HEALTH CARE IN PRISONS: HEALTH CARE IN PRISONS: AN INTERNATIONAL AN INTERNATIONAL

CHALLENGE IN CHALLENGE IN PRVEVENTIVE MEDICINE PRVEVENTIVE MEDICINE

AND PUBLIC HEALTHAND PUBLIC HEALTH

Anthony J. Silvagni, D.O., Pharm.D., M.Sc., FACOFP dist.

Professor of Family Medicine and Public Health

Nova Southeastern University College of Osteopathic Medicine

The WHY of Correctional The WHY of Correctional Health CareHealth Care

• Why treat inmates?Why treat inmates?– Civilization is measured by how it cares for Civilization is measured by how it cares for

society’s outcasts. (deToqueville)society’s outcasts. (deToqueville)– It is the ethical and humane thing to doIt is the ethical and humane thing to do– In many countries it is the law (e.g. USA)In many countries it is the law (e.g. USA)– Diseases will spread within the prison Diseases will spread within the prison

population and when released, within the population and when released, within the general populationgeneral population

– The cost of providing appropriate health The cost of providing appropriate health care to prisoners is most likely less than not care to prisoners is most likely less than not providing the care due to the greater providing the care due to the greater spread of diseases.spread of diseases.

World World PopulationPopulation of of InmatesInmates

• Over 9 million inmates world-wide in prisons Over 9 million inmates world-wide in prisons and jailsand jails

• US, China and Russia lead the world in US, China and Russia lead the world in incarceration rates. (Probably other countries incarceration rates. (Probably other countries are high but data gathering is inconsistent)*are high but data gathering is inconsistent)*

• In many countries- remand to PRISON while In many countries- remand to PRISON while awaiting trial- therefore people who are NOT awaiting trial- therefore people who are NOT CONVICTED of anything are in prisons (not CONVICTED of anything are in prisons (not jails)jails)

• Walmsley, R., Kings College London- International Prison Studies from Walmsley, R., Kings College London- International Prison Studies from http://www.scribd.com/doc/328143/World-Prison-Population-List-2007http://www.scribd.com/doc/328143/World-Prison-Population-List-2007

Incarceration: a global response to crime Incarceration: a global response to crime and disorderand disorder

• >2,020,000 persons in prisons or jails >2,020,000 persons in prisons or jails

– 1,360,000 in Federal and State 1,360,000 in Federal and State prisonsprisons

– 665,000 in local jails665,000 in local jails

USA Incarcerated USA Incarcerated Populations, Midyear 2002Populations, Midyear 2002

Source: Bureau of Justice Statistics Publication #, NCJ 198877 April 2003Source: Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2002(4/2003) NCJ 198877

• >2,299,116 persons in prisons or jails – >2,299,116 persons in prisons or jails – Approximately a 14% increase from 2002Approximately a 14% increase from 2002

– 1,528,014 in Federal and State prisons1,528,014 in Federal and State prisons– 766,010 in local jails766,010 in local jails

USA IncarceratedUSA Incarcerated Populations, Midyear 2007Populations, Midyear 2007

Source: Bureau of Justice Statistics Publication #, NCJ 198877 April 2003Source: Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2007(http://www.ojp.usdoj.gov/bjs/prisons.htm)

Note Slower Pace- (Slope Note Slower Pace- (Slope more level)more level)

Source: Bureau of Justice Statistics. Correctional Populations in the United States, 1997 and Prisoners in 2004.

Typical Florida Prison Typical Florida Prison (Jefferson Correctional Institution)(Jefferson Correctional Institution)

United Nations - Seven United Nations - Seven Standards For Medical Standards For Medical

CareCare1.1. A medical officer with some knowledge A medical officer with some knowledge

of psychiatry is to be available to every of psychiatry is to be available to every institution. institution.

2.2. Prisoners requiring specialized Prisoners requiring specialized treatment are to be transferred to a treatment are to be transferred to a civil hospital or appropriate facility. civil hospital or appropriate facility.

3.3. A qualified dental officer shall be A qualified dental officer shall be available to every prisoner. available to every prisoner.

UNUN - Continued - Continued

4.4. Prenatal, postnatal and related care Prenatal, postnatal and related care are are to be provided by women's prisons; to be provided by women's prisons;

when nursing infants are allowed to when nursing infants are allowed to remain with their mothers, a nursery remain with their mothers, a nursery staffed by qualified staff is needed. staffed by qualified staff is needed.

