By John P. May, MD; Patrice Joseph, MD; Jean William Pape, MD; and Ingrid A. Binswanger, MD, MPH, Annal of Internal Medecine
Prisoners have disproportionate health care needs. Meeting those needs in a prison environment is challenging, especially in resource-poor countries such as Haiti. Even so, prior to the January 2010 earthquake, local and international organizations in collaboration with the Haitian government had been making significant progress to provide for the health needs of prisoners. The effort screened and identified prisoners for infectious disease, initiated appropriate care and treatment, and prepared prisoners for release to the community. Not only is it possible to establish an adequate prison health care program in a resource-poor country, it is necessary. Without adequate management of prisoners’ health needs, especially infectious diseases such as HIV and tuberculosis, disease burden increases. Infectious disease can spread among prisoners and impact the public’s health. Recovery for post-earthquake Haiti, as any nation rebuilding following natural disaster or conflict, requires respect for rule of law. This includes humane detention, and the delivery of justice and adequate health care for prisoners.
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Before the earthquake in Port-au-Prince, Haiti, on 12 January 2010, an effective partnership was progressing to deliver appropriate health care within the harsh environments of Haitian prisons. The primary intervention focused on the Prison Civile of Port-au-Prince, the largest penitentiary in Haiti. The prison, built to hold no more than 800 prisoners, held 4215 men when it was substantially damaged in the earthquake (Figure 1). Six prisoners were killed, and surviving prisoners fled, taking with them their health problems, including partially treated infectious diseases.
Top. The Prison Civile approximately 2 weeks before the earthquake of 12 January 2010. Bottom. Damage inside the prison after the earthquake.
In any country, prison health care is complex. Inmates have increased psychiatric problems, substance abuse, violence-related injuries, and chronic disease compared with the general population (1–3). Security constraints make basic care, such as self-administered insulin, difficult. Recruiting challenges lead to lack of highly trained health care workers. Health care in prisons is generally financed through local, regional, and federal governmental mechanisms independent of other methods (such as health insurance) (4). Finally, there are special ethical, human rights, and constitutional considerations in prison health care. Although the incarceration rate in Haiti is considerably lower than in the United States (83 per 100 000 persons vs. 753 per 100 000 persons, respectively) (5), the complexities of prison health care are compounded in a resource-poor country.
Similar to prison populations in the United States (6), most prisoners in Haiti are male. Approximately 300 female prisoners are held at the women’s prison in Petionville; these women account for approximately 5% of the total population of prisoners in Haiti. Generally, women prisoners have access to health care services from a full-time nurse and regular physician visits, including a gynecologist, and visiting physicians from church groups. Some circumstances allow children younger than 2 years of age to stay with their mothers, with care from visiting pediatricians. Record-keeping deficits before the earthquake have made data about average length of incarceration, average sentence length, and rates of recidivism or re-incarceration unavailable.
The century-old Prison Civile has been the site of malnutrition, infectious disease, and mass escapes. In 2004, the prison was overcrowded with 1028 men; during a coup d’état that year, all prisoners escaped. As kidnappings and other serious crimes increased after the coup, however, the prison population grew to record numbers. The justice system did not keep up with arrests, and fewer than 15% of the prisoners had been convicted of crimes by the time of the earthquake. Despite internationally respected constitutional requirements and the absence of capital punishment, administration of justice in Haiti has been complicated by multiple, interrelated systemic problems, including a small and ill-defined judicial inspection unit, corruption, unnecessary procedures, inadequate or no legal assistance for most defendants, and insufficient training (7).
The Prison Civile consisted of several housing units constructed in different eras, surrounded by a wall enclosing a full city block. Most prisoners were locked in small rooms that held more than 5 times more people their intended capacity. The fewer than 100 beds in the facility were typically used by prisoners with influence, while the remainder slept on the floor or in hammocks made from sheets. In the most crowded areas, prisoners slept standing. Some developed edema of the lower extremities.
Prison service cooks prepared 2 meals daily. Inmate workers delivered the meals in tubs, and prisoners scooped out portions with containers. Food from family members provided some supplementation. When the prison budget did not allow appropriate nutrition, outbreaks of systemic beriberi occurred (Figure 2), and several inmates died.
Figure 2. Beriberi in a prisoner.
Prisoners lacked the options of persons in the community who faced hunger or unsafe or unsanitary conditions. They could eat and drink only that which was given to them, and they could not walk away from crowded tuberculosis- or scabies-infested spaces, control gastrointestinal upset, or flee from others who threatened them. Tuberculosis spread, and several drug-resistant cases had been identified. Previously healthy young men died of preventable conditions.
