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Going to Prison affects trust and engagement with the community, especially in politics

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Going to Prison affects trust and engagement with the community, especially in politics

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Contact with the criminal justice system impacts not only individual experiences of political participation, but also community-wide political engagement.

by Emily Widra, March 10, 2017

New research confirms what we already know happens to people when they are locked up. Their physical isolation leads to experiences of social isolation and their very real political disenfranchisement leads to a feeling of alienation from government. These psychological effects stay with people long after the physical and legal restrictions of their prison sentences end, affecting individuals, families and communities for years after release.

Some new data shines a light on these long-term psychological effects of incarceration. A new survey about literacy behind bars also included some important questions about individual experiences of social and political isolation. The literacy findings have few surprises; like earlier studies indicate, incarcerated people score lower on various measures of literacy. ( The new U.S. Program for the International Assessment of Adult Competencies does add some new dimensions to our understanding of literacy in prisons, providing data on prison employment and educational programming.)

In the U.S. Program for the International Assessment of Adult Competencies, participants were asked to respond on a five-point scale from "strongly agree" to "strongly disagree" with the following three statements:

1. People like me don't have any say about what the government does.

2. There are only a few people you can trust completely.

3. If you are not careful, other people will take advantage of you.

The findings of these three questions about social and political isolation reinforce the conclusions of prior research, suggesting that criminal justice involvement at any level impacts political engagement and trust. Compared to the data collected from U.S. households, the survey of U.S. prisons indicates higher levels of mistrust, political disenfranchisement, and political alienation among incarcerated adults.

The fact that incarcerated people feel more socially and politically isolated fits with previous research on how incarceration impacts the relationship people have with their government, beyond explicit political disenfranchisement. For example, a 2010 study found that people with justice system involvement "withdraw from political life," evidenced by decreased participation in civic groups, decreased expression of political voice in elections, and diminished trust in government.

This issue has the capacity to affect entire communities. Research by Dr. Traci R. Burch finds that the criminal justice system shapes community political participation. She studied the ways in which political disenfranchisement restricting one individual impacts the political involvement of neighbors living around him or her in North Carolina. Dr. Burch found that people living in neighborhoods with more criminal justice-involved individuals (previously incarcerated and/or under community supervision) are less likely to vote, even if they are not disenfranchised themselves. Not only are they less likely to vote, but they are also less likely to engage in multiple forms of political participation, to be registered voters, and to participate in broader civic engagement. This means that contact with with the criminal justice system impacts not only individual experiences of political participation, but also community-wide political engagement.

With this study, we are reminded again that the harms of incarceration ripple outward from individuals throughout communities. Incarceration has a deadening effect on the political engagement of incarcerated people, and also on their families, friends, and neighbors. At this critical time, when political participation is at fever pitch, it's important to recognize that mass incarceration undermines the political participation of entire communities.

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It's not just the franchise: Mass incarceration undermines political engagement

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by Emily Widra, March 10, 2017 New research confirms what we already know happens to people when they are locked up. Their physical isolation leads to experiences of social isolation and their very real political disenfranchisement leads to a feeling of alienation from government.

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Over the past 40 years, the number of people in U.S. prisons has increased by more than 600% - an unprecedented expansion of the criminal justice system. On January 1, 2008, one of every 100 adults, or more than 2.3 million people, were behind bars. An estimated 10 million Americans are incarcerated each year. With only 5% of the world's population, the United States has a quarter of the world's prisoners. No other country locks up more of its citizens.

For black Americans, especially men with no college education, incarceration has become an alarmingly common life experience. By middle age, black men in the United States are more likely to have spent time in prison than to have graduated from college or joined the military, and they are far more likely than whites to be sent to prison for drug offenses despite being no more likely than whites to use drugs.

Much of the increase in the prisoner census is a result of the "War on Drugs" and our country's failure to treat addiction and mental illness as medical conditions. The natural history of these diseases often leads to behaviors that result in incarceration. The medical profession has the chance both to advocate for changes in the criminal justice system to reduce the number of people behind bars who would be better served in community-based treatment and to capitalize on the tremendous public health opportunities for diagnosing and treating disease and for linking patients to care after release.

Deinstitutionalization of the mentally ill over the past 50 years and severe punishment for drug users starting in the 1970s have shifted the burden of care for addiction and mental illness to jails and prisons. The largest facilities housing psychiatric patients in the United States are not hospitals but jails. More than half of inmates have symptoms of a psychiatric disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and major depression and psychotic disorders are four to eight times as prevalent among inmates as in the general population - yet only 22% of state prisoners and 7% of jail inmates receive mental health treatment while incarcerated.

The medical care that many inmates receive, in combination with a different environment, can be lifesaving. Yet correctional facilities are fundamentally designed to confine and punish, not to treat disease. The harsh and socially isolating conditions in jail or prison often exacerbate mental illness, especially when inmates are placed under solitary confinement, as is common in the "super maximum" facilities that have proliferated extensively in recent years.

Substance use and dependence are highly prevalent in the incarcerated population. More than 50% of inmates meet the DSM-IV criteria for drug dependence or abuse, and 20% of state prisoners have a history of injection-drug use. Up to a third of all heroin users - approximately 200,000 - pass through the criminal justice system annually. With growing numbers of drug users in correctional facilities, the prevalence of infectious diseases has increased correspondingly. As many as a quarter of all Americans infected with HIV and one in three with hepatitis C pass through a correctional facility each year. Chronic noninfectious diseases are also disproportionately prevalent in correctional facilities (see ).

The impact of incarceration extends far beyond the approximately 10 million people who are put behind bars each year. In low-income minority communities where a large portion of the male population is in correctional facilities at any given time, incarceration delivers a devastating blow to stable relationships, resulting in risky sexual partnerships that lead to increased rates of sexually transmitted diseases and HIV transmission and may increase rates of unwanted pregnancy. The disproportionate incarceration of young black men is also associated with low wages and rising unemployment rates, which further exacerbate disparities in health. Because no country has ever incarcerated people at such high rates, the full extent of the social and public health consequences will not be known for years to come.

Nearly all prisoners will eventually return to the community, and the post-release period presents extraordinary risks to individuals and costs to society. In the 2 weeks after release, former inmates are 129 times more likely to die from a drug overdose than members of the general public and 12 times more likely to die of any cause. Yet most released inmates lack medical insurance, and Medicaid benefits have often been terminated upon incarceration. Although discharge-planning practices vary considerably, inmates are typically released with no more than a 2-week supply of even crucial medications such as insulin and with no primary care follow-up, so the burden of care falls predominantly on emergency rooms and is financed primarily by the public sector. Addressing the health needs of this vulnerable population is thus not only an ethical imperative, but also of crucial importance from both a fiscal and a public health perspective.

Correctional facilities are a critical component of the public-safety infrastructure, but many observers believe that the social and economic costs associated with the unprecedented expansion of the U.S. correctional system now far outweigh the benefits. State correctional spending has increased by 300% since 1980, to $50 billion annually; it's now the fastest-growing area of government spending after Medicaid. In Rhode Island, the average cost in 2008 of incarcerating an inmate for 1 year was $41,346; for an inmate in a super maximum security setting, the cost jumps to $109,026 annually. Five states now spend more on corrections than they do on higher education. As alternatives to incarceration, addiction and mental health treatment programs are more humane and cost-effective and ultimately better address the underlying problems, but political support for these approaches is crippled by policymakers' fear of being labeled "soft on crime."

There are tremendous medical and public health opportunities that can be created by addressing the health care needs of prisoners and former prisoners. Perhaps foremost among these is that opened up by health care reform: the Affordable Care Act will permit most former prisoners to receive health insurance coverage, which will offer them greater access to much-needed medical care. Such access could redirect many people with serious illnesses away from the revolving door of the criminal justice system, thereby improving overall public health in the communities to which prisoners return and decreasing the costs associated with reincarceration due to untreated addiction and mental illness. To achieve these gains, we will need to ensure linkages to medical homes that provide substance-use and mental health treatment for reentering populations. Partnerships between correctional facilities and community health care providers - especially community health centers and academic medical centers - can capitalize on health gains made during incarceration and improve the continuity of care for former inmates during the critical post-release period. The success of this effort will determine not only the health of released prisoners, but that of our society as a whole.

Locking up millions of people for drug-related crimes has failed as a public-safety strategy and has harmed public health in the communities to which these men and women return. A new evidence-based approach is desperately needed. We believe that in addition to capitalizing on the public health opportunities that incarceration presents, the medical community and policymakers must advocate for alternatives to imprisonment, drug-policy reform, and increased public awareness of this crisis in order to reduce mass incarceration and its collateral consequences.

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Medicine and the Epidemic of Incarceration in the United States

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Over the past 40 years, the number of people in U.S. prisons has increased by more than 600% - an unprecedented expansion of the criminal justice system. On January 1, 2008, one of every 100 adults, or more than 2.3 million people, were behind bars. An estimated 10 million Americans are incarcerated each year.

