Crude mortality rate MCH Mother and child health SMR Standard Minimum Rules for the Treatment of Prisoners ("Nelson Mandela Rules") STI Sexually transmitted infection TB Tuberculosis UN United Nations WMA World Medical Association NGO Non-governmental organization HIV Human immunodeficiency virus EPI Expanded Programme on ImmunizationPlace of detention   Bullet-pointed lists of sample questions for each topic are included in boxes like this one. These lists are not exhaustive: they do not cover all questions and all places of detention. Every prison assessment should be adapted to the specific situation and the realities of the prison visited.# 
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of armed conflict and other situations of violence and to provide them with assistance. The ICRC also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the Geneva Conventions and the International Red Cross and Red Crescent Movement. It directs and coordinates the international activities conducted by the Movement in armed conflicts and other situations of violence.  This guide is intended for individuals or organizations dealing with the issue of health in prisons. Health personnel (doctors and nurses) who visit or work in prisons will find it especially pertinent.
It is hoped that the contents of the guide will be applicable in a broad range of contexts. Also, although the guide refers mainly to prisons, the approach it sets out, to assessing health and health determinants, may be used in other places of detention, such as police stations or immigration detention centres. 1

# Aim
The guide aims to be of assistance in assessing and documenting those aspects of life in prison that can affect the health of detainees. Collating this information can yield an objective perspective on any problems or shortcomings within a prison. The information can then be used to help the detaining authorities ensure the best possible standards of health among detainees, as required by law.
The guide provides a logical and uniform approach to assessing health and health determinants within a place of detention, which should make possible the following: Furthermore, by following a uniform approach to assessing and reporting, the guide will allow comparisons to be made between prisons.

# Using the guide
Chapters in the guide address particular aspects of life in prison that can affect the health of detainees. The chapters are divided into sections on particular subjects. These sections generally contain some background information on the issue in question, references to pertinent standards, and sample questions for prison visits.
The guide will not address every aspect of health in prisons. The final chapter includes a list of resources that provide further information.
1 For the sake of simplicity, in this guide the term 'prison' is used to refer to any facility where people are detained. The term 'detainee' is used in preference to 'prisoner' for two reasons: first, to emphasize the range of people to which the contents of the guide may apply, for not all of them have been convicted and not all are held in prisons; and, second, because, in many contexts, the term 'prisoner' tends to be loaded with unfavourable associations.

# Background concepts
The 'health pyramid'
A 'health pyramid' is useful for assessing health in prisons (see figure 1.1). Following this model, a healthy environment is 'based' on: adequate food and nutrition; adequate hygiene and sanitation; and appropriate accommodation. To build on this base, measures for the protection and promotion of health must be undertaken. In the health-pyramid model a curative approach, at the peak of the pyramid, is part of the system for sustaining overall health. However, curative medical care can be effective only where it is added to the essential components of nutrition, water, sanitation and habitat, and to measures for promoting health and preventing diseases.
Supporting the health pyramid at every level are 'psychosocial factors' , discussed below.
Curative care 

# Health promotion and disease prevention

# Psychosocial factors
Most aspects of life in detention have some impact on health. The health pyramid describes the basic and essential influences on health in prisons (food and nutrition; hygiene and sanitation; accommodation; health protection and promotion; and, finally, curative health care). However, when assessing health in prisons it is important to look beyond these basic elements. Other factorsless obvious, or even invisible -can also powerfully influence health. They are sometimes loosely called 'psychosocial factors', and include: the psychological effects of arrest and imprisonment; separation from support structures; internal prisoner hierarchies; violence including sexual violence; drug use; prison routines; respect or not of judicial guarantees; promiscuity.

# Psychological effects of arrest and imprisonment
During their arrest or interrogation, most people will experience high levels of stress. They may also be subjected to ill-treatment or torture, which could have lasting consequences for their physical, mental and social health. While in detention, they will inevitably suffer anxieties about the future, such as whether they will be released after interrogation, sent to trial, or if convicted, what life in prison will entail and what the effects on their families will be. For many people, these stresses and uncertainties go well beyond their normal range of experience. Additionally, while in prison, many people feel hopeless and suffer from low spirits and depression.

# INTRODUCTION

# Separation from support structures
People who are suddenly removed from their day-to-day world and placed in detention find themselves without their usual coping mechanisms and support structures (such as families, friends, and in many cases, their work environment). This increases their vulnerability to psychological harm.

# Internal hierarchies
Internal prisoner hierarchies and unofficial prison 'rules' exist, to a greater or lesser degree, in prison communities throughout the world. Within a prison, various criminal, political, or ethnic groups may establish rules that detainees must obey. These groups may compete with each other for influence, power or material gain; this may involve extortion, coercion, bullying, or physical or sexual violence. Various forms of discrimination might also be practised, and that could include restricted access to health-care facilities. These activities may be knowingly tolerated by the prison authorities and in some cases, may even involve the authorities directly.