5.5. Every prisoner shall be examined by Every prisoner shall be examined by the the medical officer shortly after admission; medical officer shortly after admission;

prisoners suspected of contagious prisoners suspected of contagious diseases are to be segregated. diseases are to be segregated.

UN - UN - ContinuedContinued6.6. The medical officer shall see all sick The medical officer shall see all sick

prisoners daily, along with those who prisoners daily, along with those who complain of illness or are referred to his complain of illness or are referred to his or her attention. or her attention.

7.7. The medical officer is to report to the The medical officer is to report to the directordirector

a. those prisoners whose health is a. those prisoners whose health is jeopardized by continued jeopardized by continued

imprisonmentimprisonmentb. the quality of the b. the quality of the food, hygiene, food, hygiene,

bedding, bedding, and clothingand clothingc. physical regimen of the prisoners. c. physical regimen of the prisoners.

An UN Rule Regarding An UN Rule Regarding FoodFood

• UN requires wholesome food being UN requires wholesome food being prepared daily for prisonersprepared daily for prisoners

• Not uncommon to see malnutrition in Not uncommon to see malnutrition in prisons, similar to, but worse than the prisons, similar to, but worse than the malnutrition of the country’s indigenous malnutrition of the country’s indigenous populationpopulation

United NationsUnited Nations

Standard Minimum Rules for the Standard Minimum Rules for the Treatment of PrisonersTreatment of Prisoners

• ““Where sleeping Where sleeping accommodation is in accommodation is in individual cells or individual cells or rooms, each prisoner rooms, each prisoner shall occupy by night a shall occupy by night a cell or room by cell or room by himself. If for special himself. If for special reasons, such as reasons, such as temporary temporary overcrowding, it overcrowding, it becomes necessary for becomes necessary for the central prison the central prison administration to make administration to make an exception to this an exception to this rule, it is not desirable rule, it is not desirable to have two prisoners to have two prisoners in a cell or room…” in a cell or room…”

Prison Cell in Austria

Prison Cell in East AfricaPrison Cell in East AfricaPhoto by New York Photo by New York

TimesTimes

CARIBBEAN PRISONSCARIBBEAN PRISONS

• Jamaica – Patient (prisoner) held in Jamaica – Patient (prisoner) held in Tower Prison infirmary without care. Tower Prison infirmary without care. Doctors sent to hospital but patient died in Doctors sent to hospital but patient died in hospital prior to being seenhospital prior to being seen

• Haiti - Malnutrition commonplace (beriberi)Haiti - Malnutrition commonplace (beriberi)

• HIV is frequent throughout the Caribbean HIV is frequent throughout the Caribbean prisonsprisons

NSUCOM NSUCOM International International

Medical Outreach in Medical Outreach in Jamaica PrisonsJamaica Prisons

NSUCOM Student Teaching NSUCOM Student Teaching in Jamaica Prisonsin Jamaica Prisons

Inside TowersInside Towers

Removal of Bullet- Removal of Bullet- TowersTowers

TelemedicineTelemedicineLinking Prisoners to Specialty CareLinking Prisoners to Specialty Care

Telemedicine program at the Tower Street Prison, Kingston, Jamaica

Tremendous Opportunities Tremendous Opportunities for Education in Prison for Education in Prison

Health CareHealth Care1.1. Great Teaching EnvironmentGreat Teaching Environment

1.1. Only environment where students can see Only environment where students can see long term effects of disease long term effects of disease

2.2. With or Without treatment - PATIENTS With or Without treatment - PATIENTS HAVE TO COME BACKHAVE TO COME BACK

2.2. Inexpensive to set up and run servicesInexpensive to set up and run services3.3. Tremendous wealth of pathology – some Tremendous wealth of pathology – some

advantages over a university-based advantages over a university-based residency programresidency program

4.4. A truly needed area for careA truly needed area for care5.5. Exponential effect on country’s public healthExponential effect on country’s public health

Why Bother Why Bother Teaching Students in Teaching Students in

US PrisonsUS Prisons• One of the few environments that is NOT One of the few environments that is NOT

dominated by reimbursement and insurance dominated by reimbursement and insurance policiespolicies

– 1.1. Write OrdersWrite Orders– 2.2. Progress NotesProgress Notes– 3.3. History & Physical History & Physical

OpportunitiesOpportunities– 4.4. TriageTriage– 5.5. Really sick peopleReally sick people

Universal Finding Among Incarcerated Universal Finding Among Incarcerated Populations: High Burden of DiseasePopulations: High Burden of Disease

• Inmates typically have few economic Inmates typically have few economic resources and little access to health care resources and little access to health care prior to incarcerationprior to incarceration

• They have disproportionately high rates of They have disproportionately high rates of substance dependence, mental health substance dependence, mental health disorders, high-risk sexual activity, prior disorders, high-risk sexual activity, prior violence-related injuries, head trauma, violence-related injuries, head trauma, and complications of chronic illnessesand complications of chronic illnesses

• High rates of infectiousHigh rates of infectious disease including HIV,disease including HIV, TB, STD’s, hepatitis, etc.TB, STD’s, hepatitis, etc.