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Are there public health workers in prison? 

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Are there public health workers in prison? 

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It doesn't seem to be any requirements anywhere, and even states like California don't have public health careers listed in their prisoners.

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Imagine finding out you are pregnant, but instead of shopping excitedly for stretchy jeans and cute maternity outfits, you found yourself sporting a very different type of pregnancy style...
Stripes.
According to the American Journal of Public Health, between 6 and 10 percent of incarcerated women are pregnant; in one year alone, 1,400 women gave birth while incarcerated in the United States.

So just what exactly is it like to be a pregnant prisoner?

Let's take a look...
1. Some may not even realize that they are pregnant.
Kebby Warner is a 25-year-old married prisoner in Michigan who was imprisoned for littering and passing a $350 stolen check. She writes, "My first month in prison was spent being sick. I was told by health care that my 'illness' was caused by stomach flu and that my other 'symptoms' were caused by stress. The day after I was released from quarantine, I was called to health care and informed that my 'illness' wasn't stomach flu, but that I was pregnant. Putting the dates together I had conceived my baby the night before I was sentenced to prison."
2. They have to wear "belly chains."
Warner, who has Type 1 diabetes, had to be treated at a local hospital during the duration of her high-risk pregnancy. Each time she left, she describes the "period of humiliation" she had to endure when she was strip-searched and placed in belly chains and handcuffs for the duration of each and every doctor's appointment.
3. There is a "pregnancy" unit in prison.
Warner was moved to a special pregnancy unit of her prison, where about 20 other women were incarcerated. "It made me wonder of the cold-heartedness of the judges, who would send pregnant women to prison, when there are other alternatives to incarceration," she writes.
4. They go through childbirth classes.
Warner, who found out later in her pregnancy that she was actually expecting twins, took childbirth education classes with the rest of the pregnant prisoners. She explained that they had group therapy sessions in Parenting, Substance Abuse, Domestic Violence, Prenatal Care, Childbirth, and Postpartum. A childbirth educator also came to the hospital after delivery to check on the women.
5. They have to labor alone.
"During the labor, no one is allowed in the delivery room," Warner writes. "My family didn't even know I was in labor or had her until after I left the hospital." In addition to being forced to labor without a support person present, Warner's entire labor and delivery was also monitored the entire time by prison guards.
6. They are handcuffed after giving birth.
"Thirty minutes after giving birth, I was once again handcuffed and chained, and wheeled to another floor," Warner wrote. Can you imagine trying to hold or nurse a baby with handcuffs and chains on?

According to the website and movement Women in Prison, 46 states have no legislation that restricts the shackling of pregnant women in prisons, jails, and detention centers, leaving the practice to the discretion of individual facilities. Illinois, California, Vermont, and New Mexico prohibit it entirely,although, apparently, it still does occur.
7. They have 24 hours with their baby.
In most states, the law maintains that a woman with a vaginal birth must be out of the hospital at 24 hours after delivery.

"I've seen the state of other women who have come back lost after giving birth," Warner wrote. "In a total state of shock and confusion. One woman I know turned to pills, getting high by taking others' psychotropic drugs. She walked around the unit like a zombie, trying to dull the pain from the separation of her child. One night she OD'd on these pills, was rushed to the hospital, lucky to have survived. She was then taken to segregation and placed on suicide watch. It was so hard seeing her like that. At that time I wondered how I would feel after I had to leave my baby. I used to lay on my bunk at night feeling her more, talking to her or reading a children's book I found in the library. I couldn't imagine the day I wouldn't feel her more or couldn't talk to her anymore. When that day came, I was desperate."

Warner was so desperate to stay with her baby, in fact, that she refused to eat, a move that bought her three extra days with her baby.
8. They can lose their baby.
Even if women in prison finish their time, they are at risk of losing their children if their time exceeds more than two years. After two years, most states maintain that a mother will lose all parental rights.
9. They can breastfeed.
Although it's not very likely, it is possible for prisoners to breastfeed, if the prison is nearby the child's place of residence and the fostering or adopting family is willing to cooperate by picking up frozen breast milk.
10. They are more at risk for postpartum mental disorders.
The combination of being separated from their babies, the severe isolation, and the poor physical care during the pregnancy and postpartum periods place new mothers at an increased risk for mental disorders following birth, including postpartum depression and postpartum psychosis.

What do you think? Should women who become pregnant or are already pregnant be forced to become prisoners or should other options be made available?

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10 Things You Didn't Know About Pregnancy in Prison

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Imagine finding out you are pregnant, but instead of shopping excitedly for stretchy jeans and cute maternity outfits, you found yourself sporting a very different type of pregnancy style... Stripes. According to the American Journal of Public Health , between 6 and 10 percent of incarcerated women are pregnant; in one year alone, 1,400 women gave birth while incarcerated in the United States.

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UMass Medical School's Warren J. Ferguson, one of the nation's leading experts on health care for criminal justice populations, will speak at the upcoming Association of American Medical Colleges (AAMC) annual meeting in Boston.

Director of academic programs for UMass Medical School's Health and Criminal Justice Program, Dr. Ferguson will participate in a Nov. 5 session on "Social Justice Behind and Beyond the Bars: Criminal Justice Health and Academic Medicine."

Thousands of medical school deans, researchers, clinicians, hospital executives and university administrators will gather Nov. 3-7 at the Hynes Convention Center in Boston for "Learn Serve Lead 2017," the AAMC's annual meeting.

Ferguson will discuss the impact of incarceration on the health of individuals caught up in the criminal justice system as well as the special challenges and conditions medical practitioners face in a correctional facility setting.

"Incarceration has an impact on people's health on multiple levels," said Ferguson, who is chair of the Academic Consortium on Criminal Justice Health, which he helped found. "Individuals in many respects lose much of their humanity when they are incarcerated. It can be a very dehumanizing experience."

Ferguson has been recognized for his long-standing efforts training the next generation of professionals dedicated to improving healthcare outcomes for the incarcerated and other vulnerable groups. He routinely mentors criminal health justice students and junior investigators.

But at a time when there is already a shortage of primary care physicians, recruiting new medical personnel to work in prisons and jails across the country can be challenging.

"Jails and prisons are at the bottom of the totem pole in terms of recruitment," said Ferguson, who is also professor and vice chair of UMass Medical School's Department of Family Medicine & Community Health.

Those seeking to build a career in the correctional health system also must learn to navigate a unique culture as well.

"You never ask about the crimes they have committed," Ferguson says. "You are there to provide health care. You are not a police officer, a lawyer or a judge. Leave the politics out of it."

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The Challenges of Being a Prison Health Care Provider

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UMass Medical School's Warren J. Ferguson, one of the nation's leading experts on health care for criminal justice populations, will speak at the upcoming Association of American Medical Colleges (AAMC) annual meeting in Boston. Director of academic programs for UMass Medical School's Health and Criminal Justice Program, Dr. Ferguson will participate in a Nov.

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"Consideration of prisoners as well as others for transplantation includes evaluation of medical and non-medical factors relative to their impact on transplant outcome" -- When a deceased's organs are used to help another individual, should there be bias on whether or not these organs will last longer in an individual who isn't incarcerated?

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Introduction Robert M. Sade, MD

Ten years ago, Christian Longo had been deeply enmeshed in a career of minor crimes and crushing financial burdens that had led to bankruptcy. He saw only one way out: relieving his family, his wife Mary Jane and their three children, of their dependency on him. He strangled Mary Jane and 2-year old daughter Madison, put them into suitcases and threw them into Yaquina Bay in Newport, Oregon. He stuffed his 3-year old daughter Sadie and 4-year old son Zachery into pillow cases, weighted them down with rocks, and threw them, still alive, into a nearby pond where they drowned.

His crime was discovered when Zachery's body floated to the surface of the pond. He was placed on the FBI's 10 most wanted list, was found two years later living with his girlfriend in Cancun, Mexico, and was arrested, brought back to Oregon, put on trial, found guilty on four counts of murder, and sentenced to death.

Several months ago, he wrote an editorial that was published in the New York Times: "Giving life after death row." The editorial began with these words: "Eight years ago I was sentenced to death for the murders of my wife and three children. I am guilty. I once thought that I could fool others into believing this was not true. Failing that, I tried to convince myself that it didn't matter. But gradually, the enormity of what I did seeped in; that was followed by remorse and then a wish to make amends."

He continued: "There is no way to atone for my crimes, but I believe that a profound benefit to society can come from my circumstances. I have asked to end my remaining appeals, and then donate my organs after my execution to those who need them." He went on to say, "And yet, the prison authority's response to my latest appeal to donate was this: `The interests of the public and condemned inmates are best served by denying the petition.'"