# Drug use
In many contexts, a sub-culture of drug use exists within prisons and often it is intertwined with the internal prisoner hierarchies mentioned above. Intravenous drug use greatly increases health risks in prison settings. Two factors contribute to this increased risk: first, the prevalence of blood-borne diseases tends to be higher among people in prison than among the general population; second, the scarcity of clean needles, and the fact that drug paraphernalia must be concealed from authorities, leads to more sharing of needles and other equipment. Some prisons have established needle exchange programmes to tackle these issues.

# Sexual behaviour
Sexual behaviour in prisons may be consensual or non-consensual and may include sexual violence. There is often risk of exposure to sexually transmitted infections, including HIV, because of the greater than usual prevalence of the disease in prisons and the scarcity of condoms. In response, some prisons have introduced condom distribution programmes.

# Prison environment and routines
Many aspects of the detention environment and routines that are governed by official prison regulations may also have an impact on health. The extent to which prisoners are in contact with their families, either through mail (and Red Cross messages) or through family visits; access to work, or being forced to work; access to fresh air, physical activity or sports; the extent to which prisoners are able to enjoy recreational activities such as reading and games; being able to practice their religion; access to education (especially for children, but also further education for adults); and of course, access to health care: all these factors may have a direct or indirect impact on health, but they can also be subject to interference from prisoner hierarchies or from guards and the prison administration.
It will be clear from the above that most aspects of life in detention may be encompassed by the term 'psychosocial factors' . Many of these factors may be difficult to understand, deal with or change. However, it is important to be aware of them and of the ways in which they can affect the health of the prison population.

# Availability, accessibility and quality
It is important while assessing prison health to distinguish between availability and accessibility. AVAILABILITY describes the existence of infrastructure and services within the prison: health-care facilities, drugs, water and sanitation facilities, kitchens, food, etc. ACCESSIBILITY describes the extent to which detainees have equal access to these facilities and services without barrier or interference.
Facilities and services within prisons should operate on the principle of non-discrimination and must be equally accessible to all; they must also acknowledge that certain vulnerable or marginalized groups may have greater needs (for instance, women, children, the elderly, the disabled, those with HIV/ AIDS, and ethnic minorities). Accessibility can be further divided into physical accessibility (for instance, does the location of the facilities interfere with physical access?); economic accessibility (are there any financial barriers that hinder access to the facilities, services, food, and so on?); and access to information (for instance, can detainees ask for and receive information on health, sanitation and nutrition, and can they themselves provide information or feedback?).
The accessibility and the quality of services and infrastructure are two of the main determinants of health in prisons.

# Understanding the prison staff
It is tempting sometimes to regard detaining authorities as 'the bad guys' , particularly where the treatment of detainees seems especially poor. In most cases, however, the authorities are unlikely to fit this description. And adopting an adversarial position with regard to the prison staff is unlikely to benefit anyone, especially the detainees. During the prison assessment, it is important to try and move beyond a simplistic conception of the detaining authorities.
If possible, look into the facilities available to the prison staff for accommodation, hygiene and recreation. Also look into the quality of their food and health care. Sometimes the facilities and services available to prison staff are not much better than those for detainees. Obviously, this cannot justify poor conditions for detainees. However, it should be recognized that poor conditions for the prison staff will affect their morale and well-being, and that will ultimately affect their work and their attitude towards the detainees.
Study how motivated the prison staff are, and the challenges they have to face. Find out about their payment and reward structure. Ask whether they applied for their jobs and if so, why. And ask whether they enjoy their job and why they enjoy it (or why they do not enjoy it). These conversations may provide useful information and may also help to establish more collaborative relationships.

# The role of the health professional in prison assessments
Health professionals (doctors or nurses) generally take a public-health approach to the assessment of health in prisons: they address the health of the prison population as a whole, not that of individual inmates. 2 The health

# INTRODUCTION
professional must assess the organization of the prison and conditions within it, as well as their effects on the general health of the prison population. Health professionals must also identify anything in the conditions or regime that has an adverse impact on detainee health. Finally, practical recommendations and suggestions for solutions must be drawn up for submission to the detaining authorities. This guide aims to be of assistance in carrying out prison assessments. To that end, it draws attention to those aspects of a prison's conditions and regime that are most likely to affect health, and provides sample questions that should be of help in analysing them. Note that the lists of questions contained in each section are only examples and will need to be adapted to each place of detention. Also, this guide is not meant to be a checklist; it provides an approach to prison assessment, one that is general and analytical. Where the prison assessment reveals shortcomings in the conditions or regime, the health professional must aim to analyse the causes and evaluate their impact on the health of detainees.
A thorough assessment of health in a prison entails assessing the prison health system in depth, through observation, discussions with the prison health staff, and private talks with sick and/or healthy detainees. This will take time. The health professional may also have to assess such matters as accommodation, food, hygiene, water and general sanitation, as well as various psychosocial factors associated with detention. Whenever possible, a prison assessment should include a visit to the local health facility to ascertain the level of health care available to the community, and to find out if there are any issues in connection with detainees referred to that facility.
It is important to be clear about what the health professional must not do during an assessment of prison health. In general, he or she should not take over the work of the prison staff or run a parallel health system by performing individual health checks and treating detainees. Prison authorities or members of the prison assessment team should generally not be encouraged to draw up lists of detainees who 'want to see the doctor' .
However, the health professional should meet selected detainees individually, to discuss issues relating to the health system. The health professional may use general or specific criteria for choosing these detainees. General criteria may include: most recently arrested detainees, female detainees, or detainees above or below a certain age. Specific criteria may include: detainees who have passed through specific places of interrogation, who exhibit features of a particular disease, or who show clear signs of mental illness.
In contexts where ill-treatment is an issue, the health professional may want to assess detainees who have been subjected to it, in order to medically document it.

