Prison As a Social Determinant of Health

The UN Standard Minimum Rules for the Treatment of Prisoners (1955) declares that, beside the protection of society against crime, the purpose and justification of a sentence of imprisonment is the social rehabilitation of the offender.

To ensure that after their realise, prisoners are not only willing but able to lead a law-abiding and self-supporting life we should provide them adequate health care interventions.

Globally, considering pretrial detainees, remand prisoners, individuals convicted and sentenced, more than 10 million people are held in prisons. Despite substantial variations between countries, most prisoners are individuals from a lower socio-economic status and from vulnerable communities, with recent trends indicating an increase of migrants and people with a minority ethnic background in prisoner population. Moreover, since drug abuse is often accompanied by criminal behaviour, people with drug use disorders (DUD) form a large proportion of the imprisoned population.

This intricate mix of structural determinants and behavioural factors contributes disproportionately to wider health inequalities in the prison populations and to increasing the likelihood of inmates contracting infections prior to incarceration. The chance to acquire a communicable disease grows further during incarceration.

A mix of structural determinants and behavioural factors contributes disproportionately to wider health inequalities in the prison populations

Increased risk is attributable mainly to three reasons: first, within detention structures, there is a high density of infected individuals. Second, deleterious health behaviours in prisons such as tobacco use, injection drug use, share of injecting equipment, high-risk sex, tattooing, piercing and violence (with wounds and blood mingling) are rampant. Finally, most of the prison settings, through malnutrition, overcrowding, limited access to basic health services, and inhumane attitudes and practices of custodial officers toward inmates, contribute to the exacerbation of the health status of individuals.

The increased prevalence of communicable diseases among inmates can also constitute a health risk for those working in prison settings and for the general population. In the European Union the average length of stay in prison is seven months and more than 95% of detainees eventually return to their communities, hence it is crucial to prevent or treat their infections.

Following release, prisoners face problems with housing, unemployment, social stigma, negligence and a cautious attitude by civil society. A former detainee with a communicable disease carries a double burden of stigma related to both imprisonment and infection. Given that, an ill former prisoner has an increased likelihood of involvement in criminal activity, and re-incarceration. Thus, a vicious cycle, in which prisons play a central role, persists. Awofeso affirms that prison itself constitutes a social determinant of health as prisons heighten health inequities between individuals in contact with the criminal justice system and the general community.

A former detainee with a communicable disease carries a double burden of stigma related to both imprisonment and infection

Prison settings represent both a difficult challenge and an opportunity to address complex needs of vulnerable and underserved populations, with tailored and equitable health care provision. To tackle the burden of infectious diseases in prisons, the World Health Organization (WHO) has proposed a comprehensive package of interventions. Unfortunately, despite numerous studies confirming the effectiveness of these interventions in reducing the spread and the negative consequences of infectious diseases, an enormous gap remains in the implementation of these services in prisons.

In order to address prison health problems, the criminal justice and public health systems should be coordinated and cooperate. To avoid released inmates’ re-incarceration, they should be provided with enough assistance –granting access to services such as housing, employment, continuation of treatment and psychological support– to facilitate their reintegration in the community. In addition, to reduce mass incarcerations of particularly vulnerable and marginalised people and their exposure to potentially life-threatening infections in prison, legislative reforms to decriminalise drug use and sexual behaviours are crucial.

In order to address prison health problems, the criminal justice and public health systems should be coordinated and cooperate

Prison health is part of public health and prisons are part of our society. When a state deprives people of their liberty, it must provide them with the best possible care. The recognition of the fundamental human rights of prisoners, as members of society, is the crucial first step to promote the full-scale implementation of above-mentioned interventions. Finally, socio-politically, more equitable societies have a significantly greater capacity to fully address the upstream social determinants that lead individuals to prison.