Prison optics

On any given day in Canada, our federal prisons house 13 000 inmates and provincial prisons another 18 700.1 Our incarceration rate of 118 per 100 000 population is roughly equivalent to Britain's and about one sixth of the US rate (the highest in the world).2 Each year, 5000 people are released from Canadian prisons to the community.

The Canadian Centre on Substance Abuse estimates that 54% of federal inmates and similar proportions of men and women in provincial custody abused alchohol or drugs on the day of their offence.1 The Correctional Service of Canada estimates that almost 7 out of 10 federal prison inmates have a substance abuse problem.3 Plainly, substance abuse exacerbates crime, but it is equally clear that a high proportion of people behind bars suffer from dependency problems and their associated health effects. HIV and hepatitis C infections are far more prevalent among prison inmates than in the general population, and the gap appears to be widening.4

Imprisonment is an imperfect cure for addictions. As in the world outside prison walls, drugs are traded for money, goods and sex. Prison life presents impediments to drug use (70% of women surveyed in a BC prison used injection drugs before sentencing, but only 21% during their prison term), but it also creates inducements to unsafe practices (of those women who injected drugs, 82% shared needles).5

In spite of the fact that most prisoners have substance abuse problems, acceptance of harm reduction strategies has been slow. It took a Charter challenge (see News, page 1154) to instate methadone maintenance therapy (MMT) as the right of all federal prisoners who need it, but there is no such guarantee in provincial prisons. Provincial prisons in PEI and Newfoundland do not offer MMT, and in other provinces, inmates are eligible only if they were receiving MMT before their incarceration. Condoms have been available in federal prisons since 1992, but not in the provincial institutions of New Brunswick, Newfoundland and PEI.6 Distributing bleach is the only prison-sanctioned method of ensuring clean injection and tattooing equipment; in the culture of “corrections,” needle exchange appears to be unthinkable.

In the Panopticon, the model prison proposed by Jeremy Bentham in 1791, inmates were to be controlled by the knowledge that anything they did might be observed. Panopticism is still a necessary aspiration of prison security, but the management of prison health issues has been characterized by blind spots just the same. Despite what is known (and surmised) about infectious disease and high-risk behaviours behind bars, prison harm reduction programs are repeatedly criticized for failing to achieve the accessibility and discretion required for them to be effective.

Security, surveillance and zero tolerance have not put an end to high-risk behaviours. What we need now is for federal and provinical correctional institutions to take a coordinated, synoptic view of the health problems and human rights of incarcerated people. Prison health must fall under the pragmatic and proactive gaze of public health. — CMAJ