# Organizing prison assessments
Assessments of prison health by health professionals will often take place during team visits to prisons. At the ICRC, these teams usually consist of detention delegates, legal advisers, water and sanitation engineers, nutritionists, etc. During these visits, other team members may assess specific aspects of a prison and have discussions with detainees. Good teamwork and coordination are essential to ensure that no issues are overlooked during an assessment, and that no duplication of work takes place. All team members should be aware of who will gather what information within the prison. The division of tasks will depend upon the size of the team and the issues and circumstances associated with the prison. For example, an acute health crisis in a prison might consume the bulk of the visiting health professional's attention and require that much of his or her usual workload be delegated.
Non-medical team members may assess accommodation, food, hygiene, water and general sanitation as well as many of the psychosocial factors associated with detention. A health professional can then use the findings to judge the impact on health within the prison, or to determine whether further investigation is needed. Thus, non-medical members of the prison assessment team may find the contents of this guide useful. The guide is not, however, meant to take the place of a health professional in the prison assessment team. A medical background is required for understanding many health issues. Nonmedical team members assessing health-related issues in prisons must discuss their findings with a health professional.
After a prison visit, team members, including the health professional, should collaborate in reporting their findings and making recommendations. These recommendations may be for internal use (for example, strategies for monitoring developments in the prison) or for submission to the prison authorities (for example, recommending changes to the prison environment or regime). Recommendations for action should aim to be as comprehensive as possible, taking into account all challenges and all stakeholders. This guide concerns itself only with the process of prison health assessment; it does not contain advice on the measures to be taken.

# Discussions with detainees
Discussions with detainees are an important source of information about health, health determinants, and health care in prisons. Below are some suggestions for making these discussions as fruitful as possible.

# Arranging the interviews
Before arriving at the prison, decide which groups of detainees you would like to meet. Try to meet detainees from vulnerable groups, such as women, children, the elderly, the disabled, and foreigners. People in prison may also be vulnerable for reasons of ethnic, religious or political affiliation. Vulnerable groups are at particular risk of health problems.
Do not let the prison authorities choose which detainees will talk to you.
Use a quiet space for discussions, out of earshot of other detainees and the prison authorities.
Avoid, as far as possible, any imbalance in the situation: for example, try to use chairs of the same height, and ensure that detainees are not shackled during discussions.

# Working with interpreters
Let interpreters know in advance the subjects you plan to discuss with detainees, especially if they are sensitive matters. Interpreters will then have time to prepare suitable expressions or words to use and will not be taken by surprise.
Speak slowly and clearly in short sentences. Working with interpreters can be very challenging; make sure you continue to speak slowly and clearly even if you are feeling frustrated.

# INTRODUCTION

# Introductions
Introduce yourself to detainees with your name and your job title; tell them what you are there for. Explain that even though you will be discussing health-related issues you cannot treat them or provide clinical advice. This is important: you must not give detainees the impression that you will personally intervene in their behalf. It will also ensure that you are not requested to provide medicines or referrals.
Assure them of the confidentiality of your conversations with them. Explain that if they do not want you to disclose any details of the conversations to anyone, you will not do so; also, that should they give you permission to talk to others about these conversations, the sources of any information you pass on will remain anonymous.
Explain to the detainees that they are not obliged to talk to you.

# During the discussion
Be polite and respectful at all times.
The different groups within a prison may provide very different stories and perspectives. This may reflect actual differences in experience, or different beliefs about the way things should be. As there is no single 'truth' , do not be surprised if you hear conflicting accounts.

# Closing
At the end of the discussion, ask the detainee if he or she has any questions or anything further to say. This will signal the end of the discussion. It may also elicit useful information -by now the detainee will have a good idea of the sort of information you are seeking and may provide information on matters that you did not bring up.

# Standards for detention and imprisonment
'Standards' include laws, recommendations, and principles of good practice. They exist for most aspects of detention. Where these standards are not met, they can be used to guide action.
There are three main types of standard that can be referred to during prison assessments:
- national standards, which may be found in domestic laws relating to detention, or in publications by national health bodies (public health associations, for example) 
- regional standards set by regional bodies, such as the Council of Europe and the African Commission on Human and Peoples' Rights 
- universal standards on prison conditions set by the UN.
These three kinds of standard will be described in greater detail below.
The ICRC has also established some reference values in the area of water, sanitation and habitat, drawn from its long experience of work in prisons. 3 Standards do not always consist of clearly defined indicators or figures. Reference values for basic health indicators (such as crude mortality rates and numbers of medical consultations) are generally not available for prison populations. However, in some instances, reference values developed for displaced persons (including refugees) are used as an approximation or 'best estimate' for prison populations. 4 In relation to the accessibility of health care, the standard often invoked is that of equivalence with the community: in other words, people in prison should have access -to health care -that is at least equivalent to that afforded to people in the community.

