0
Ideas and Opinions |

Health Care for Prisoners in Haiti FREE

John P. May, MD; Patrice Joseph, MD; Jean William Pape, MD; and Ingrid A. Binswanger, MD, MPH
[+] Article and Author Information

From Health through Walls, Miami, Florida, and Les Centres GHESKIO, Port-au-Prince, Haiti.


Acknowledgment: The authors thank Hebert Norvelus, MD; Michelle Karshan; Mark C. Andrews, MEd; and Commissioner Jean R. Celestin. The authors especially acknowledge Maryse Thimothee, Head of GHESKIO Bacteriology Laboratory, who died in the earthquake.

Grant Support: By the Robert Wood Johnson Foundation Physician Faculty Scholars Program (Dr. Binswanger), Fogarty International Center (grant TW006896), and USAID (grant 521-G-00-09-00030-00; Dr. May).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0662.

Requests for Single Reprints: John P. May, MD, Armor Correctional Health Services, 4960 SW 72nd Avenue, Suite 400, Miami, FL 33155; e-mail, drjpmay@aol.com.

Current Author Addresses: Dr. May: Armor Correctional Health Services, 4960 SW 72nd Avenue, Suite 400, Miami, FL 33155.

Drs. Joseph and Pape: GHESKIO Centers, 1300 York Avenue, Box 125, New York, NY 10065.

Dr. Binswanger: Division of General Internal Medicine, University of Colorado Denver School of Medicine, Mail Stop B180, Aurora, CO 80045.

Author Contributions: Conception and design: J.P. May, P. Joseph, J.W. Pape, I.A. Binswanger.

Analysis and interpretation of the data: J.P. May, J.W. Pape.

Drafting of the article: J.P. May, P. Joseph, I.A. Binswanger.

Critical revision of the article for important intellectual content: J.P. May, J.W. Pape, I.A. Binswanger.

Final approval of the article: J.P. May, P. Joseph, J.W. Pape, I.A. Binswanger.

Provision of study materials or patients: J.P. May.

Obtaining of funding: J.P. May, J.W. Pape.

Administrative, technical, or logistic support: J.P. May, J.W. Pape.

Collection and assembly of data: J.P. May.


Ann Intern Med. 2010;153(6):407-410. doi:10.7326/0003-4819-153-6-201009210-00270
Text Size: A A A

Abstract

Prisoners have disproportionate health care needs. Meeting those needs in a prison environment is challenging, especially in such resource-poor countries as Haiti. Even so, before 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 for such infectious diseases as HIV and tuberculosis, disease burden increases. Infectious disease can spread among prisoners and impact the public's health. Recovery for postearthquake 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.

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.

Grahic Jump Location
Figure 1.
The Prison Civile.

Top. The Prison Civile approximately 2 weeks before the earthquake of 12 January 2010. Bottom. Damage to the prison after the earthquake.

Grahic Jump Location

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 (13). Security constraints make basic care, such as self-administered insulin, difficult. Recruiting challenges lead to a 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 that 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, female 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 the 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 their intended capacity. The fewer than 100 beds in the facility were typically used by prisoners with influence, whereas 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.

Prisoners lacked the options of persons in the community who faced hunger or unsafe or unsanitary conditions. They could eat and drink only what 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, which was 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 the 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 the Joint United Nations Programme on HIV/AIDS (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 the U.S. Agency for International Development (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 (813). 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.

References

Binswanger IA, Krueger PM, Steiner JF.  Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009; 63:912-9. PubMed
CrossRef
 
Binswanger IA, Merrill JO, Krueger PM, White MC, Booth RE, Elmore JG.  Gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates. Am J Public Health. 2010; 100:476-82. PubMed
 
May JP, Ferguson MG, Ferguson R, Cronin K.  Prior nonfatal firearm injuries in detainees of a large urban jail. J Health Care Poor Underserved. 1995; 6:162-75. PubMed
 
Binswanger IA, Elmore JG.  Clinical care of incarcerated adults. Ross B UpToDate. ver. 17.2. Wellesley, MA: UpToDate; 2010.
 
International Centre for Prison Studies; King's College London.  Entire world—prison population rates per 100,000 of the national population. Accessed atwww.kcl.ac.uk/depsta/law/research/icps/worldbrief/wpb_stats.php?area=all&category=wb_poprateon 1 June 2010.
 
Sabol WJ, West HC, Cooper M.  Bureau of Justice Statistics Bulletin: Prisoners in 2008. Washington, DC: U.S. Department of Justice; 2009.
 
