg

BA&usg=AFQjCNGh01QV2vqmC6OlH5110rVFbuL91g,

accessed 10 November 2013).

European Court of Human Rights, 26 October 2000

(http://hudoc.echr.coe.int/sites/eng/pages/search.aspx?i

=001-58920#{“itemid”:[“001-58920”]}, accessed

10 November 2013).

European Court of Human Rights, 19 April 2001

(http://hudoc.echr.coe.int/sites/eng/pages/search.

aspx?i=001-59413#{“itemid”:[“001-59413”]}, accessed

10 November 2013).

American Civil Liberties Union and Human Rights Watch,

2012.

London, International Centre for Prison Studies, 2009.

European Committee for the Prevention of Torture

(CPT) country reports. Strasbourg, Council of Ministers,

2013 (http://www.cpt.coe.int/en/states.htm, accessed

10 November 2013).

Haney C. Mental health issues in long-term solitary and

49(1):124–156.

2005.

36

Pre-trial detainees are a particularly vulnerable group

when it comes to health conditions and the provision of

health services.

• Many more people move in and out of pre-trial

detention than will spend time in prison after

conviction.

• People in pre-trial detention have been arrested and

accused of a crime but not been found guilty of the

crime(s) charged.

• Places of pre-trial detention are often ill-equipped to

provide health services.

• People in pre-trial detention often spend time in

worse conditions than people who have already been

convicted.

• According to international legal standards, health

interventions should be available at the earliest

possible stage in the criminal justice system.

• Particular attention should be devoted to ensuring

continuity of treatment at all stages of the criminal

justice process.

• Under international legal standards, pre-trial detention

is to be used as an exceptional cautionary measure and

wide use is to be made of alternatives to detention.

• Pre-trial release (release pending completion of the

criminal justice process) can be an effective health

intervention by allowing people to be supervised in

the community where health services are more readily

available. It is also an effective way to reduce prison

overcrowding.

It is estimated that about one third of the global prison

population is detained prior to the completion of a

criminal justice process. In a single year, more than

10 million people globally will spend some time in this

type of detention. That is, they have been arrested

for an alleged offence and are held but have not been

found guilty of that crime. In many countries, pre-trial

detainees account for the majority of people incarcerated

by the criminal justice system, thereby contributing to

overcrowding issues (where such exist).

In some instances, pre-trial detainees are held in special

pre-trial detention centres but in others, they are held

in police cells or in prisons along with the convicted

population. Where pre-trial detainees are held in special

pre-trial detention centres, these centres may not provide

the same health services as the prisons because they are

considered short-term detention facilities. Police cells are

often ill-equipped to house detainees longer-term, and

often lack even basic necessities such as toilets or beds.

On the other hand, where pre-trial detainees are held in

prisons with convicted prisoners, they may not be provided

with access to the existing facilities owing to their nonconvicted

status. For example, they may be denied

treatment that requires a long-term commitment (such

as treatment for TB) because they are deemed temporary

detainees, or they may not have access to prison services

simply because they are not under the legal jurisdiction of

the prison while they are awaiting trial. In addition, people

frequently experience interruption of critically important

medications, such as medication to treat HIV, TB or drug

dependence, upon arrest, when they are detained in

police cells, transferred to pre-trial detention facilities or

appearing in court.

Most criminal justice systems formally differentiate

between sentenced and unsentenced prisoners, that is,

people who have been charged and convicted of a crime

and people who have been arrested on suspicion of a crime

but have yet to be tried and convicted. It is helpful to note

that the terms unsentenced prisoner, pre-trial detainee,

remand prisoner, remandee, awaiting trial detainee and

untried prisoner are used interchangeably in the literature.

According to Penal Reform International, “remand

prisoners are detained during criminal investigations and

pending trial. Pre-trial detention is not a sanction, but a

countries will also afford individuals who are accused

but not convicted a different legal status, in keeping with

international standards and norms.