# National standards
Many countries have domestic laws related to detention. A law on prisons will often have a name like 'Prison Act' or 'Jail Act' . These laws do not define prison conditions, but they usually stipulate the drawing up of 'prison rules' or 'prison regulations' containing detailed provisions on the management of prisons, including matters touching on health. Prison regulations often set out responsibilities for prison doctors or nurses that go beyond the provision of curative health care and include oversight of matters related to hygiene and nutrition, for example. However, some provisions of these national 'prison rules' might be outdated and/or contrary to internationally accepted practice.
Professional health associations such as national medical associations may have issued other national standards 5 or participated in intersectoral meetings on health care in detention and adopted their findings. These do not have the force of law, but might be useful points of reference.
Regional standards Some regional human rights bodies have developed standards on conditions of detention that also address health aspects: for example, the European Prison Rules adopted by the Council of Europe. 6 One of the basic principles underlying the European Prison Rules is maintaining the health of people in custody. The Council of Europe also established the CPT, which has developed binding standards for police custody and imprisonment, including provisions on health. 7 In addition, the Council of Europe has elaborated recommendations on the ethics and the organization of health care in prisons. 8 The African Commission on Human and Peoples' Rights adopted the Robben Island Guidelines in 2002. 9 The principal aim of these guidelines is the prevention of torture, but they include provisions on conditions of detention. The Committee for the Prevention of Torture in Africa 10 is mandated to

# INTRODUCTION
disseminate the Robben Island Guidelines and promote their implementation. The Kampala Declaration on Prison Conditions in Africa, adopted by the UN in 1997, addresses prison conditions in Africa, overcrowding in particular.
Recommendations made by the Special Rapporteur on Prisons and Conditions of Detention in Africa, appointed by the African Commission on Human and Peoples' Rights, are a useful point of reference.
In Latin America, the findings of the Inter-American Commission on Human Rights and the Inter-American Court of Human Rights are pertinent.

# Universal standards
The main source of guidance for the treatment of detainees and the management of penal institutions is the SMR. 11 The "original" SMR were approved by the UN Economic and Social Council in 1957. They have been substantially reviewed to reflect significant evolutions in internationally accepted practice and norms (human rights, correctional science, and medical services and ethics): the revised SMR (now also called the "Nelson Mandela Rules") were adopted unanimously by the UN General Assembly in 2015. 12 However, the SMR do not constitute a binding treaty; they are a set of recommendations or guidelines. 13 These 'rules' should be adapted to every country because social, economic, legal, climatic and geographical conditions vary from one State to the next. 14 In 1988, the UN adopted the Body of Principles for the Protection of All Persons under any Form of Detention or Imprisonment. 15 Principles 24 to 26 make clear the necessity of the following: a proper medical examination for every newly arrived detainee, unhindered access to medical care, and proper medical record-keeping.
Other relevant standards are: the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty and the 2010 UN Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (the Bangkok Rules).
The International Covenant on Economic, Social and Cultural Rights is a binding treaty that came into force in 1976. Article 12 of the treaty assures "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. " An elaboration of that statement asserts that parties to the treaty will refrain from "denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services. "
With regard to universal health ethics in detention, reference may be made to statements and declarations made and principles defined by bodies such as the UN, 16 the International Council of Nurses, 17 and the WMA. 18 Of particular note is the Declaration of Tokyo, adopted by the WMA in 1975, which provides guidelines for doctors regarding "torture or other forms of cruel, inhuman or degrading procedures, " including force-feeding.
Standards for detention during armed conflicts (international humanitarian law) and the role of the ICRC
The Third Geneva Convention deals with the internment of prisoners of war during international armed conflicts; internment of civilians is dealt with by the Fourth Geneva Convention. Both Conventions contain specific articles addressing the provision of health care, as well as accommodation, food, water, exercise, etc. Consult the pertinent Convention and give it close attention. 19 The rules applicable to non-international armed conflicts are found in Article 3 common to the four Geneva Conventions and in Protocol II of 8 June 1977 additional to the Geneva Conventions (Additional Protocol II), 20 as well as in customary international humanitarian law. 21
The ICRC has a mandate to work for the protection of both prisoners of war and civilians during international armed conflict. And, under common Article 3, the ICRC may offer its services to parties in a non-international armed conflict. The ICRC also has -under the Statutes of the International Red Cross and Red Crescent Movement -a right of humanitarian initiative in circumstances that do not amount to armed conflict. 22 16 

# ACCOMODATION, WATER, SANITATION AND HYGIENE

# Accommodation and overcrowding
Prison authorities should ensure that detainees have: adequate shelter and protection from the elements; access to hygiene and sanitary facilities; sufficient space for sleeping, exercise and recreation; and protection from violence. They should also ensure prevention of the spread of infectious disease. These are essential elements of prison accommodation and must not be affected in any way by the requirements of security and deprivation of freedom that are inherent in a place of detention.