Longo claimed that half of the other inmates on death row wanted to do the same and that there was no valid reason to prohibit them from donating. The question of who was right, the condemned prisoner or the prison parole board., was debated at the Southern Thoracic Surgical Association Annual Meeting in November 2011. by Dr. Shu Lin, who sided with the prisoner, and Dr. Jay Pal on the side of the parole Board.

Shu S. Lin, MD, PhD and Lauren Rich, RN, BSN

Introduction

As a member of the transplant community, I recognize the problem we face with the seemingly insurmountable shortage of donor organs; as a transplant surgeon, I also greatly understand the importance of seizing every appropriate opportunity for patients with end-stage organ failure, by performing one transplant at a time, to better their lives. As such, when it was brought to my attention that prisoners on death row have been vocal about wanting an opportunity to donate their organs after the execution, the question that came to my mind was, why not?

Why Allow Death Row Inmates to Donate?

My rationale for allowing death row inmates to donate their organs is simple and logical. One more organ donor means at least one life, and typically more lives, saved. It is not necessarily, as some medical ethicists such as Arthur Caplan of University of Pennsylvania speculate, an attempt to "close the ever-widening gap between demand and supply of organs" in transplantation. It is, quite simply, to help individuals suffering from end-stage organ disease. The center of attention, in my mind, should be the patient, and how we, as healthcare providers, can help them. There is no question that, when there is a therapy (i.e., transplantation in this discussion) with known benefits to the patients that we serve, everyone would agree that we should attempt to implement that therapy pending the risks or the drawbacks of that therapy.

An important part of transplantation is organ donation, which is generally governed in the United States by two documents-the National Transplant Act of 1984 and the Uniform Anatomical Gift Act, neither of which explicitly prohibits organ donation by death row inmates. Specifically, the National Transplant Act stipulates that organ donation cannot be made for "valuable considerations," including that in exchange for any monetary or material benefit or, in the case of prisoners, for a shorter sentence to the donor-which obviously would not be an issue for death row inmates. Furthermore, the Uniform Anatomical Gift Act, which is drafted by the National Conference of Commissioners on Uniform State Laws in the U.S. and governs organ donation for the purpose of transplantation as well as the making of one's cadaver to be an anatomical fit to the study of medicine, states in its Section 5 that all that is required for one to be a donor is some type of a document, such as a donor card or an indication on a driver's license. Therefore, the more critical question in this debate, of whether death row inmates should be allowed to donate their organs for transplantation, is what are the reasons not to permit this practice? In the sections to follow, I will outline some of the objections raised against the idea of using death row inmates as donors and discuss why those arguments, with deliberate and informed consideration, are not necessarily valid.

Why Not Allow Donation?

Presumptive arguments have been made in an attempt to answer the question of why death row inmates should not be allowed to donate their organs. Arthur Caplan has articulated some of these points in a recently published article in The American Journal of Bioethics [A]. In general, these objections can be categorized into those due to practical barriers and those involving ethical or moral concerns. It is important to recognize up front that, due to wide cultural differences, what is being discussed here must be considered in the context of how it would apply in the United States and not in other countries.

The practical barriers include what is believed to be a low yield of transplantable donor organs from these prisoners, the concern over the quality of these donors, the perceived difficulty in carrying out the organ procurement in these executed prisoners, and potential lack of public support or acceptance of capital punishment. However, even opponents of this proposal admit that the practical barrier of not being able to meet the demands of organ donation is irrelevant in this discussion.

The ethical or moral concerns, on the other hand, involve two seemingly opposite rationale-the fear of coercion and the intention to preserve the morality of capital punishment. The former insinuates that death row inmates are not being adequately protected, while the latter implies that the rights of these same individuals are given too much protection. Specifically, the idea of preserving the morality of capital punishment stems from the belief that this type of donation is not consistent with the intended justifications of capital punishment, which some argue is to achieve retribution and deterrence in our society. Nonetheless, this line of argument, that donation "undercuts the morality of execution," is challenged by various philosophy, ethics, and religion experts such as Gardner, Johnson, and Murphy.

Practical Barriers

Ethical/Moral Concerns

Opinion Polls

Clearly, as in Christian Longo's case and others, there are plenty of examples of death row inmates requesting the option to donate their organs for transplantation. In the preceding paragraphs, we have outlined how proponents and opponents of this proposed practice would argue their respective points. Forgetting all that, and never mind what the transplant surgeons or the ethicists think, how does the general public feel about this issue? After all, we live in a society where public acceptance of a policy or a practice is at least somewhat important because of the democracy of our government.

In all five opinion polls that we were able to find related to this topic, there is an overwhelming support for the idea that condemned prisoners should be allowed to donate their organs for transplantation.[Table 1] [H,I,J,K,L]. For example, to the question of "Should death row inmates be permitted to donate organs?" posed on a political forum website, 100% of the voter responded "yes", although there were very few responders, 19 to be exact, in this poll [H]. In a similarly small survey of 21 voters, over 85% of them responded "yes" to the question, "Should organ donation be allowed on death row?"[I] Interestingly, in this survey, there were more people who were undecided than who answered "no," which perhaps reflect that uncommitted voters are generally still open-minded about this issue. In a larger scale survey conducted by MSNBC news organization in April of 2011, almost 80% of 86,736 voters responded "yes" to the question, "Should death row inmates be allowed to donate their organs?" [J] Even when the public was asked about a specific situation, as in an Indiana University poll which dealt with the Gregory Scott Johnson case, the majority of the 3370 voters agreed that the state of Indiana should delay his execution to see if he can donate part of his liver to his ailing sister [K]. Finally, in an opinion poll, released in conjunction with the story of Christian Longo, that asked, "Should man who killed wife and two children be allowed to donate his organs?", nearly 90% of 588 voters responded "yes" to this question [L]. Clearly, the general public seems to see these death row inmates as potentially acceptable donors for those who are in dire need of transplantable organs.

In terms of valued opinions, what might be more important is how the potential transplant recipients feel about receiving an organ of a condemned prisoner. In one public opinion poll, 12 out of 14 voters responded "yes" when asked if they would accept a donor heart from a death row inmate [M]. This is a survey from a political forum website and therefore obviously reflects what the general public believes if they were in that situation of being a patient suffering from end-stage heart failure.

To more accurately assess, from the point of view of those who would actually be undergoing the organ transplant, whether death row inmates are indeed acceptable organ donors, we surveyed all of the patients that are on the Duke Lung Transplant Program's active waiting list. We posed the following hypothetical question: "If we knew a donor was disease-free and their lungs were in good condition, would you be willing to accept lungs from a death-row inmate?" Sixteen patients were on the active waiting list at the time of the survey, and 12 of them responded "yes" and 4 responded "no." One individual that replied "yes" commented that this is an acceptable practice "even if just one person was helped." Of those who responded "no," one person stated that the response would have been "yes" if that person's condition was more unstable. Thus, there is an agreement, even among those who are actually on the "receiving" end of the debate, that condemned prisoners are indeed acceptable donors for organ transplantation. The 75% positive response rate is consistent with all of the other polls mentioned above.

Summary

Provided that there is appropriate screening, there is no medical reason that death row inmates cannot be a suitable donor for organ transplantation. Individuals with criminal records in the past and those with unknown medical and social background are currently not excluded from organ donation, and what used to be considered "marginal" donor organs are now known to contribute safely to helping patients that are suffering from end-stage organ failure. Thus, there should be no logical reason why condemned prisoners, after the execution, cannot donate organs that might be useable and, in some cases, provide one of the rare matches for certain potential recipients. Death row inmates are willingly requesting it, general public supports it, and potential recipients accept it. Should moral objection of a few people prevent the precious opportunities for those who might benefit from receiving those organs? Ultimately, whether people are for or against donation after capital punishment is a reflection on our society and the values of our society-Are we more interested in retribution and deterrence, or in actually helping those who have no other options?

Jay D. Pal, MD, PhD

Introduction

Organ donation is a life-saving treatment for patients who suffer from advanced organ failure. Since the first kidney transplant in 1954, thousands of patients have benefited from the "Gift of Life" that is organ donation. With the exception of living related kidney (and to a much smaller extent, liver) donors, most transplanted organs are obtained from cadaveric donors. As such, organ transplantation remains limited by the number of available donors. Despite the incidence of traumatic death in the U.S.A, only 6,000-8,000 deceased donors are available annually, compared to 112,718 patients currently awaiting transplantation[1, 2]. Approximately 18 individuals will die each day while awaiting a suitable organ donor[2].16 Therefore, many novel attempts have been made to increase the potential donor pool. These have included donor registries, first-person consent, surrogate consent, and the use of prisoners as a source of organs.

There has been renewed interest in the use of condemned prisoners as organ donors, as recently highlighted by a New York Times editorial by Christian Longo[3].1 Mr. Longo, convicted of murder, awaits the death penalty in Oregon. He states his desire to donate his organs after his execution, and claims that half of the death-row inmates in Oregon share his desire. However, the prison board has denied his petition in the "best interests of the public and condemned inmates."