Prisoners in Thailand

Infectious Diseases in Infectious Diseases in PrisonPrison

• BRING THEM IN WITH THEMBRING THEM IN WITH THEM• Despite the movies- the HIV in prison is Despite the movies- the HIV in prison is

NOT prisoner-prisoner transmission- less NOT prisoner-prisoner transmission- less than 0.032% in FL-DOC and 0.033% in than 0.032% in FL-DOC and 0.033% in FBOP for P-P transmissionFBOP for P-P transmission

• Hepatitis C- 20-65% of inmates infected Hepatitis C- 20-65% of inmates infected primarily due to IVDU on the outsideprimarily due to IVDU on the outside

• FDOC had not had a TB death (12 total FDOC had not had a TB death (12 total cases in 2002 all from the outside)cases in 2002 all from the outside)

Translating Infectious Translating Infectious Disease Treatment into Disease Treatment into Correctional PracticeCorrectional Practice•   Correctional physicians care for a Correctional physicians care for a

population with a burden of infectious population with a burden of infectious diseases disproportionate to their numbers diseases disproportionate to their numbers in the community. in the community.

• For example, the prevalence of hepatitis C For example, the prevalence of hepatitis C among releases' is approximately ten times among releases' is approximately ten times that among the general population, and that among the general population, and one-third of all hepatic C disease is born by one-third of all hepatic C disease is born by those leaving prison and jails. However, the those leaving prison and jails. However, the prevalence of infectious diseases does prevalence of infectious diseases does change time over time. Best practices for change time over time. Best practices for the management of specific infectious the management of specific infectious diseases also change, so an update on the diseases also change, so an update on the medical management of communicable medical management of communicable diseases is essential! diseases is essential!

Prison HIV PreventionPrison HIV PreventionHarm Reduction Strategies Harm Reduction Strategies

• Prison Condom Prison Condom AvailabilityAvailability– Examples: Australia, Examples: Australia,

Brazil, Canada, most Brazil, Canada, most European Countries, European Countries, South Africa, and moreSouth Africa, and more

• Prison Needle ExchangePrison Needle Exchange– Examples: Switzerland, Examples: Switzerland,

Germany, Spain, Germany, Spain, Moldova, Kyrgyzstan, Moldova, Kyrgyzstan, Belarus, and IranBelarus, and Iran

Tuberculosis Behind Tuberculosis Behind Prison WallsPrison Walls

• ““Prison walls curtain the Prison walls curtain the freedom of prisoners, freedom of prisoners, but not the freedom but not the freedom from spread of from spread of tuberculosis. Prisons tuberculosis. Prisons form a reservoir of form a reservoir of tuberculosis which tuberculosis which threatens not only threatens not only prisoners, but also prisoners, but also prison staff, visitors, and prison staff, visitors, and the wider community.”the wider community.”

WHO and ICRCWHO and ICRC Guidelines for the Control of Prisons, 1998Guidelines for the Control of Prisons, 1998

Tuberculosis in Russian Tuberculosis in Russian PrisonsPrisons

• Over one million Over one million prisonersprisoners

• In the 1990’s, In the 1990’s, approximately one in approximately one in ten with active TBten with active TB

• At least 20% sick with At least 20% sick with MDR-TBMDR-TB

The Global Impact of Drug-Resistant The Global Impact of Drug-Resistant Tuberculosis. Harvard Medical School. 1999Tuberculosis. Harvard Medical School. 1999

OTHER DISEASES OTHER DISEASES AND CASESAND CASES

• Acute & Chronic cases and FREQUENTLY Acute & Chronic cases and FREQUENTLY SEVERESEVERE

• Hypertension; Seizure Disorders; Cardiac Hypertension; Seizure Disorders; Cardiac Disease; Asthma; Cancer; Diabetes; Disease; Asthma; Cancer; Diabetes; Hepatic Disease; Psychiatric; Behavioral; Hepatic Disease; Psychiatric; Behavioral; Trauma (including self-inflicted); Etc.Trauma (including self-inflicted); Etc.