# Capacity
Detention facilities and prisons have an official capacity: the number of people the facility can accommodate whilst fulfilling their basic needs for space, light, ventilation, hygiene, sanitary installations, water, sufficient kitchen capacity, and health-care services, as well as the requirements of safety and security. The official capacity is established when the building is constructed: there are a fixed number of cells, each for a specified number of detainees. Occupancy refers to the actual number of people being held in the prison. Occupancy rate is the indicator usually cited.

# Occupancy Occupancy rate (%) =
x 100 Capacity When the occupancy rate is 100%, the prison contains the number of detainees that it was designed for. Where it rises beyond 100% (especially when it exceeds 150%), essential needs may not be adequately met (see the section on 'overcrowding' , below).

# Space
'Space' refers to both the size of the facility and the accommodation space available to each individual. The assessment must also take into account the amount of time the detainees are locked up in their cells. Rule 13 of the SMR states: "All accommodation provided for the use of prisoners and in particular all sleeping accommodation shall meet all requirements of health, due regard being paid to climatic conditions and particularly to cubic content of air, minimum floor space, lighting, heating and ventilation. "
The vagueness of this formulation reflects the impossibility of defining the space necessary per person, given the wide variation in detention facilities worldwide. There is considerable global variation in regulations covering space in prisons. In Europe, a general standard exists of 6 m 2 per person for prison cells, but 3.0 to 3.5 m 2 is considered acceptable for dormitory-style accommodation. The Russian Federation have set 2.5 m 2 as the minimum space per adult male offender in their prisons. At an interministerial meeting on prisons in Guinea-Conakry in 2002, the minimum was set at 2 m 2 .
The ICRC recommends -purely as a guideline and not as an absolute rule -a minimum of 20-30 m 2 per person within the prison compound. In sleeping quarters, the minimum recommended space is 3.4 m 2 of surface area per person for cells with multiple occupants and 5.4 m 2 for single-occupancy cells. 23 

# Light
Rule 14 of the SMR sets out the standards for light and ventilation thus:
'"In all places where prisoners are required to live and work, a) The windows shall be large enough to enable the prisoners to read or work by natural light, and shall be so constructed that they can allow the entrance of fresh air whether or not there is artificial ventilation; b) Artificial light shall be provided sufficient for the prisoners to read or work without injury to eyesight. "

# Temperature and ventilation
The temperature in the prison and the requirements relating to it depend on the climate of the country: there should be adequate heating in cold climates and means of cooling in hot climates. Ventilation of cells is important for ensuring circulation of fresh air and preventing the spread of airborne infections such as tuberculosis and influenza.
The ICRC recommends that the size of the cell opening be at least 1/10 of the cell's surface area, to allow renewal of air and proper lighting.

# Bedding
The bedding provided in prisons must be adapted to the climate, but would generally be expected to include some form of mattress or bedroll, sheets and/or blankets. The requirements of personal hygiene also extend to bedding. Mattresses must be kept clean, aired and exposed to sunlight regularly. Clean sheets, or facilities and materials for detainees to be able to wash their sheets, must also be ensured.

# Access to open air
For their physical and mental well-being, detainees should be permitted regular access to the open air. They should also have access to sports facilities or adequate space to exercise. The generally accepted minimum, as stated in the SMR, is that access to the open air should be granted to all categories of detainee for a minimum of one hour each day, and protection from the elements ensured during these periods -through covered areas and through suitable clothing (for example, heavy coats should be made available in winter). Ideally, detainees should spend as much time as possible outside their cells.

# Minimum recommendations for accommodation space
Overall available space in compound 20-30 m 2 /person (ICRC) Minimum floor space in single-occupancy cell 5.4 m 2 /person (ICRC) Minimum floor space in multiple-occupancy cell 3.4 m 2 /person (ICRC)
Memorize the layout of the facility and draw a plan after the visit.

# Overcrowding
Overcrowding in prisons causes health problems because of the overuse of resources and the competition for them. It is not simply a matter of physical space. Overcrowding affects the mental and physical health of detainees through the pressure it puts on every aspect of their lives: food and water, sanitary facilities, work, medical services, rest and recreation, and even in the form of increased competition for family visits.
This competition for resources may contribute to poor nutrition or malnutrition. It may threaten the maintenance of good hygiene for the prison population and lead to the spread of disease (vector-borne, faecal-oral transmission, etc.). And it may cause tensions amongst both detainees and prison staff, which contribute to bullying, coercion, and physical and sexual violence. Overcrowding may also lead to an increase in drug use, raising the risk of blood-borne disease. All of these factors, to a greater or lesser degree, may also have an impact on the mental health of detainees.