Transplant physicians are regularly confronted by the effects of an inadequate donor population on patients awaiting transplantation. However, deeper consideration of the use of prisoners as organ donors raises several concerns. These reservations can be grouped into three categories: Legal, moral/ethical, and logistical. Thoughtful insight into these concerns will provide ample evidence that death row inmates are not suitable organ donors.

Legal Issues

Two basic tenets of organ transplantation as stated by the World Health Organization and the World Medical Association are that vitals organs should only be removed from dead patients, and that living patients should not be killed for or by organ procurement. This "dead-donor" rule has been fundamental in the identification of potential organ donors since the 1950s. Accordingly, the accepted definition of death can be by (1) traditional cardiopulmonary criteria, which is the cessation of circulatory and respiratory functions; or (2) brain-death criteria, which is the irreversible cessation of brain function including brain-stem activity (Uniform Declaration of Death Act of 1981). Although there have been recent discussion regarding the modification of the dead-donor rule in the case of patients with irrecoverable brain injury with remaining brain-stem activity, the prevailing norm is that potential donors meet the currently accepted definitions of death[4-7].

The concept of brain death provided the legal justification for organ procurement[8]. More recently, the declaration of brain death has been clarified and standardized[9]. The primary obstacle for organ donation from executed prisoners is that they do not die (brain-death) on life support, as is typical for most organ donors. The most common method of execution in the United States is a three drug protocol to cause sedation, respiratory and circulatory arrest. After a waiting period of 10-15 minutes, the prisoner is examined for evidence of cardiac activity, and in its absence, declared dead. Any modification of the method of execution to decrease this ischemic time would result in death occurring due to organ procurement, which places the surgeon in the role of executioner.

The second legal question to arise in the use of organs from death row inmates is the ability to consent. The concept of informed consent requires the ability to understand the procedure, as well as the autonomy to make a decision without coercion. While there are some differences between states, all prisoners lose some component of citizenship rights at the time of conviction. Death row inmates, in particular, are expressively stripped of the right to make personal decisions. In most states, the prisoner becomes a ward of the state, or a property of the state, and therefore, the state holds the legal authority to consent for the inmate. In every case regarding prisoner donation of organs, state prison boards have upheld this authority and denied inmate petitions. Furthermore, numerous legal reviews have provided arguments against the legality of organ donation from executed prisoners[10-12].

Moral/Ethical Issues

A far more problematic issue in the use of organs from death row inmates is the ethical dilemma of obtaining organs from patients who are being executed. Prisoners are subject to physically and psychologically stressful conditions which undoubtedly affect the decisions they make. Mr. Longo states that he "spend(s) 22 hours a day locked in a 6 foot by 8 foot box on Oregon's death row[3]." The Uniform Anatomical Gift Act requires that all organ donation be provided without coercion. However, prisoners are particularly vulnerable to both direct and implied coercion, by virtue of their incarceration. The National Institute of Health explicitly acknowledges this coercion in its rules regarding prisoner consent: "Prisoners may not be free to make a truly voluntary and uncoerced decision... the regulations require additional safeguards"[13].

Organ procurement in the setting of such coercion is often cited by bioethicists as a reason to avoid the use of executed prisoners as organ donors[14-16]. In addition, the American Society of Transplant Surgeons states that the use of organs from executed prisoners is unacceptable and that procurement under these circumstances violates the basic principles of transplantation.

The World Medical Association has issued a similar statement, specifically with regards to organ procurement from executed prisoners in China[17]. More than 5,000 prisoners are executed in China annually, and organs are harvested for transplantation from suitable prisoners. Prisoners who are destined to become organ donors are executed via a temporal gun shot wound. The prisoners are declared dead secondary to execution, rather than the usual definitions of brain-death or circulatory-death, and transported to a hospital for organ procurement. This process has been described as "death-row inmates received unfinished execution in the surgery theater at the hospital, and their execution is continued after the firing squad and finished by the transplantation surgeons.[18]" The process of execution without consent for organ procurement, as well as a lack of confirmation of brain-death, has led to numerous calls for the end of organ procurement from executed prisoners[14,19-22].,

Given the numerous outstanding ethical issues regarding organ procurement from executed prisoners, the Organ Procurement and Transplant Network/United Network of Organ Sharing Ethics Committee generated a white paper which concluded: "The UNOS Ethics Committee has raised a small number of the many issues regarding organ donation from condemned prisoners. The Committee opposes any strategy or proposed statute regarding organ donation from condemned prisoners until all of the potential ethical concerns have been satisfactorily addressed."

Logistical Issues

A third argument against the feasibility of transplanting organs from prisoners is the logistical and practical difficulties in procuring and preserving organs after execution. The most common method of execution in the United States is lethal injection. Prisoners are typically sedated, paralyzed to induce respiratory arrest, then injected with potassium to induce cardiac arrest. After a waiting period of 10-15 minutes, the prisoner is examined for evidence of cardiac activity, and in its absence, declared dead. Since executions are performed in maximum security prisons and not in medical facilities, the prisoner would be dead for an extended period before the donor is transported to a hospital and organ procurement can be performed. Due to this delay, very few organs would be recoverable.

A possible solution would be to move the execution to a facility where organs can be recovered more rapidly, similar to donation after circulatory death (DCD) procedures. But that would require moving an inmate to a hospital prior to execution. The process of moving an inmate to an unsecured location would be difficult, given the uncertainty of the appeals process, protests, demonstrations, security requirements, and potential for escape. Also, many hospitals will likely be resistant to accepting prisoners for execution. Despite the potential financial benefit from providing a location for organ procurement, the public relations impact of becoming a center of execution would be detrimental.

Similarly, to minimize ischemic time from execution to organ procurement, physicians and surgeons would need to be intimately involved in the execution process itself. While most physicians would not consider participating in the execution itself, the procurement procedure in conventional brain-dead donors is deliberately separate from the declaration of death. However, DCD procedures create some ambiguity that many physicians find disturbing. Consider the case of Dr. Hootan Roozrokh, the transplant surgeon who was accused of hastening the death of a potential organ donor in order to expedite organ procurement. While he was ultimately acquitted, this case highlights the public misunderstanding of organ procurement and the heightened emotions associated with this process. The processes of death and organ donation must be kept separate, but organ procurement from an executed prisoner makes this distinction difficult. For this reason, the American Medical Association and the American Society of Anesthesiology have both issued position statements precluding members from participating in executions.

Conclusion

While organ donation after prisoner execution will continue to be debated, it is helpful to consider how much benefit may actually be realized. In the first nine months of 2011, 10,558 individuals donated organs in the United States. In contrast, 39 inmates were executed. The average age of executed prisoners is over 50, and many suffer from chronic illnesses such as diabetes and hypertension. By conventional criteria, such as age, medical conditions, and communicable disease, half of these prisoners would not be eligible donors[10]. Therefore, the net increase in donors is less than 1/5 of one percent. And given the DCD nature of these donations (with prolonged ischemic times), only kidneys are likely to be recoverable.

Given the contentious nature of this topic, we must evaluate the legal, moral, and logistical impediments to organ procurement from prisoners for the net gain of only 20 donors per year. Less controversial methods to increase the number of donor organs can be obtained by increasing public awareness of organ donation, creating donor registries, and improving organ yield from the eligible donors.

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Prisoners on Death Row Should be Accepted as Organ Donors

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Ten years ago, Christian Longo had been deeply enmeshed in a career of minor crimes and crushing financial burdens that had led to bankruptcy. He saw only one way out: relieving his family, his wife Mary Jane and their three children, of their dependency on him.

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Redefining what a prison is is the way forward. From my understanding, a prison is supposed to restrict freedom, making it an undesirable place to be. In our fulfillment of this basic function of a prison - and since prisoners are seen as scum of the earth - we have chosen to ignore basic human needs that would do the prisoners more harm than good in the long run. But what do we care?
So redefining what a prison is; allowing certain necessary freedoms - not to the point where the prison resembles a boarding school - is very important. With that definition, we can reinvent the prison system.

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Are inmates given nutritional supplements?

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British Journal of Nutrition

There are limited studies on the adequacy of prisoner diet and food practices, yet understanding these are important to inform food provision and assure duty of care for this group. The aim of this study was to assess the dietary intakes of prisoners to inform food and nutrition policy in this setting. This research used a cross-sectional design with convenience sampling in a 945-bed male high-secure prison. Multiple methods were used to assess food available at the group level, including verification of food portion, quality and practices. A pictorial tool supported the diet history method. Of 276 eligible prisoners, 120 dietary interviews were conducted and verified against prison records, with 106 deemed plausible. The results showed the planned food to be nutritionally adequate, with the exception of vitamin D for older males and long-chain fatty acids, with Na above upper limits. The Australian dietary targets for chronic disease risk were not achieved. High energy intakes were reported with median 13·8 (se 0·3) MJ. Probability estimates of inadequate intake varied with age groups: Mg 8 % (>30 years), 2·9 % (<30 years); Ca 6·0 % (>70 years), 1·5 % (<70 years); folate 3·5 %; Zn and I 2·7 %; and vitamin A 2·3 %. Nutrient intakes were greatly impacted by self-funded snacks. Results suggest the intakes to be nutritionally favourable when compared with males in the community. This study highlights the complexity of food provision in the prison environment and also poses questions for population-level dietary guidance in delivering appropriate nutrients within energy limits.