International human rights norms emphasize the important

distinction between people who have been found guilty

(convicted by a court of law and sentenced to prison) and

those who have not. Prisoners awaiting their trial, or the

outcome of their trial, are regarded differently because

The use of pre-trial detention is restricted by several

international human rights treaties. The International

Covenant on Civil and Political Rights states the following

37

Health in pre-trial detention

Anyone arrested or detained on a criminal charge shall be

brought promptly before a judge or other officer authorized

by law to exercise judicial power and shall be entitled to trial

within a reasonable time or to release. It shall not be the general

rule that persons awaiting trial shall be detained in custody, but

release may be subject to guarantees to appear for trial.

International standards permit detention before trial only

under certain, limited circumstances. In 1990, the Eighth

United Nations Congress on the Prevention of Crime and

principle:

Pre-trial detention may be ordered only if there are reasonable

grounds to believe that the persons concerned have been

involved in the commission of the alleged offences and

there is a danger of their absconding or committing further

serious offences, or a danger that the course of justice will

be seriously interfered with if they are let free.

One of the major achievements of the Eighth United

Nations Congress was the adoption, by consensus, of the

United Nations Standard Minimum Rules for Non-custodial

pre-trial detention shall be used as a means of last resort

in criminal proceedings, and that alternatives to pre-trial

detention shall be employed at as early a stage as possible.

The tenor of international norms and standards in relation

to pre-trial detention is clear: restricting a defendant’s

freedom should be used sparingly and under prescribed

circumstances only. It follows that detention of an

accused should occur under circumstances that preserve

the presumption of innocence and will not entail a

punishment without a trial.

Pre-trial detainees can be a particularly vulnerable

group. The hours following an arrest can be confusing:

there may be a delay in communicating with the outside

world; torture to obtain confessions, when it happens,

typically occurs before trial; and temporary places of

detention (such as police cells) are often dirty, poorly lit

and ventilated, overcrowded and lacking basic equipment

such as beds and toilets.

Various factors exacerbate poor health conditions in

pre-trial detention. Firstly, pre-trial detention is seen as

a temporary circumstance with the ultimate goal being

dismissal of charges, acquittal or conviction after trial.

This creates three subsets of problems:

• in many countries pre-trial detention occurs in facilities

that are ill-equipped to deliver health services or to

house long-term residents, such as police stations;

• in other countries, pre-trial detainees fall under the

jurisdiction (care) of an institution other than the

agency that oversees convicted prisoners, leading to

accountability and oversight problems;

• in many countries, pre-trial detainees are not entitled

to participate in programmes that facilitate recovery

and re-entry into the community because these are

characterized as rehabilitation programmes and

a person who has not been convicted cannot by

definition be rehabilitated.

Unfortunately for pre-trial detainees, the short-term nature

of their status is often part of an illusory legal construct.

In 2003, the average length of pre-trial detention in 19 of

the then 25 member states of the European Union (EU)

was five and a half months, according to a European

(such as France), pre-trial detention can be allowed for

years and there are reports of people spending as many

individuals can spend 12 months without even a review

In many developing countries, the situation is worse. In

2005, the average length of pre-trial detention in Nigeria

detainees had been detained for between 5 and 17 years,

with cases reported of detainees awaiting trial for up

more time behind bars awaiting trial than the maximum

sentence they would receive if eventually convicted”

detainees must be brought to trial within 30 days of their

arrest.

In many countries the majority of people in prison are pretrial

detainees. Likewise, in many countries, prisons are

overcrowded by housing many more inmates than they

were designed to hold. Where these two factors conflate,

the health problems associated with prison overcrowding

arise from a failure to provide provisional release – in

violation of international norms – to people who have not

been convicted and are qualified to await their trial in the

community.

Interruption of treatment is one of the most complex

issues facing pre-trial detention centres and detainees.

For people who have been receiving treatment for a

medical condition in the community, arrest and detention

represent a potentially deadly interruption of treatment.

Treatment may be discontinued for short or long periods of

time following arrest and detention in police cells, when

detainees are transferred to other facilities or have to

appear in court, and upon release. Of particular concern

38

Prisons and health

is the interruption of treatments (such as for HIV) that

can lead to negative health outcomes for the individual

patient and also, through development of drug-resistant

strains of HIV, to negative public health consequences.