Health care in the prison had not been equivalent to that in the community. A physician was present only intermittently, essential medications were unavailable, laboratory and radiography testing could not be performed, and dying inmates were not provided medical support. Persons in the community typically have family and neighbors who harness the resources to bring a sick person to places where care can be accessed. Quality health care exists in the community, even for Haitians with no income. In the prison, few resources were available to transport prisoners to the hospital or pay for treatment.
GHESKIO (Groupe Haïtien pour l’étude du sarcome de Kaposi et des infections opportunistes, or Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections), a Haitian institution and the world’s first AIDS clinic, had intermittently provided consultation and services upon request to the Prison Civile since the early 1980s. Health through Walls, a Florida-based not-for-profit correctional health organization, began regularly bringing medications, equipment, guidance, and services to the prison in 2001. The International Committee of the Red Cross worked to support systems of sanitation and health. After the 2004 coup, other international organizations and professional societies, including the United Nations Department of Peacekeeping Operations, American Correctional Association, International Corrections and Prison Association, and Correctional Services of Canada, contributed to improving the safety and health of the staff and prisoners. Only months before the earthquake, the U.S. Department of State built a prison infirmary with space for respiratory isolation, set to open by February 2010.
In 2008, Health through Walls obtained a grant from the Gilead Foundation and teamed with GHESKIO to create the first comprehensive program for prevention and treatment of HIV within the prison. Before this, there was no formal care for prisoners with HIV infection. Routine laboratory testing was not conducted, except for approximately a dozen prisoners who had already been receiving antiretrovirals in the community and whose care was continued by GHESKIO. Antiretroviral medication had never been initiated in subsequent HIV-infected prisoners. In May 2008, Health through Walls and GHESKIO met with Michelle Duvivier Pierre-Louis, then prime minister of Haiti, and received support to begin screening and treatment for HIV, other sexually transmitted diseases, and tuberculosis. A formal Memorandum of Agreement was created through Dr. Daniel Henrys, Chief of Cabinet and included the Ministry of Justice, Ministry of Health, Ministry of Social Affairs, the United Nations, International Committee of the Red Cross, Health through Walls, and GHESKIO.
Local Haitian health professionals were recruited and educated on correctional health issues. Staff received training on HIV prevention, testing, care, and treatment. In a program supported by UNAIDS and modeled after a program of the Florida Department of Corrections and Department of Health, a team of 25 prisoners educated their peers about HIV. Through these programs, prisoners were offered screening for HIV, tuberculosis, and syphilis; volunteered for testing; and eagerly accepted treatment. GHESKIO supervised their treatment, and antiretroviral medications were provided through the U.S. President’s Emergency Plan for AIDS Relief.
Health through Walls also partnered with Rural Justice Center, a nongovernmental legal organization based in New Hampshire, to establish a system of legal case management at the prison. Together, they established a program to reduce the population of prisoners held in pretrial detention, a root cause of overcrowding and disease transmission, through database tracking and case management. In July 2009, this became the first international prison health project to receive an award from USAID.
By the day of the earthquake, more than 2000 prisoners had received comprehensive physical assessments and legal interviews, more than 400 had been screened for HIV, 250 had been screened for tuberculosis with sputum smears, and 86 prisoners newly identified with HIV and 50 with tuberculosis had begun receiving care and treatment of their disease. A laboratory for HIV testing and other routine tests within the prison was being established, and digitalized radiography equipment was purchased. The program was building to conduct health assessments and legal reviews of all prisoners, routinely screen for infectious disease, provide clinical care consistent with international standards for resource-poor settings, identify pretrial prisoners needing facilitation of the judicial process, and establish linkage and care with Haitian health care workers after release. This prison was to serve as a model for other Haitian prisons.
The earthquake interrupted this progress. Despite the damage to the Prison Civile, it started receiving prisoners again within 1 month of the earthquake. Whereas outdoor exercise and other activities, including an art and crafts program, sports, and classes, were available before the earthquake, prisoners’ movement outside of cells is now restricted owing to unusable spaces and security concerns. The health care program has resumed.
Internationally, resources typically fail to reach prisons, in part because of the diminished value placed on prisoners’ lives. Yet, failure to meet the health needs of prisoners has public health consequences. Prisons are important reservoirs and loci for transmission of infectious diseases (8–13). Distributing health resources according to a system based on disparate value of human life disrupts and defeats control of infectious diseases (14).
Recovery for any nation after conflict or natural disaster requires security and rule of law, including detention centers. A stable prison system necessitates respect for human rights, administering justice, and meeting health needs. Tracking data on pretrial detention, length of incarceration, recidivism rates, and prevalence and incidence of disease are needed. The health and justice programs are more challenged than ever, but the pathway to meet the needs is in place. Healing Haiti must include tending to the health and justice of prisoners.