* Corresponding author: M. Hannan-Jones, fax + 61 7 3138 3980, email m.hannan-jones@qut.edu.au

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What do prisoners eat? Nutrient intakes and food practices in a high-secure prison | British Journal of Nutrition | Cambridge Core

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British Journal of Nutrition There are limited studies on the adequacy of prisoner diet and food practices, yet understanding these are important to inform food provision and assure duty of care for this group. The aim of this study was to assess the dietary intakes of prisoners to inform food and nutrition policy in this setting.

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This article shows the legal right to medical care in correctional facilities. I feel like it leaves a lot of room for interpretation because it says "appropriate care differs from person to person"

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Is bias within the medical professionals in prisons significant? How do we address it? 

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Is bias within the medical professionals in prisons significant? How do we address it? 

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https://www.americannursetoday.com/from-our-readers-resolving-the-forces-of-bias-and-duty-in-caring-for-incarcerated-patients/

http://blog.diversitynursing.com/blog/unconscious-bias-in-healthcare

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4308970/

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KEY POINTS:

Sharing needles for drug use, the unavailability of condoms and rape are persistent issues within prison environments which increase the risk of HIV transmission.

Lack of HIV prevention and harm reduction programmes increase the risk of HIV transmission among prisoners.

For prisoners living with HIV, adherence to antiretroviral treatment is often difficult and the everyday stresses of living in a prison can compromise an already weakened immune system leading to poor health and risk of co-infections.

Re-thinking the number of people sent to prison for treatable substance use disorders would reduce HIV transmission and improve lives.

Explore this page to find out more about why prisoners are at risk of HIV, preventing HIV among prisoners, treatment and support, and the way forward.

Every year, 30 million people spend time in prisons or other closed settings and more than 10.2 million are incarcerated at any given time. 1 2

At least 90% of prisoners worldwide are adult men, who tend to be economically poor and socially marginalised. and tend to be economically poor and socially marginalised. 3 The UN Special Rapporteur on Extreme Poverty and Human Rights reported in 2011 that:

disproportionately high numbers of the poorest and most excluded are arrested, detained and imprisoned. 4

It is estimated that 3.8% of the global prison population are living with HIV and 2.8% have active tuberculosis (TB). 5 However, prevalence differs greatly between regions with HIV prevalence greater than 10% reported in 20 low-income and middle-income countries. 6

The regions where prisoners are most affected by HIV are East and Southern Africa and West and Central Africa, both of which have a high HIV prevalence in the general population, and Eastern Europe and Central Asia and Western Europe, reflecting the over-representation of people who inject drugs in prison-a group with a high prevalence of HIV. 7

About 6.5% of the world's prisoners are women. 8 Overall, female prisoners have higher HIV prevalence then men, although there are significant variations between regions. In West and Central Africa, HIV prevalence among female prisoners is almost double that of men (13.1% vs 7.1%), and in Eastern Europe and Central Asia it is almost three times higher (22.1% vs 8.5%). 9

Prisons are a high-risk environment for HIV transmission with drug use and needle sharing, tattooing with homemade and unsterile equipment, high-risk sex and rape commonplace. Overcrowding as well as stress, malnutrition, drugs, and violence weaken the immune system, making people living with HIV more susceptible to getting ill. 10 Yet, prisoner wellbeing is often neglected and overlooked.

HIV prevention programmes are rarely made available to inmates, and many prisoners with HIV are unable to access life-saving antiretroviral treatment (ART). 11 In many parts of the world, prison conditions are poor and inmates living with HIV barely receive the most basic healthcare. Moreover, mandatory HIV testing is enforced by some prison authorities, which is often seen as a breach of human rights.

Prison conditions are often ideal breeding grounds for onward transmission of HIV infection. They are frequently overcrowded. They commonly operate in an atmosphere of violence and fear. Tensions abound, including sexual tensions. Release from these tensions, and from the boredom of prison life, is often found in the consumption of drugs or in sex. 12

Injecting drug use

The use of contaminated injecting equipment when using drugs is one of the primary routes of HIV transmission in prisons. Many prisoners begin injecting drugs for the first time in prison. 13 Where there are high numbers of imprisoned people who inject drugs, there is a higher risk of HIV transmission.

Within prisons it is difficult to obtain clean injecting equipment. Possessing a needle is often a punishable offence and therefore many people share equipment that has not been sterilised between uses.

There are a lot of people who come in, and haven't done drugs before who become addicted inside and come out with a HIV or hepatitis C infection. I saw a young guy who came in on a 16-month sentence, became addicted to drugs and contracted HIV. He ended up hanging himself in his cell. If they had needle exchanges in institutions a long time ago, it would have saved a lot of people's lives. So many people have become infected from one dirty needle.

- Corey, Halifax, Nova Scotia 14

Although reliable data on prisoners who inject drugs are difficult to obtain, more than 70% of injecting drug users reported sharing equipment in Ukraine and Indonesian prisons and it has also been documented in Australia (13%), Iran (6%) and Mexico (61%). Evidence of HIV transmission in prisons via drug injection has resulted in HIV outbreaks in Iranian, Lithuanian, Thailand, the United Kingdom (UK), and Ukrainian prisons. 15

In Eastern Europe and Central Asia it is estimated that people who inject drugs represent more than a third of prisoners across the region, with the level as high as 50-80% in some countries. 16 A 2016 study published in The Lancet estimated that between 28% and 55% of all new HIV infections over the next 15 years in Eastern Europe and Central Asia will be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. 17

I was shocked to learn that drug injection in...prison was worse than on the streets of Gatchina, where I lived. The guards helped supply drugs and prison leaders made sure we remained addicted. Many of us paid with our lives. Some guys overdosed, others became HIV-infected like me and tuberculosis finished off the rest of us. Even though all of us were sick, seeing a doctor and getting care was nearly impossible.
- Sasha, an injecting drug user from Russia 18
Sexual violence, unsafe sex and other high-risk behaviours

Prison populations consist mainly of 19 to 35 years old men - a segment of the population that is at higher risk of HIV infection prior to entering prison. 19 The prevalence of sexual activity in prisons is largely unknown and thought to be significantly under reported due to denial, fear of stigma and homophobia as well as the criminalisation of same sex conduct. 20

What is known is that incarceration disrupts stable partnerships and prisoners face the risk of forming new and sometimes coercive sexual partnerships with several individuals in contexts where access to condoms and lubricants are extremely limited. 21

Reliable data on sexual activity in prisons is difficult to obtain although a 2016 study estimated that between 1 and 19% of prisoners are involved in consensual same sex activity while incarcerated. 22 In a 2012 survey of more than 2,000 Australian prisoners, 7.1% reported having sex without a condom in prison with other prisoners and 2.6% admitted to being coerced into sexual acts. Similarly, two large US surveys found that 2-4% of prisoners reported being sexually victimised, and studies conducted in African prisons reported sex being exchanged for food, sleeping space and commodities. 23

Unavailability of condoms

Prison systems in Western Europe, North America, Australia, Indonesia, Iran, South Africa and parts of Eastern Europe and Central Asia provide condoms in prisons, however, many do not. Even in countries where condoms are available, access is still problematic. For example, as of 2016 only two state prison systems and a handful of jails in the United States of America (USA) allowed the distribution of condoms, despite the practice being recommended by the US Centers for Disease Control and Prevention (CDC). 24

A study of HIV transmission among male prisoners in Georgia, USA found that only 30% of those who reported having consensual sex used condoms or improvised condoms (such as rubber gloves or plastic wrap). 25

Similarly, most prisons in the UK only provide condoms when prescribed by a doctor and will refer to section 74 of the Sexual Offences Act 2003, which prohibits sexual activity in a 'public place'. A 2005 report by the Prison Reform Trust and the National AIDS Trust found that different UK prisons interpret the guidance on condoms differently so, while they are easily accessible in some prisons, in others they are difficult or impossible to access.