Even where pre-trial detainees have access to the same

services as convicted prisoners, prison health care is

often limited in some ways. Prisons may not have the

necessary specialized equipment, they may carry some

types of medication but not others, the medical team in

the prison may not be experienced in a particular illness,

and/or prison regulations may prevent family members

from providing medical assistance, such as doctors or

medication, even when it is not available in the institution

Health delivery in prisons should meet the minimum standards

set out in international laws, rules and conventions. Most of

the problems described here would be greatly diminished by

a reduction in pre-trial detention and the use of less restrictive

alternatives, such as provisional release paired with a referral

to community health care. Without reduced use of pre-trial

detention and the attendant problems of overcrowding,

it is difficult to imagine how these problems will be

excessive use of pre-trial detention and greatly increasing

the use of non-custodial alternatives to imprisonment

are essential components of any response to HIV and

other health issues in prisons and other closed settings”

in which health services could be improved and the possibility

enhanced for observing the health rights of persons in

detention. Some of these measures might also generate

information that would be helpful in advocating the reduced

use of pre-trial detention. Some avenues toward improved

practices and enhanced information are described below.

Pre-trial health services and staffing are often inadequate

compared to those in prisons and do not fulfil the state’s

obligation for early detection of health problems and

initiation of care. The non-involvement of ministries of

health in remand health services undermines links to

community-based care and may compromise the quality

of health services in remand facilities and the right to

equivalence of services for detainees. Pre-trial detention

is often a missed opportunity to avert illness and even

death, especially in cases of HIV, hepatitis, TB and some

mental disorders that require extended treatment and for

which early detection and treatment are crucial to good

outcomes. As mentioned above, it is extremely important

to ensure the continuation of therapy begun before a

person’s entry into detention. Each of the situations in

which treatment may be interrupted should be addressed

and mechanisms established to ensure this does not

happen. Policies and guidelines should be developed

specifying that people living with HIV (and other conditions

necessitating uninterrupted treatment) are allowed to

keep their medication with them, or are to be provided

with their medication upon arrest and detention and at

any time they are transferred within the system or to court

hearings. Police and staff working in detention settings

need to be educated about the importance of continuity

of treatment. Particular attention should be devoted to

discharge planning and links to community aftercare.

Because the organization of pre-trial detention may be

chaotic, with a rapid turnover of detainees, there is a

tendency not to initiate services that could be sustained

even in such an environment. Again, links between

community-based and prison-based care are crucial.

It should be possible to include pre-trial detention in a

continuum of care with regard to methadone therapy,

for example, as well as directly observed treatment,

short-course for TB and antiretroviral treatment for HIV.

Health promotion and information involving peers should

be possible, even with a high turnover, if staff develop

rapid orientation and training to build capacity for peer

leadership and engagement.

Finally, the provision of adequate basic services, including

health care, water, sanitation, food and protection from

the cold and/or heat, would have important benefits

beyond the obvious public health outcomes. To the degree

that detainees, including children and women, have to

trade sex for access to food, blankets and water, adequate

provision of these basic services will be a disincentive to

coercive sex. Violence linked to competition for access to

basic amenities would also be reduced.

Much of what is known about the unhealthy and

inhumane conditions faced by pre-trial detainees is

8 It is commonplace in the United States, for example, to refuse to provide any medication to inmates that was not purchased through the prison system, to avoid

issues of provenance and legality of substances. This means that if, for instance, a schizophrenic person is arrested and is carrying medication on his/her person,

the authorities will confiscate that medication, assuming that it is contraband, and substitute the closest equivalent found in the prison dispensary.

39

Health in pre-trial detention

found in reports of occasional visits by regional and

international human rights monitors. There is an urgent

need to open pre-trial detention conditions to wider

scrutiny, and to establish regular monitoring and public

reporting mechanisms. In many countries, access to legal

counsel and to the courts by pre-trial detainees would

be one avenue for addressing abusive and negligent

health practices. There should also be functioning and

sustained mechanisms for detainees to report abuses

and seek redress without endangering themselves. Such

mechanisms should involve competent and independent

health professionals.

Health professionals working in detention settings

need to be able to make independent, evidence-based

decisions to ensure that health needs and rights are met.

Their role as advocates for the health of detainees should

be safeguarded. They should also be protected from

being complicit in any practice that may constitute cruel,

inhuman or degrading treatment or torture, but must be

held accountable if they cross that line.