Fuller A, Texier P, Brosseau M. et al.  Prolonged Pretrial Detention in Haiti. New York: Vera Institute of Justice; 2002.
 
Greifinger R.  Health status in US and Russian prisons: more in common, less in contrast. J Public Health Policy. 2005; 26:60-8. PubMed
 
Larouzé B, Sánchez A, Diuana V.  Tuberculosis behind bars in developing countries: a hidden shame to public health. Trans R Soc Trop Med Hyg. 2008; 102:841-2. PubMed
 
HIV and prisons in sub-Saharan Africa: opportunities for action. Joint report by ACTafrica World Bank, The Joint United Nations Programme on HIV/AIDS, and United Nations Office on Drugs and Crime assisted by World Health Organization Regional Office for Africa. October 2007.
 
Levy MH, Treloar C, McDonald RM, Booker N.  Prisons, hepatitis C and harm minimisation. Med J Aust. 2007; 186:647-9. PubMed
 
Levy M.  International public health and corrections: models of care and harm minimization. Greifinger RB Public Health Behind Bars: From Prisons to Communities. New York: Springer Science and Business Media; 2007; 73-87.
 
Shakarishvili A, Dubovskaya LK, Zohrabyan LS, St Lawrence JS, Aral SO, Dugasheva LG, et al. LIBRA Project Investigation Team.  Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation. Lancet. 2005; 366:57-60. PubMed
 
. Farmer P Pathologies of Power: Health, Human Rights, and the New War on the Poor. Los Angeles: Univ of California Pr; 2005.
 

Figures

Grahic Jump Location
Figure 1.
The Prison Civile.

Top. The Prison Civile approximately 2 weeks before the earthquake of 12 January 2010. Bottom. Damage to the prison after the earthquake.

Grahic Jump Location

Tables

References

Binswanger IA, Krueger PM, Steiner JF.  Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009; 63:912-9. PubMed
CrossRef
 
Binswanger IA, Merrill JO, Krueger PM, White MC, Booth RE, Elmore JG.  Gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates. Am J Public Health. 2010; 100:476-82. PubMed
 
May JP, Ferguson MG, Ferguson R, Cronin K.  Prior nonfatal firearm injuries in detainees of a large urban jail. J Health Care Poor Underserved. 1995; 6:162-75. PubMed
 
Binswanger IA, Elmore JG.  Clinical care of incarcerated adults. Ross B UpToDate. ver. 17.2. Wellesley, MA: UpToDate; 2010.
 
International Centre for Prison Studies; King's College London.  Entire world—prison population rates per 100,000 of the national population. Accessed atwww.kcl.ac.uk/depsta/law/research/icps/worldbrief/wpb_stats.php?area=all&category=wb_poprateon 1 June 2010.
 
Sabol WJ, West HC, Cooper M.  Bureau of Justice Statistics Bulletin: Prisoners in 2008. Washington, DC: U.S. Department of Justice; 2009.
 
Fuller A, Texier P, Brosseau M. et al.  Prolonged Pretrial Detention in Haiti. New York: Vera Institute of Justice; 2002.
 
Greifinger R.  Health status in US and Russian prisons: more in common, less in contrast. J Public Health Policy. 2005; 26:60-8. PubMed
 
Larouzé B, Sánchez A, Diuana V.  Tuberculosis behind bars in developing countries: a hidden shame to public health. Trans R Soc Trop Med Hyg. 2008; 102:841-2. PubMed
 
HIV and prisons in sub-Saharan Africa: opportunities for action. Joint report by ACTafrica World Bank, The Joint United Nations Programme on HIV/AIDS, and United Nations Office on Drugs and Crime assisted by World Health Organization Regional Office for Africa. October 2007.
 
Levy MH, Treloar C, McDonald RM, Booker N.  Prisons, hepatitis C and harm minimisation. Med J Aust. 2007; 186:647-9. PubMed
 
Levy M.  International public health and corrections: models of care and harm minimization. Greifinger RB Public Health Behind Bars: From Prisons to Communities. New York: Springer Science and Business Media; 2007; 73-87.
 
Shakarishvili A, Dubovskaya LK, Zohrabyan LS, St Lawrence JS, Aral SO, Dugasheva LG, et al. LIBRA Project Investigation Team.  Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation. Lancet. 2005; 366:57-60. PubMed
 
. Farmer P Pathologies of Power: Health, Human Rights, and the New War on the Poor. Los Angeles: Univ of California Pr; 2005.
 

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Topic Collections
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)