Additionally, prisoners often feel inhibited from asking for condoms because of lack of confidentiality. Prisoners often have to make an appointment in order to get condoms, which can have an impact on their right to confidentiality about their sexuality or HIV status. When this is the case, uptake is generally low. 26

Sexual activities are often forbidden in prisons, with some believing the provision of condoms condones such behaviour and potentially leads to an increase in such activities. However, various studies have found this is not the case. For example, a 2013 Australian study of prisons in New South Wales, where condoms are freely distributed, and Queensland, where they are not, found no evidence that condom provision increased consensual or non-consensual sexual activity in prison. However, they did find evidence that, where condoms were available they were being used by prisoners engaging in anal sex. 27

Indeed, prisons that have implemented condom programmes to date have not reversed their policies. 28 These schemes are generally accepted by staff and inmates, and very few problems, such as drug smuggling, have been reported. 29 However, where there are deeply held prejudices against homosexuality, education about condoms as well as their provision should be introduced to counter the stigma that people engaging in same-sex activity face. 30

Now condoms are hard to come by in prison. As I went down to the medical quarters twice a day (to get my medication), I used to ask there. But I was rationed to one a day (...) I was told that if I took the dirty condom back - to prove it had been used - they would give me more (...) But even taking dirty condoms back didn't always guarantee fresh supplies.

- An HIV positive inmate in the UK who was forced to have sex with a fellow inmate in exchange for protection from other violent inmates 31

Rape and sexual abuse

While most sex in prisons is consensual, rape and sexual abuse is used to exercise dominance over other inmates. 32 Roughly 25% of prisoners suffer violence each year, while 4% to 5% experience sexual violence and 1% to 2% are raped. 33

Allegations of sexual abuse in US prisons are increasing according to a Department of Justice study. 34 The report found that between 2009 and 2011 administrators reported about 25,000 allegations of sexual victimisation in prisons, jails and other adult correctional facilities. Prison staff were allegedly responsible for 49% of reported incidents.

Prosecution for crimes committed by staff is extremely rare. Over three quarters of staff responsible for sexual misconduct were allowed to resign before an investigation concluded or were dismissed. Around 45% were referred for prosecution but only 1% of perpetrators were convicted. The US government has warned states that they may lose some federal funding if they do not take steps to detect and reduce sexual assaults of prisoners. 35

Women prisoners are also vulnerable to sexual assault, including rape by both male prisoners and male prison staff. They are also at risk of sexual exploitation and may engage in sex for the exchange of goods. 36

Transgender people confront high rates of unemployment, homelessness, and marginalisation, which often force them to work in the underground economy, including sex work. In the USA, one in six transgender people report a history of incarceration; and nearly half of African American transgender women have been incarcerated. Once incarcerated, 35% of transgender women experience sexual victimisation from other prisoners or from correctional staff. 37

During my incarcerations I witnessed innocence, vibrancy and youth snatched from countless transgender women of color, especially HIV positive women. At least eight of my friends probably became infected in jail. Once released, they had to engage in sex work outside to survive, just as in jail. None of them lived to the age of 35. I live with the trauma of this experience daily.

- Tela La'Raine Love, an African-American transgender women from Greater New Orleans. 38

Tattooing

Tattooing is still commonplace among prisoners. It usually involves multiple skin punctures with recycled, sharpened, and altered implements including staples, paper clips and plastic ink tubes found inside ballpoint pens. 39

Those who perform the tattooing tend not to have new or sterilised tattooing equipment. For example, more than 60% of inmates in a Puerto Rican prison acquired tattoos in prison in which the reuse of needles and sharp objects was common. 40 Some people use metal points connected to a battery or other electrical source which increases the number of skin punctures, elevating the risk of HIV transmission. 41

There have only been a few reported cases of HIV transmission due to tattooing. However, one study of Iranian prisoners reported a significant association between HIV prevalence and tattooing. 42

Punitive laws and overcrowding

Punitive laws lead to the incarceration of people living with HIV and other key affected populations who are disproportionately represented in prisons worldwide as a result. 43

For example, sex workers are at a high risk of incarceration as more than 100 countries criminalise sex work or aspects of sex work. 44 Likewise, 76 countries criminalise same sex activity, increasing this risk for men who have sex with men. 45 In addition, there are 72 countries that have adopted HIV-specific laws that prosecute people living with HIV for a range of offences. 46

In places with weak criminal justice systems, people who are detained may have to wait for long periods during the investigation of a crime, while awaiting trial and before sentencing. These delays increase their likelihood of HIV infection while in prison. 47

Moreover, inappropriate, ineffective and excessive national laws and criminal justice policies lead to high incarceration levels and overcrowding. Prison overcrowding is a systemic problem in more than half of countries globally: in 117 countries, prison occupancy is more than 100% of capacity, in 47 countries it is more than 150% and in 20 it is above 200%. 48

Overcrowding makes HIV services harder to access and increases the risk of violence and abuse. 49

Tuberculosis (TB), HIV and prisons

Overcrowding also allows diseases like TB to thrive, and people living with HIV are more likely to develop TB because their immune systems are severely weakened. 50 A 2016 systematic review found that the incidence of TB is 23 times higher in prison populations than in the general community, and that the prevalence of drug-resistant TB is also substantially higher. 51

Despite TB being the leading cause of death among prisoners in many countries, only 63 countries provide TB treatment in prisons, while screening for hepatitis is equally uncommon. 52 53 54
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Denial of access to prevention and treatment services

In many places, HIV and other relevant health services in prisons are severely limited or are simply not available, either due to government policy or a lack of resources. In 2016, ART was only available in prisons in less than a third of countries worldwide.

A survey of US prisons found that, while 90% of prisons provided ART, only half offered substance abuse counselling and support designed for the needs of people living with HIV. 55

The scarcity of specialised care, the unavailability of specific ART regimens, and an unwillingness on the part of individuals to disclose their HIV status to prison guards, medical staff or other inmates all act as barriers to HIV treatment inside prisons. 56

The effectiveness of treatment can also be undermined by substandard prison conditions, poor nutrition and violence. 57 Moreover, prison health services often have too few or poorly trained staff, inadequate health assessments on entry, poor record keeping, and breaches of confidentiality. Even in adequately staffed facilities, prison staff have negative attitudes towards key populations, contributing to poor monitoring and treatment of HIV as well as TB, hepatitis and drug dependency. 58

In prisons where effective treatment is available, the number of AIDS-related deaths has been found to be similar to, or better than, the rate in the non-incarcerated community. For example, the rate of AIDS-related deaths in US state prisons dropped to less than the rate for the US general population in 2009. 59

Despite the high risk of HIV transmission among prisoners, HIV prevention and treatment programmes are often limited in prisons and other closed settings. Those that do exist also rarely link to national HIV prevention programmes.

In 2012, a comprehensive package of 15 key HIV interventions for prisoners was put forward by the United Nations Office on Drugs and Crime (UNODC) and includes:
* HIV testing and counselling (HTC)
* treatment, care and support
* information, education and communication
* harm reduction
* condom programmes. 60

Some of the main interventions to prevent HIV among prisoners, and their effectiveness, are detailed below.

HIV testing and counselling (HTC)

Evidence shows that if HIV testing and counselling (HTC) is made readily available on entry to prison and throughout incarceration, uptake increases. This is especially true if HTC is part of a comprehensive treatment and care programme.

Compulsory or mandatory testing (that requires all inmates to have an HIV test) is used in some prisons as a means of identifying those who are living with HIV. 61 This is despite the World Health Organization (WHO), the European Centre for Disease Prevention and Control (ECDC), and CDC all opposing mandatory HIV testing on ethical grounds. 62 Research suggests that mandatory testing and segregation of prisoners living with HIV breaches human rights by taking away the right of the individual to make their own decisions and is also costly and inefficient. 63 64

Despite this, in 2012, 11 states in the USA were conducting mandatory testing for HIV for all inmates upon admission and 8 states were conducting mandatory testing on release. 65

The test was forced upon me also no counselling was given or offered. I was held in isolation until the results were known. 66

By contrast, voluntary HIV testing has been found to increase the likelihood that prisoners are tested and receive their results before they are discharged or transferred to another prison. 67 Rapid testing in particular allows prisoners to know their HIV status in minutes. 68

Opt-out testing (where people have the option to refuse an HIV test) has also been found to be popular among prisoners and staff. A study of incarcerated men in Jamaica who were offered opt-out HIV testing recorded an acceptance rate of 63%. 69

Other studies have shown how HTC programmes can be more cost-effective if done in conjunction with other prevention initiatives such as providing condoms and testing for sexually transmitted infections (STIs). For example, a study of incarcerated men who have sex with men at Los Angeles County Men's Jail estimated that a 10-year intervention offering HIV and STI testing, as well as condoms, could save $180,000 in treatment costs. 70

A 2016 systematic review of 11 studies on ART adherence among prisoners found 54.6% of prisoners included in these studies were successfully adhering to ART. 71

Provision of ART for prisoners varies greatly between countries. For example, in South Africa, 97% of inmates living with HIV are currently on treatment and there is an 84% TB cure rate in these settings. 72 By contrast, in Russia just 5% of prisoners living with HIV are on ART. 73

To increase treatment adherence in prisons, confidentiality must be guaranteed and positive relationships with prison health staff is essential. A study from Namibia also identified insufficient access to food, and a lack of knowledge about how HIV is transmitted and managed as barriers to good adherence. 74

Most inmates are going for days and months without proper food...this has led to a deterioration of health for most inmates, especially those living with HIV. Some are not provided with regular counselling and treatment which further compromises their health.