Achieving equivalence of care in prisons and remand

facilities to that of care in the community argues for

greater involvement of ministries of health. At a minimum,

they should be responsible for monitoring the quality

of care for detainees. The complete isolation of prison

and remand health services from the principal health

authorities of the state is a recipe for trouble.

In addition to the need for more information and research,

there is an urgent need for what is already known

about health in pre-trial detention to be more widely

disseminated, especially to those whose actions might

affect change. Ministries of health may be shielded

from day-to-day knowledge of conditions and services

if they are not involved in remand facilities, but their

involvement and awareness of conditions are important

for positive change to happen. Beyond the health sector,

judges, prosecutors, police, juvenile justice officials

and other people involved in law enforcement must be

made aware of the health consequences of heavy use

of pre-trial detention. Human rights commissions and

nongovernmental organizations not already involved with

prison health should be engaged.

Access to detention settings for researchers may be

restricted in many countries. The fact that health services

may be managed in remand facilities by ministries other

than the ministry of health may be a barrier to researchers

accustomed to interacting with health sector officials. In

particular, there are research needs in the following areas:

• better data on the extent of pre-trial detention,

particularly among women, children, people living

with drug dependency, people with mental illness and

others vulnerable to abuse and health problems;

• the relationship between the extent and duration of

pre-trial detention and a variety of health outcomes;

• the physical and mental health impact of overcrowding

in pre-trial detention, including whether it is possible

to determine critical levels of crowding that trigger

accelerated transmission of infectious diseases;

• the physical and mental health impact of extended

pre-trial detention on men, women and children;

• the difficulties faced by health professionals in

situations of pre-trial detention where services are

inadequate and abuse is prevalent;

• best practices for ensuring continuity of care for a

wide range of physical and mental health conditions

between the community and pre-trial detention, and

pre-trial detention and prison or the community;

• the feasibility of and best practices in TB detection,

treatment and support in pre-trial detention and

beyond.

Where there are efforts to reform pre-trial justice and

reduce the use of pre-trial detention, health officials

and practitioners should be involved in the planning and

implementation of reforms, and the health impact of

reforms should be documented.

International, 2013 (http://www.penalreform.org/

wp-content/uploads/2013/11/Factsheet-1-pre-trialdetention-

v10_final2.pdf, accessed 10 December 2013).

Geneva, Office of the High Commissioner for Human

Rights, 1966 (Article 9, sections (3) and (4)) (http://

www.ohchr.org/en/professionalinterest/pages/ccpr.

aspx, accessed 13 November 2013).

New York, NY, United Nations, 1955 (http://www.

unhcr.org/refworld/docid/3ae6b36e8.html, accessed

10 November 2013).

International Law, Organization of American States,

2012 (Article 7, sections (5) and (6), and article 8,

section (2)) (http://www.oas.org/dil/treaties_B-32_

American_Convention_on_Human_Rights.htm, accessed

13 November 2013).

40

Prisons and health

(https://wcd.coe.int/ViewDoc.jsp?id=955747, accessed

7 November 2013).

1990 (Article 17 (2)(b), p. 157) (http://www.asc41.com/

UN_congress/8th%20UN%20Congress%20on%20the

%20Prevention%20of%20Crime/026%20ACONF.144.28.

Rev.1%20Eighth%20United%20Nations%20Congress

%20on%20the%20Prevention%20of%20Crime%20

and%20the%20Treatment%20of%20Offenders.pdf,

accessed 13 November 2013).

MI, University of Michigan, 1990 (http://www1.

umn.edu/humanrts/instree/i6unsmr.htm, accessed

13 November 2013).

29 August 2006:10–11 (SEC(2006)1079) (http://

ec.europa.eu/governance/impact/ia_carried_out/

docs/ia_2006/sec_2006_1079_en.pdf, accessed

13 November 2013).

London, Fair Trials International, 2011:25–26 (http://www.

fairtrials.net/documents/DetentionWithout TrialFull

Report.pdf, accessed 13 November 2013).

10. Nwapa A. Building and sustaining change: pre-trial

2008:86.

11. Fapohunda O. Fayemi’s victory. Justice administration’s

allafrica.com/stories/printable/201010190813.html,

accessed 13 November 2013).

201007270184.html, accessed 13 November 2013).