# Overcrowding
Overuse & increased competition for resources (space, food, water, etc.) 

# Water: Source, storage, distribution and access
When considering water in prisons it is useful to think of WATER IN -the water that arrives at the facility -and WATER OUT -the wastewater (from cooking, washing and cleaning) and sewage that is produced and that should leave the facility. Wastewater is considered in Section 2.5. below. 

# Water quantity and quality
With regard to water, matters related to quantity should be tackled before concerns about quality. Data on water-related diseases show that it is better to have the right quantity of medium-quality water than small quantities of high-quality water. Also, there are simple ways to make water safe for drinking purposes (boiling for 20 minutes, chlorination, filtration, etc.).
Water quantity is defined as the number of litres available per person per day. The quantity of water used by individuals varies globally, depending on availability, climate, cultural preferences and practices. The ICRC considers 10-15 litres per person per day to be the minimum amount of water sufficient for all purposes. This includes water for drinking, cooking, and personal hygiene (for washing clothes, using the sewage system, cleaning the facilities). Because cells are often locked from sunset to sunrise, at least 2 litres of water per person should be available overnight, but this, too, depends on the climate and on the availability of water. Women in prison require special consideration because pregnancy, menstruation, and the nursing of babies all increase the need for water. Hospital wards and clinics also add to water requirements in prisons.
The prevalence of poor standards of cleanliness within a prison, and poor personal hygiene and diseases related to this (mostly skin diseases), may indicate that the prison needs more water.
Water quality is defined by the level of microbiological and chemical contaminants, but in practice such things as colour, taste and smell have also to be taken into account, since the water will be drunk and used in cooking. Note that the mere presence of microbiological agents or chemicals does not render the water unsafe: it is only when specific thresholds are reached that problems may arise. Acceptable levels of microbiological agents and chemicals are usually defined by each country (by water boards or departments of public health, for instance); where this is not the case, WHO standards may be referred to.
Water from boreholes is usually safe for drinking. Nevertheless, all water sources and secondary storage containers (buckets, drums, jerrycans) can, in principle, be sources of contamination.
One simple sign of poor water quality may be the prevalence of water-borne diseases among detainees.
When assessing water quantity and quality in prisons, it is important to also study and understand constraints that the surrounding civilian population may be facing, in connection with access to water. 

# Personal hygiene
Poor personal hygiene leads to greater incidence of skin disease and the transmission of faecal-oral infections. It may also have an impact on the mental well-being of the population. Infested mattresses and clothes may give rise to a never-ending spread of skin diseases and some vector-borne diseases as well.
Water is essential for the maintenance of personal hygiene, but it must be accompanied by sufficient amounts of soap and regular access to facilities for bathing. In the interest of personal hygiene, but also of public health within the prison, inmates must be informed of the rules of basic hygiene (see box below) and encouraged to respect them. Instruction can be given to prison nurses or health assistants who can then conduct hygiene-promotion sessions for the detainees.
Each detainee should be given body soap (100-150 grams per month) and laundry soap regularly. Note that some soap is suitable only for laundry, because of the quantity of alkali that it contains, and the type of soap supplied should be checked. Frequency of showers or baths will depend on the climate and on the workload of the detainees. Pregnant and menstruating women, as well as women imprisoned with their children, will need to bathe more frequently.
Cultural and religious norms must also be taken into account, since these may require people to bathe more often. While the SMR (Rule 16) recommend at least one shower per week in temperate climates, more frequent showering is necessary in tropical climates. Those engaged in moderate to heavy physical exercise must be permitted to shower daily.
The level of personal hygiene also depends on the frequency with which clothes can be laundered. This again depends on the climate and on the amount of physical exercise undertaken. Detainees will probably not be provided with regular changes of clothing, in which case they should have access to laundry facilities and laundry soap, to wash their clothes. Bedding also has to be washed regularly; it must also, wherever possible, be aired regularly.
Unrestricted access to free-of-charge sanitary items for women (sanitary towels, etc.) and children (diapers) must be ensured. 

# Toilets
Toilets will be overused if there are not enough of them. This will lower the level of basic hygiene and permit the spread of contagious diseases.
Detainees should have access to some form of toilet facility at all times. For instance, toilet blocks can be situated in the prison's compound if detainees have free access to that part of the prison. If they are locked up in cells or blocks (for example, at night), and if they are not allowed outside, there should be a toilet within the cell or block. If the toilets are kept locked then the mode of access should be looked into: for instance, is the key held by a guard or by a detainee? Evidence of open defecation, anywhere on the prison site, suggests a problem related to access to toilets or that the toilets are not working.
Given the resource constraints of many contexts, a toilet within the cell may not be feasible; in such cases, a bucket that can be closed with a lid is acceptable.
Toilets within a cell should be separated from the living area, for reasons of both privacy and hygiene. If a bucket is used it should be emptied daily, in a suitable spot at a distance from water and food sources.
Access to water and soap must be provided, for the washing of hands after use of the toilets. Sanitary conditions in the vicinity of prison toilets is vital to the health of the detainees. - The Sphere Project (www.sphereproject.org) defines minimum standards in humanitarian response. In prison contexts however, pre-existing limitations of space and structure may prevent the construction of additional toilets (unlike in refugee camps and other situations of humanitarian crisis where there is usually sufficient space to construct the required number of toilets). ICRC experience has shown that 1 toilet for 50 persons may be acceptable in resource-constrained contexts, but only if the toilets are well maintained and clean. This should not preclude the construction of more toilets where that is indicated and feasible. Water engineers may refer to water as 'white' , 'grey' or 'black' .