- A prison guard at Chikurubi Maximum Prisons, Zimbabwe 75

It has also been found that being released from prison can often disrupt ART, especially for women. Many factors contribute to this, including relapse to substance use, unstable housing and unemployment, failure to access ART in the community because of loss of health entitlements, and reduced access to health care. Similarly, the immediate period after release has been associated with poorer HIV treatment outcomes (such as increased viral load and decreased CD4 cell count), higher risks of HIV-related mortality, and drug overdose. 76

HIV information, education and communication (IEC)

Prisoners and prison staff should be informed about HIV/AIDS and about ways to prevent HIV transmission, with special reference to the likely risks of transmission within prison environments and to the needs of prisoners after release. 77

Even in high-income countries, information, education, and communication programmes for prisoners about HIV and other STIs are insufficient to affect transmission. Sessions that include topics beyond HIV, such as employment and housing concerns, have been shown to have high success in changing prisoner risky behaviours, and peer-based interventions have also been shown to be successful yet very few prisons implement these type of programmes. 78
CASE STUDY
High levels of illiteracy among prisoners can also complicate IEC programmes. For example, 70% of prisoners in the USA have the literacy levels of a nine-year-old. 79 As a result, inmates often cannot understand the HIV prevention information they are given, which points to the need to better tailor programmes to meet prisoners' specific needs.

A programme in Ghana recruits inmates who are literate, have good communication skills and can maintain confidentiality as peer educators. The peer educators receive five days of training on HIV prevention, stigma and discrimination, STIs, sexual and gender-based violence and facilitation skills. They run film sessions and drama performances on HIV-related issues and distribute educational materials. Confidential HTC is also provided, with referrals to treatment and support services. In 2014, the programme reached nearly 220,000 prisoners and 248 prison officers with advocacy sessions. Roughly 30,000 prisoners received HTC for HIV, 228 of whom tested positive and were referred for treatment.

Harm reduction

Making needles and syringes and opioid substitution therapy (OST) available in prisons has been shown to reduce injecting drug use and needle sharing by up to 75%, thereby reducing the risk of HIV. 82

However, prison-based harm reduction continues to be extremely vulnerable to budget cuts, and changes in political environments. Regional overviews continue to paint a bleak picture: harm reduction in prisons tends to be either absent or plagued by restrictions, inconsistency and uncertainty. 83

Needle and syringe programmes (NSPs)

Needle and syringe programmes (NSPs) provide drug users with access to clean needles and syringes, in order to reduce the frequency of injecting with contaminated equipment. NSPs have been shown to lead to reductions in needle sharing in prisons, decreases in drug abuse and ultimately, lower levels of HIV transmission. 84

In 2016, only eight countries (Armenia, Germany, Kyrgyzstan, Luxembourg, Moldova, Spain, Switzerland, and Tajikistan) were implementing NSPs in at least one prison. Important legal and policy developments in France and Nepal could see the introduction of NSPs in prisons in both countries soon. 85

NSPs are entirely unavailable to prisoners in seven regions. Until 2014, Iran was providing NSPs in some prisons but reports suggest this has now ceased. 86

Opioid substitution therapy (OST)

Opioid substitution therapy (OST) is another harm reduction approach that aims to reduce heroin use by providing a substitute in the form of either methadone or buprenorphine. Prison-based OST programmes can be effective in reducing injecting drug use and needle sharing and have additional benefits for the health of prisoners and the community. 87

In 2016, some form of OST was provided in prisons in 52 countries, representing a 21% increase since 2014. Between 2014 and 2016, OST was initiated in at least one prison in India, Lebanon, Macau, Morocco, and Vietnam, while OST services have been expanded to two more prisons in both Greece and Moldova. Guidelines on OST in prisons have also been developed in Tajikistan, although actual implementation of the service is still under consideration. Despite this progress, OST is still extremely limited and in certain countries where the need is great, it remains illegal. For example, the Russian government views OST as merely replacing one addiction with another. Its use is punishable with up to 20 years in prison. 88

Even where OST services exist for prisoners, the quality varies considerably, and serious barriers including stigma and discrimination, unnecessary restrictions and long waiting times persistently impede access. 89

Where effective OST is available for prisoners a number of studies have reported high acceptance and retention rates. In one study from Geneva, Switzerland, OST was offered to all dependent users and all patients accepted treatment. 90 Another study monitoring the roll out of OST in Tihar Prisons in India recorded a 98% retention rate after 12 months. 91

HIV in prisons is both a public health and a human rights issue that needs to be addressed urgently. However, worldwide, governments are failing to address the issue.

As a group of leading academics argued in the Lancet in 2016, the first step to addressing HIV among prisoners is to reduce the numbers of people in prison by rethinking detention for substance use, sex work, and other non-violent offences. In the past decade, people who use drugs have been incarcerated in what have proved to be profoundly misguided and harmful approaches to treatable substance use disorders. Mass incarceration has destroyed countless individual lives, had lasting negative effects on prisoners' families and communities, and, in many settings, increased rates of HIV and TB. Efforts to provide alternatives to prison for people who use drugs must be intensified. 92

For those who are imprisoned, a substantial body of evidence shows that targeted HIV prevention programmes can reduce HIV transmission. Existing efforts need to be scaled-up, particularly comprehensive HIV prevention and treatment programmes, in order to provide prisoners living with HIV with the services they need.

The provision of effective harm reduction programmes, both inside and outside of prisons, must be urgently prioritised and resourced. 93 Protective laws, policies and programmes that are adequately resourced, monitored and enforced can also improve the health and safety of prisoners as well as the community as a whole. Without addressing these needs, a crucial gap in the HIV response will continue to hamper progress.
- Desmond M Tutu, Archbishop Emeritus of Cape Town Photo credit: ©iStock.com/melnichuk_ira. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo. 94
Imagine, if you can, languishing with untreated HIV or tuberculosis, and lacking the freedom to do anything about it. Fearing HIV exposure or acquiring tuberculosis, and being denied the basics of prevention. Across Africa, our prisons and jails are overcrowded with men and women who are at risk for HIV and tuberculosis, or who are already living with these treatable infections-but who are being denied the care they so urgently need. We have left them behind. This is unacceptable to God and it should be unacceptable to all of us.

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KEY POINTS: Sharing needles for drug use, the unavailability of condoms and rape are persistent issues within prison environments which increase the risk of HIV transmission. Lack of HIV prevention and harm reduction programmes increase the risk of HIV transmission among prisoners.

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Should inmates be on transplant lists? Maybe their own transplant lists? Who makes that decision?

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Journal of Ethics | American Medical Association

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Should a Prisoner Be Placed on the Organ Transplant Waiting List?

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Should shackling and other prison policies be modified for pregnant women?

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Should shackling and other prison policies be modified for pregnant women?

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Journal of Ethics | American Medical Association

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A society should be judged not by how it treats its outstanding citizens but by how it treats its criminals.
Dostoevsky
The United States has the highest incarceration rate of women in the world, with over 205,000 women currently behind bars in either state and federal prisons or jails and another million on probation or parole [1]. With an eightfold increase in the female incarcerated population since the 1970s, more women are incarcerated now than at any other point in U.S. history, and this rapid, unprecedented growth is predicted to continue [2]. Numerous studies indicate that the increase in numbers of incarcerated women is largely the result of the "war on drugs," the governmental policy changes on drug sentencing that include mandatory minimum sentencing laws for low-level drug offenses and the prioritization of drug arrests by law enforcement [3, 4]. Because women are more likely than men to be in prison or jail for nonviolent, low-level drug-related crimes, women, especially poor women of color, bear a significant burden of this "war" [5].

As a historically male-focused institution, correctional facilities often fail to address the needs of incarcerated women. These needs include appropriate medical and psychiatric health care (such as reproductive health care, gender-specific substance abuse treatment, and counseling for histories of abuse), family services, appropriate bathroom and recreational facilities [6, 7], and protection against sexual victimization while incarcerated [8].

While incarcerated, many women-already vulnerable and marginalized in multiple ways-are pregnant or give birth. The majority of women in prison and jail are in their reproductive years with a median age of 34 [9, 10]. Between 5 and 10 percent of women enter prison and jail pregnant, and approximately 2,000 babies are born to incarcerated women annually [11]. Given the mother's status as an offender, pregnancy and birth are frequently handled in ways considered unacceptable in any other circumstance. Two aspects of this care deserve particular attention: the shackling of women in labor and the treatment of mothers and newborns after birth.