(http://www.thenews.com.pk/TodaysPrintDetail.

aspx?ID=45633&Cat=9, accessed 13 November 2013).

on Drugs and Crime, 2013 (http://www.unodc.org/

documents/hiv-aids/HIV_prisons_advance_copy_

july_2012_leaflet_UNODC_ILO_UNDP_Ebook.pdf,

accessed 13 November 2013).

NY, United Nations, 1990 (http://www.ohchr.org/EN/

ProfessionalInterest/Pages/BasicPrinciplesTreatment

OfPrisoners.aspx, accessed 7 November 2013).

York, NY, United Nations, 1988 (http://www.tjsl.edu/

slomansonb/10.3_DetentionImprisonment.pdf, accessed

15 November 2013).

Commissioner for Human Rights, 1989 (United Nations

General Assembly resolution 44/25, 2 September 1990)

(http://www.ohchr.org/EN/ProfessionalInterest/Pages/

CRC.aspx, accessed 15 November 2013).

2013 (http://www.wma.net/en/30publications/10policies/

c18/, accessed 8 November 2013).

Geneva, World Health Organization, 2007 (Evidence

for action technical papers) (http://www.who.int/hiv/

idu/OMS_E4Acomprehensive_WEB.pdf, accessed

13 November 2013).

Office on Drugs and Crime, 2008 (http://www.unodc.

org/documents/justice-and-prison-reform/women-andimprisonment.

pdf, accessed 13 November 2013).

Geneva, UNAIDS and New York, NY, World Bank, 2007

(http://data.unaids.org/pub/Report/2007/hiv_prison_

paper_en.pdf, accessed 13 November 2013).

Geneva, World Health Organization and UNAIDS, 2006

41

Health in pre-trial detention

(http://data.unaids.org/pub/Report/2006/20060701_hivaids_

prisons_en.pdf, accessed 13 November 2013).

penalreform.org/wp-content/uploads/2013/06/rep-1996-

kampala-declaration-en.pdf, accessed 15 November

2013).

Jurgens R, Nowak M, Day M. HIV and incarceration:

Jurgens R, Ball A, Verster A. Interventions to reduce HIV

London, Penal Reform International, 2013 (http://www.

penalreform.org/priorities/pre-trial-justice/, accessed

10 December 2013).

Drugs and Crime and Geneva, World Health Organization,

2009 (http://www.unodc.org/documents/balticstates/

Library/PrisonSettings/UNODC_WHO_2009_Policy_

Brief_TC_in_Closed_Settings-EN.pdf, accessed

13 November 2013).

2011 (http://www.opensocietyfoundations.org/sites/default/

files/ptd-health-20111103.pdf, accessed 13 November 2013).

2004.

Schonteich M. The scale and consequences of pre-trial

(http://www.opensocietyfoundations.org/sites/default/files/

Justice_Initiati.pdf, accessed 15 November 2013).

www.justdetention.org/pdf/StoriesFromInside032207.

pdf, accessed 13 November 2013).

Tomasini-Joshi, D. Pre-trial detention: scale and relevance

13(2/3):68–70.

London, International Centre for Prison Studies, 2008 (http://

www.internationalpenalandpenitentiaryfoundation.org/

Site/documents/Cape%20Town/WPTRIL%20published%20

January%202008.pdf, accessed 13 November 2013).

Working Group on Arbitrary Detention [web site]. Geneva,

United Nations High Commissioner for Human Rights,

2010 (http://www.ohchr.org/EN/Issues/Detention/Pages/

WGADIndex.aspx, accessed 13 November 2013).

42

Prisons and health

43

The essentials: why prison health deserves priority in the interests of public health,

the duty of care, human rights and social justice

44

45

• The prevalence of HIV, hepatitis B and hepatitis C is

particularly high in pre-trial detention centres and in

prisons.

• All modes of transmission of these diseases occurring

in the community also occur in prisons: through blood,

sexual activity and vertical transmission to a child.

• Measures to address HIV and hepatitis in prisons

should be comprehensive.

• Guidelines and standard operating orders should be

developed, in line with national guidelines and based

on international guidelines, to address bloodborne

viral diseases in prisons.

• All preventive, curative and supportive interventions

for HIV, hepatitis C and B that are available in the

community are effective, feasible and needed in

prisons.

