The promotion of health in prison is based on an inherent paradox: the prison universe as a place of deprivation of liberty is in contradiction with the very principle of health education: the principle of autonomy of the patient.
Frédéric Le Marcis
The studies that comprise this special issue show that in Brazil, as well as in the Ivory Coast, the United States and France, ensuring health in prisons remains a major challenge in a context that is essentially focused on security. In Brazil, given the significant increase (575% between 1990 and 2014) in the number of prisoners (> 600,000), most of them from underprivileged communities with limited access to health and confined in insalubrious and overcrowded prisons, it is hardly surprising that, particularly their health is deplorable and that high prevalences are found of tuberculosis, HIV infection and mental disorders. To address this situation, the prison health system is under-funded, under-equipped and under-staffed with under-motivated professionals applying inappropriate strategies that are essentially prescriptive. Controlled by the hierarchy of prisoners and prison guards, access to the health service is inequitable and often “granted” according to criteria that are unrelated to health. The right to health of persons deprived of liberty (PDL) is guaranteed in Brazil by a key legislative and regulatory measure. However, the role of supervisory bodies and defenders of human rights such as the Public Prosecution Office, the Public Defender, NGOs and parliamentary committees comes up against the indifference of those in charge and the inertia of the institutions. The PDL can hardly “be included” in a political discourse essentially focused on security that transforms the prison system into an instrument of segregation and social exclusion. The situation of mothers living in prison with their children born during incarceration, often after incomplete prenatal care and sometimes a violent and unaccompanied childbirth, is particularly emblematic.
In this context, how can the health of PDL be assured? Obviously, it is essential to work tirelessly to give greater visibility to the problem by introducing it in the public debate and improve the conditions of imprisonment and the prison health system, even prompting the regulatory agencies to intervene. Furthermore, it is necessary that the development and implementation of health strategies – maintaining independence from the prison administration and the hierarchy of prisoners – consider the specificities of life in each penitentiary, with its power distribution lines, rules and balances. This involves taking into account not only the security requirements of the penitenciary administration, but also the influence of the hierarchy of prisoners to whom tasks are “delegated” with great impact on the health of PDL, such as access to health care and food, which generates major iniquities. It is to also important not to neglect the health needs of the penitentiary officers who are exposed to stress and to the risk of infection shared with PDL. Realities such as the circulation and consumption of drugs in prison should be acknowledged by the prison administration such that risk reduction programs can be developed, the implementation of which, as demonstrated by the French experience, should include all the actors in prison life. This example and several others presented in this issue prove that it is possible to promote health in the penitentiary context provided that prison is regarded as a living environment and PDL are acknowledged as persons, who when ill, have the right to be treated without any discrimination.
Alexandra Sánchez 1, Maria de Carmo Leal 2, Bernard Larouzé 3
1 Centro de Referência Professor Hélio Fraga, Escola Nacional de Saúde Pública (ENSP), Fundação Oswaldo Cruz (Fiocruz)
2 Departamento de Epidemiologia e Métodos Quantitativos em Saúde, ENSP, Fiocruz
3 Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Equipe d´Epidémiologie Sociale, Paris, France