• It is the only setting where you can see the It is the only setting where you can see the natural course of untreated disease- WHY? natural course of untreated disease- WHY? Rights of inmates and close monitoring Rights of inmates and close monitoring

Intentional TraumaIntentional Trauma

• The following slides are from one inmate The following slides are from one inmate who has a compulsive swallowing disorder who has a compulsive swallowing disorder and exacerbated by sticking things into his and exacerbated by sticking things into his woundswounds

• HE HAS NO AXIS 1 PSYCHIATRIC HE HAS NO AXIS 1 PSYCHIATRIC DIAGNOSISDIAGNOSIS

• He does have an anti-social personality He does have an anti-social personality disorderdisorder

Special Care Unit for HIV Special Care Unit for HIV Positive Inmates in Florida Positive Inmates in Florida

PrisonPrison

Crop Garden at Same Crop Garden at Same PrisonPrison

Correctional Correctional Medicine Medicine

FellowshipFellowship

PROGRAM DIRECTOR: PROGRAM DIRECTOR:

David Thomas, MD, JDDavid Thomas, MD, JD

2 Year Fellowship 2 Year Fellowship ProgramProgram

• 15 months in various correctional facilities 15 months in various correctional facilities as a fellow (post-residency)as a fellow (post-residency)– Prison HospitalPrison Hospital– Reception FacilityReception Facility– Women’s FacilityWomen’s Facility– JailJail– Private Facilities and Public facilitiesPrivate Facilities and Public facilities

• About 9 months in administrative and legal About 9 months in administrative and legal experience and field experience for the experience and field experience for the MPH DegreeMPH Degree

• Only 1 year if fellow has an MPH DegreeOnly 1 year if fellow has an MPH Degree

Requirements to Requirements to FinishFinish

• Successful completion of two year program Successful completion of two year program including completion of MPH Degreeincluding completion of MPH Degree

• Competence in:Competence in:– QM/QA- Quality driven programsQM/QA- Quality driven programs– Mortality ReviewMortality Review– Systems Design Systems Design – Hands on Patient careHands on Patient care

• HIV; Hepatitis; Seizure Disorder; Acute HIV; Hepatitis; Seizure Disorder; Acute Detoxification; Chronic Illness clinics; Detoxification; Chronic Illness clinics; etc etc

Admission Admission RequirementRequirement

• Board Eligible or Board Certified in a medical or Board Eligible or Board Certified in a medical or surgical specialtysurgical specialty

• Acceptable to Federal, State, and Private Acceptable to Federal, State, and Private partnerspartners

• Dedication to underserved and/or correctionsDedication to underserved and/or corrections

• Desire to get or have the MPH DegreeDesire to get or have the MPH Degree

• Desire to become Competent in Correctional Desire to become Competent in Correctional Health care and Correctional Systems and be a Health care and Correctional Systems and be a Board Certified Correctional Medicine PhysicianBoard Certified Correctional Medicine Physician

Goals of FellowshipGoals of Fellowship• Create a cadre of physicians competent in Create a cadre of physicians competent in

all aspects of correctional careall aspects of correctional care– Public sector - State and FederalPublic sector - State and Federal– Private Sector - Contract or ownedPrivate Sector - Contract or owned– Jails Jails – PrisonsPrisons– Systems ApproachesSystems Approaches

• Raise the Quality and Efficiency of Raise the Quality and Efficiency of Correctional HealthcareCorrectional Healthcare

At Conclusion of At Conclusion of ProgramProgram

• Graduating Fellows should:Graduating Fellows should:– Be readily employable at the senior Be readily employable at the senior

levels of large systems (Regional levels of large systems (Regional Medical Director or Executive Director of Medical Director or Executive Director of a large and complex facility)a large and complex facility)

– Be readily employable as the Medical Be readily employable as the Medical Director of a smaller system with Director of a smaller system with system-wide responsibilitiessystem-wide responsibilities

• All of our partners have agreed to give All of our partners have agreed to give preferential hiring to graduated Fellows.preferential hiring to graduated Fellows.

Sample Resources on Sample Resources on Correctional HealthCorrectional Health

www.icpa.cawww.icpa.ca

• International organization dedicated International organization dedicated to advancing professional corrections to advancing professional corrections with a mission to contribute to public with a mission to contribute to public safety and healthier communities. safety and healthier communities.

• Newly formed Health Care CommitteeNewly formed Health Care Committee

• 2007 Conference attended by 300 2007 Conference attended by 300 delegates from more than 50 countriesdelegates from more than 50 countries