Shackling Policy in U.S. Prisons and Jails: Explanations, Consequences, and Ethics

As most correctional facilities do not have on-site obstetric care, pregnant women are typically transported to community-based providers for prenatal care, and women in labor are transferred to medical facilities for delivery. Though policies vary by jurisdiction, during transport, labor, delivery and post-delivery, women are frequently shackled with handcuffs, leg irons and/or waist chains [12]. In response to tremendous community advocacy and institutional support from organizations including the Rebecca Project and the American Public Health Association, 10 states have passed legislation prohibiting the use of restraints on pregnant women and women in labor [12]. The Federal Bureau of Prisons and the Departments of Corrections in 13 additional states have internal policies that similarly prohibit this practice. However, reports from the ACLU and Amnesty International show that such policies are not strictly enforced [7, 13]. And, in the remaining 27 states, pregnant women are regularly shackled during transport to and from medical facilities and chained to hospital beds by the ankle, wrist, or both during labor and delivery.

The practice of shackling pregnant women and women in labor is principally a remnant of protocols designated for male institutions and is not based on genuine security concerns [14]. Because the number of male prisoners overwhelmingly exceeds the number of female prisoners-prisons and jails are over 90 percent male-these institutions have not prioritized the appropriate health and safety protocols for women during transport to a medical facility [15]. Correctional institutions shackle inmates during transport to prevent escape attempts and to protect correctional officers and other personnel, such as medical professionals, from physical harm [16]. However, during the physical and emotional stress of labor and delivery, the risk of a woman's escaping while accompanied by armed officers is highly unlikely. Furthermore, we believe it is wrong that this shackling, which occurs as part of a uniform policy, does not account for a woman's history of violence (most female inmates are incarcerated for nonviolent crimes), escape attempts (the vast majority have not made such an attempt), and physical capacity to escape [7].

Shackling a woman by the ankles, wrists, and/or waist during pregnancy and delivery is not only unnecessary for security reasons, it is also medically hazardous and emotionally traumatizing. While shackled, pregnant women are at increased risk of falling and sustaining injury to themselves and their fetuses [17]. During labor and delivery, shackling interferes with a woman's ability to assume various positions and prevents her immediate transport to the operating room if necessary [18, 19]. Echoing these concerns, in 2011, the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion concluding that "[p]hysical restraints have interfered with the ability of physicians to safely practice medicine by reducing their ability to assess and evaluate the physical condition of the mother and the fetus, and have similarly made the labor and delivery process more difficult than it needs to be; thus, overall putting the health and lives of the women and unborn children at risk" [17].

The 1976 Supreme Court case Estelle v. Gamble explicitly affirmed that the Constitution requires prisons to provide medical care to inmates by holding that "deliberate indifference to serious medical needs of prisoners" violates the Eighth Amendment's prohibition on cruel and unusual punishment [20]. The use of restraints on pregnant women and women in labor contradicts this legal and ethical principle by knowingly increasing the risk of significant medical harm to the mother and unborn child.

All patients should be protected from indignity while receiving medical care, but incarcerated people, regardless of their medical conditions, describe feeling humiliated in the hospital, where they must interact with medical professionals and other hospital staff while in restraints. Giving birth in shackles is a devastating emotional experience for many women, as evidenced in reports by Amnesty International and other human rights organizations [21, 22]. Incarcerated women in labor express the physical pain of giving birth while unable to move, the medical complications resulting from this lack of mobility, and the psychological distress of holding their newborns while chained to the hospital bed. The birth of a child-a momentous, joyful experience for many-is turned into a traumatic event for incarcerated women. A woman who gave birth while incarcerated, describes the experience:

When they shackled me I had two handcuffs, one was on my wrist and the other one was attached to the bed...My leg and my arm were attached to the bed so there was no way for me to move and to try and deal with the labor pains. And the metal, cause when you're swollen, it would just cut into your skin. I had bruises after the fact that stood on me for three weeks. I mean, purple bruises from my ankle and my wrist from them having them shackles and handcuffs on me. Even when I had to get an epidural, they didn't take the shackles and the handcuffs off. I just had to bend over and just pray that I could stay in that position while they were putting that needle in my back through the whole procedure. Not once did he [ the correctional officer] try and loosen them. And the doctor asked him, you know, 'Can't you take them off of her? She can't go nowhere. She can't walk. She's not goin' nowhere.' 'It's procedure and policy. Can't do it' [23].

Personal accounts like these illustrate that the routine use of restraints on pregnant women, and particularly on women in labor, is a cruel and unsafe practice.

Post-Delivery Treatment of the Mother and Her Newborn

In addition to shackling, many pregnant women who deliver while incarcerated are almost immediately separated from their newborns after delivery. After giving birth, most incarcerated mothers are allowed only 24 hours with their newborns in the hospital; the infants are then either placed with relatives or in foster care, and the mothers are returned to prison or jail [24]. This separation is devastating for both mother and infant. For infants, maternal separation at birth can lead to multifaceted, severe emotional and behavioral problems in later life including low self-esteem, less successful peer relationships, and difficulty coping with life stressors [12, 24]. For mothers, this separation can also be psychologically traumatizing and has been shown to increase the risk of recidivism [25].

With the growing number of women in prison, departments of corrections in 12 states now offer prison-based nursery programs that house mothers and their newborns in special units. However, these programs have widely differing capacities and rehabilitative services. While incarcerated women have very high rates of substance abuse and mental illness, histories of sexual and physical abuse, and multiple medical problems such as HIV and hepatitis C, less than half of these nursery programs offer appropriate services such as substance abuse treatment, mental health care, and domestic violence counseling [26]. Massachusetts is the only state to offer a community-based alternative, where mothers can keep their infants with them for up to 24 months in correctional residential programs in the community; however, these women may have to return to prison later to finish their sentences [22]. While new and limited in scope, prison and jail diversion programs-through which sentenced individuals attend community-based drug treatment programs as an alternative to incarceration-have also been successful at keeping mothers and their newborns together [27]. And yet, despite the expansion of prison and community-based nurseries, most incarcerated women are separated almost immediately from their newborns [24], a devastating situation for both mother and child.

Legislation contributes to the difficulty mothers face reuniting with their children after release. In an effort to place children in permanent adoption more quickly, the Adoption and Safe Families Act (ASFA) implemented in 1997 requires states to terminate parental rights to children who have been in foster care for 15 of the last 24 months [13]-with no exception for incarcerated parents. Because the average sentence for women in prison is 18 months, by the time parents are released it is likely they will no longer have custody of their children. Thus, a sentence as short as 15 months can result in the lifelong separation of a mother and her children.

Alternatives

All women, regardless of incarceration status, deserve to have a safe, healthy, and dignified pregnancy and delivery, which necessarily entails freedom from medically unsafe and dehumanizing restraints. With the growth of the female prison and jail populations, legislative action to end shackling is imperative. Moreover, reproductive rights for all women do not end with birth; society must uphold the right of a competent parent to raise her own children-and a woman's incarceration status alone does not indicate incompetence. Despite the recent expansion of prison and community-based nurseries, incarcerated women continue to have these rights violated. Many incarcerated mothers and newborns are separated after delivery, and, with the implementation of the ASFA, such separation can result in the permanent termination of parental rights. States should prioritize expanding the capacity of community-based nurseries, increasing the permitted length of stay, and ensuring that parenting classes, substance abuse and mental health counseling, and social services are offered.

Most importantly, however, broader efforts must be made to prevent inappropriate imprisonment of women in the first place. Incarcerated women are arguably one of the most marginalized groups in the U.S. population, and it can be argued that many of them should not be behind bars. Nearly half of the women in prison are African American, and two-thirds are women of color [28]. The majority are unemployed, lack high school diplomas, and face extremely limited access to social services, health care, and stable housing prior to incarceration [5, 29, 30]. Women in prison have disproportionately high rates of infectious and chronic disease and histories of physical and sexual abuse, mental illness, and substance abuse. Improving social institutions such as schools, housing and health care, providing employment opportunities and ending the governmental "war on drugs" would strengthen families and communities, especially poor communities of color disproportionately targeted in the epidemic of incarceration. Such initiatives will also reduce inappropriate involvement of women in the criminal justice system and ultimately contribute to a more just society.

Citation

Virtual Mentor. 2013;15(9):779-785.

DOI
10.1001/virtualmentor.2013.15.9.pfor2-1309.
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information

Jennifer G. Clarke, MD, MPH is a physician at the Rhode Island women's prison, associate professor of medicine and obstetrics/gynecology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, and the director of health disparities research at Memorial Hospital of Rhode Island. Her areas of expertise include women's health, motivational interviewing to improve reproductive health outcomes, and health care delivery for incarcerated populations.

Rachel E. Simon is a second-year medical student at Harvard Medical School in Boston. She graduated with an ScB in human biology from Brown University in 2011, where she wrote her undergraduate thesis on the cognitive and affective response to incarceration for substance-using women. Her interests include drug policy and incarceration, women's health, and health care disparities.

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Shackling and Separation: Motherhood in Prison

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A society should be judged not by how it treats its outstanding citizens but by how it treats its criminals. Dostoevsky

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Health care professionals should not know what the inmates are in prison for. They should treat them with the same standard of care as anybody else.