• Continuity of treatment is key in the response to HIV,

including for people going into, transferring between

or released from prisons.

• Measures to address HIV and AIDS in prisons also

address HIV and AIDS for staff working in prisons, for

people visiting prisons and for the entire community.

• HIV testing cannot be mandatory and all health

interventions need to have the informed consent of

the people concerned.

• People living with HIV should not be segregated.

People in prisons and other closed settings, including

people working in prisons, are particularly at risk

for hepatitis B, hepatitis C and HIV, due to their own

vulnerability compounded by the characteristics of the

environment. The prevalence of individuals who use

drugs, including injecting drugs, is particularly high

in prisons in Europe, a region with an HIV epidemic

concentrated among the most vulnerable populations,

especially people who inject drugs. Such people are also

particularly affected by viral hepatitis, especially hepatitis

C. Each of these diseases is preventable and each has

a treatment. The overuse of imprisonment and pretrial

detention for drug users is responsible for the high

prevalence of HIV and hepatitis among prisoners. In the

absence of preventive measures, transmission can also

occur in prisons. The lack of access to preventive, curative

and palliative care in prisons, poor prison conditions and

poor prison management all contribute to increasing the

risk of transmission of bloodborne diseases.

HIV is a virus that infects cells of the human immune system

and progressively impairs their function. Infection with HIV

leads to immune deficiency, making people vulnerable to

a wide range of diseases. About one year after an initial

infection, symptoms will develop. AIDS describes the

collection of symptoms and infections associated with the

deficiency of the immune system caused by HIV infection.

The level of CD4 cells (cells from the immune system) and

the appearance of certain infections or cancers are used

as indicators that HIV infection has progressed to AIDS.

Diseases associated with severe immunodeficiency are

known as opportunistic diseases. In the prison context,

the most significant of these is TB, which can spread very

quickly in overcrowded conditions.

HIV is transmitted when infected blood, semen, vaginal

fluids or breast-milk enter another person’s body. This

occurs during unprotected sex, when sharing needles

during injection drug use or tattooing and piercing, through

blood transfusion, through unsafe medical care (such as

the use of improperly sterilized syringes and other medical

equipment in health-care settings) or through accidental

puncture with contaminated medical wastes. Women

living with HIV who become pregnant can transmit HIV

to their babies during pregnancy or delivery as well as

through breastfeeding. All these modes of transmission

can occur in prisons if appropriate measures are not taken.

HIV is not transmitted through casual contact. HIV infection

is asymptomatic for a long period during which the virus

can be transmitted to another person. The only way to

determine whether HIV is present in a person’s body is by

taking a test for it. There is no vaccine to prevent HIV, and

there is a treatment but no cure. Antiretroviral therapy

(ART) slows down the progression of the disease by

decreasing the amount of virus (viral load) in an infected

body. The decrease in viral load, for example when people

are on antiretroviral treatment, also reduces the risk of

transmission to another person.

Hepatitis B is a viral infection of the liver that can cause

both acute and chronic disease. About 10% of infected

adults will develop chronic liver disease, with a high risk

of death from cirrhosis of the liver and/or liver cancer.

The virus is transmitted through contact with the blood

46

Prisons and health

or other bodily fluids (semen and vaginal fluid) of an

infected person or from an infected mother to her child

at birth. Hepatitis B is not spread through food or water

or by casual contact, such as hugging, kissing and sharing

food or drinks with an infected person. The transmission

of hepatitis B is thus similar to HIV but the virus is 50

to 100 times more infectious than HIV. Hepatitis B virus

(HBV) can survive outside the body for at least seven days.

It is an occupational hazard for health workers, but it is

preventable with a vaccine and is curable. More and more

countries vaccinate infants against hepatitis B during

national immunization.

Hepatitis C is also a liver disease, caused by the

hepatitis C virus (HCV). It can also be acute or chronic,

but most of the time the acute phase is unnoticed.