# Toilet standards

# SAMPLE QUESTIONS ON HYGIENE AND TOILETS
'Whitewater' is clean water suitable for drinking.
'Greywater' or 'wastewater' is dirty water from washing (of hands or bodies); it may also include water from kitchens or laundry.
'Blackwater' or 'sewage' is any water that contains human faeces or urine.
Where there is no municipal sewage system, separate outflows should be provided for grey and black water. Greywater or wastewater may then be recycled (for use in irrigation, for instance), but only if it is not contaminated by sewage. The outflow of greywater may be via a closed system of pipes or tanks or via uncovered drainage channels. Blackwater outflow may go directly into pit latrines, or into septic tanks, or out through a piped sewer system. Ideally, the blackwater/sewage system should be covered or closed. Black water/sewage may be deposited in septic tanks, but in order to work properly these must not be contaminated by detergents that might be present in grey water. The detainees responsible for cleaning the wastewater and sewage disposal systems must be issued with protective clothing (rubber gloves, boots and apron) and additional soap, and must also be given time to shower.

# SAMPLE QUESTIONS ON WASTEWATER AND SEWAGE
Wastewater and surface water drainage 

# Sewage outflow system
  Does the sewage system use pit latrines, septic tanks, or closed sewage pipes?
  What state is the system in? Mention specific problems, if any (blockages, breaks, leaks), and their location.
  Are the septic tanks soak pits that do not need to be emptied, or are they sealed tanks that require emptying? If they are sealed tanks, how often are they emptied? (Once every year or two may be sufficient if the tanks are not overused.)
Who is responsible for sewage and for emptying septic tanks (e.g. municipality, detaining authority)?
  How does the functioning of the wastewater and sewage system affect the community?

# Waste management and hygiene of premises
Areas where detainees live should be cleaned daily with water, and once a week with disinfectant. This also applies to the kitchen and to the toilet blocks.
Solid waste, which may be organic (food) or non-organic, should be stored before collection, and after removal from the prison, buried or burnt. Stored organic waste should be placed in rat-proof pits (these need be nothing more than raised, smooth-edged concrete cylinders) and covered, to discourage flies and other insects. If possible, the prison should use the solid-waste-collection services of the community, where such services exist. Organic waste -food remnants, for instance -can also be fed to animals such as pigs. The frequency of waste removal will depend not only on the climate (hot climates necessitate daily collection), but also, where such a service exists, on the schedule of the community's services. Bear in mind that because prisons concentrate large numbers of people in a confined space, the risks to public health are greater when the waste-collection system is not functioning well or when it is non-existent.
Medical waste (needles, used swabs, etc.) is a significant source of infection, which may be contracted through needlestick injuries or exposure to pathogens. All waste of this kind must be collected separately (e.g. in 'sharps boxes' for used needles) and then burnt and buried.
Minimum recommendations for solid waste 

# Vectors and pests
Insects, parasites and rodents thrive in prisons. Some of these are hosts to pathogens and may act as disease vectors. They may transmit disease by bites, via excreta, or simply by mechanical carriage (e.g. flies carrying faecal material with pathogenic agents from one spot to another).
The following factors may encourage the proliferation in prisons of flies, mosquitoes, lice, cockroaches and other insects, as well as rodents: poor personal hygiene amongst detainees, overcrowding, poor standards of cleanliness within the prison, and the existence of refuges and breeding grounds (holes or cracks in walls, stagnant water, and piles of rubbish).
Insects and rodents can be disease vectors, transmitting diseases among humans. Control of insects and rodents is an important measure to prevent the spread of disease in a prison. Methods include: ensuring good hygiene amongst detainees and on the premises, regular removal of refuges and breeding grounds, screens on windows and doors, mosquito coils, fumigation, and spraying (keep in mind that fumigation and spraying both require the involvement of a knowledgeable technician).
Stray dogs, cats and other animals such as pigs may also act as reservoirs for disease, or contribute to unhygienic conditions. 