About 70% of infected persons develop chronic liver

disease. In the absence of treatment, after 20 years

of evolution, 5–20% will develop cirrhosis and 1–5%

will die from cirrhosis or liver cancer. HCV is most

commonly transmitted through contact with the blood

of an infected person, such as through receipt of

contaminated blood transfusions, blood products and

organ transplants; injections given with contaminated

syringes, needle-stick injuries; injection drug use; and

vertical transmission from an HCV-infected mother. It is

less commonly transmitted through sex with an infected

person and sharing of personal items contaminated with

infectious blood. Hepatitis C is also very infectious. It

is not spread through breast-milk, food or water or by

casual contact such as hugging, kissing and sharing food

or drinks with an infected person. Currently, there is no

vaccine to prevent hepatitis C but it is curable.

HIV prevalence is generally higher in prisons and pretrial

detention centres than in the community. People in

prisons typically come from socially and educationally

disadvantaged groups with poor access to health care and

prevention in the community. The populations at highest

risk for HIV, hepatitis B and C infections in the community,

such as people who inject drugs and sex workers, are

over-represented in prison populations. In the absence

of preventive measures, transmission occurs in prisons.

Risky behaviour such as sexual intercourse (consensual

or forced) without protection, sharing injection equipment

and tattooing and piercing equipment, sharing razors or

scissors or sharing blood through brotherhood rituals

occur in prisons in all countries in the world. Epidemics

have been described in several countries such as

Estonia (2002), where 300 people were infected in less

than 6 months. Factors related specifically to the prison

system and environment that contribute indirectly to HIV

vulnerability are: overcrowding, poor prison conditions,

violence, sexual abuse, gang activities, poor classification,

lack of protection for vulnerable prisoners, stigma and

discrimination, corruption and poor medical services.

Medical services that are separate from national public

health programmes, especially from HIV programmes,

often do not access or use the resources available

in the community such as medication and guidelines

for prevention, diagnosis, follow-up or treatment.

Underfunded and underskilled medical services and

programmes may be responsible for transmission through

the use of contaminated medical or dental equipment,

inadequate sterilization procedures and absence of or

inadequate universal precautions. In the absence of

programmes for comprehensive prevention of motherto-

child transmission, pregnant and nursing mothers can

transmit hepatitis B or HIV to their children.

As mentioned above, there are many factors and co-factors

contributing to the prevalence of bloodborne diseases

in prisons. Health authorities alone cannot address

prevention, early identification and treatment. Attention

from other actors, such as in the environmental, criminal

justice and prison management areas, is often required.

The health sector does, however, have a crucial role to

play in the implementation of health-specific measures

and in raising the awareness of prison managers about

other essential interventions.

A comprehensive approach needs to be taken, including

protecting staff, since transmission can occur in prisons,

people entering prison can already be infected with HIV

and some can be severely ill (Fig. 1). In 2013, UNODC in

collaboration with the International Labour Organization,

the United Nations Development Programme, WHO and the

Joint United National Programme on HIV/AIDS (UNAIDS)

published a policy brief on a comprehensive response to

of interventions, mainly in connection with the health

sector, as under:

• information, education and communication;

• condom programmes;

• prevention of sexual violence;

• drug dependence treatment including opioid

substitution therapy;

• needle and syringe programmes;

• prevention of transmission through medical or dental

services;

• prevention of transmission through tattooing, piercing

and other forms of skin penetration;

• post-exposure prophylaxis;

47

HIV and other bloodborne viruses in prisons

• HIV testing and counselling;

• HIV treatment, care and support;

• prevention, diagnosis and treatment of TB;

• prevention of mother-to-child transmission of HIV;

• prevention and treatment of sexually transmitted

infections;

• vaccination, diagnosis and treatment of viral hepatitis;

• protection of staff from occupational hazards.

By definition, an intervention that is effective in the

community to prevent or to treat a disease should be

effective in prisons. However, the prison system, and

sometimes each prison in the system, needs to develop

or adapt new implementation modalities to ensure

effective access to and impact from the intervention.

There is a need to be creative and to discuss the objective

of the interventions with all stakeholders to ensure

they understand and to identify the best modalities for

implementation and evaluation. Prison-specific evidence

has been collected on the prevention of sexuallytransmitted

infections (STIs) and programmes for condoms,

treatment for HIV, needle and syringe programmes and

treatment for drug dependence in prisons.

The similarities in modes of transmission of bloodborne

diseases means that measures for their prevention are

almost all valid for all three diseases.