# Main vectors and vector-borne diseases

# FOOD AND NUTRITION
Food is an important and complex issue in prisons. Significant financial resources are required in order to ensure its regular supply; good practices of hygiene are needed for its storage and preparation; it has to be provided in the form of a well-balanced diet; and its distribution has to be equitable. Its importance and the sensitivities that surround the subject in prisons are such that food may be at the root of tensions and even of riots in these settings.
'Food' refers to edible items, and the term 'nutrition' to the metabolic impact on individuals of what they eat.
This chapter discusses issues related to food, using the concept of THE FOOD CHAIN, which refers to the supply, storage and preparation of edible items, as well as the access to or distribution of such items. NUTRITION is then dealt with by outlining the basic caloric and nutrient requirements of the human body, the underlying and immediate causes of malnutrition, and sample questions for assessing the nutritional status of detainee populations.
It is always good practice to conduct a rapid assessment of the food system within a prison and record the findings, even where no significant problems are immediately apparent. This assessment will establish the baseline functioning of the prison food system and will be useful in the event of any future problems, or to enable comparison between prisons. A more comprehensive assessment is required only in prisons where the initial rapid assessment reveals a food or nutritional problem. The nutritional assessment should be carried out by a multidisciplinary team that includes a health professional with expertise in nutrition.
This chapter makes references to two documents:
1. Guidelines for ICRC Activities on Behalf of Persons Deprived of their Freedom in the Event of Nutritional Problems (2010), which provides a framework for nutritionrelated activities in places of detention. When the ICRC is deciding whether to act in place of the authorities, it is guided mainly by this document.

# Food and Nutrition Guidelines in Places of Detention: A Practical Guide for
Detention Teams (2016), which aims to provide practical and standard references for assessing and responding to nutrition issues in detention.
The guidelines are intended for the entire detention team (protection staff, nurses, doctors, nutritionists, economic security staff, etc.) and are in the form of three separate booklets: 

# The food chain
The FOOD CHAIN refers to food supply, including budgeting, storage, preparation, and access (distribution). All of these factors are likely to be subject to constraints within prisons; there tends to be less food along the prison food chain. Assessments of the food chain must focus on its weak links. Critical points in the chain include: the budget for food supply; the procurement system; the supply or storage phase (especially with regard to nutritionally valuable items such as oils and pulses); food storage conditions; and cooking procedures. Assessment of the food chain will require interviewing authorities, cooks and detainees, as well as inspecting food stores and kitchens and examining methods of food preparation and distribution.  Assessment of nutrition includes those elements that follow or occur 'downstream' of food supply, storage, preparation and access. A nutrition assessment looks at the actual nutritional content of food consumed by detainees, and is based on the quality and quantity of that food. It also involves consideration of the potential biological utilization of ingested food (for example, the presence of intestinal parasites may reduce the availability of nutrients). Finally, the general nutritional status of the detainees can also be assessed. Evidence of malnutrition in a prison is a sign of a food or nutrition problem. Other factors can exacerbate the situation: the health status of detainees (TB, HIV, mental health, etc.), the relationship between detainees, how food is shared, etc.
When evaluating the food situation in prisons, all testimonies must be carefully weighed. Remember that both the authorities and detainees may have their own reasons for influencing visitors' views on the food in their prisons, and ways of doing so. For instance, detaining authorities may prepare food -different from that usually given to detainees -specifically for the benefit of visitors. And detainees may complain about food simply to release pent-up tension. It is also useful to compare the food situation in the prison with that in the community outside (for example, local dietary habits and patterns during 'normal' and 'exceptional' circumstances).

# Food supply
All essential food groups should be represented in sufficient quantities in the food supplied to prisons, so that detainees can benefit from a balanced and varied diet. A proper supply of food for prisons requires:  - Planning and budgeting by the prison authorities National or local prison regulations may stipulate a set daily food ration for each detainee.
- Logistics management Food may be supplied to the prison daily (if pre-cooked), weekly (if bought on the open market), monthly or even quarterly (when provided by central authorities). Arrangements for this supply must be properly managed to ensure reliability. Food may also be supplied from prison gardens; this, too, requires proper planning and management.
Insufficient supplies of food from the authorities may be the result of poor planning, inadequate finances, fluctuations in food prices, or corruption. Both the officially stipulated food rations and the food actually received by detainees should be assessed and compared with nutritional requirements.
Official prison food supplies are often supplemented by food from families, NGOs, or shops or stalls within the prison, as well as from detainees who obtain extra food while working outside in the community. Nonetheless, prison authorities should be expected to provide a full daily food ration that, in quality and quantity, meets the nutritional needs of detainees. Additional supplies should not be included in calculations of a prison's food supply; they should be assessed separately. Additional food sources (and their often unequal distribution) will be considered further in Section 3.5. below, on access to food. 

# Food storage
Food must be stored properly in order to keep it free of contaminants, prevent spoilage by pests, and to preserve its nutritional content (infested cereals and pulses have fewer proteins, for example). Food stores should be clean, dry, well protected from the elements, and free of rodents and insects. Food storage facilities should be inspected and food losses due to improper storage noted.   Make a tally or inventory of the food in stock and record the information in a 'bin card' with batch numbers and expiry dates.

# Minimum recommendations for food storage

# Food preparation
The kitchen is usually a critical point in the food chain: food can be stolen or diverted here. Poor cooking processes can also result in the loss of nutrients. Improperly handled food in the kitchen can become contaminated and cause disease among detainees. Prison kitchens are also workplaces with their concomitant occupational health hazards. Kitchen inspections must always be part of a prison health assessment.
The kitchen will probably be visited during the tour of the premises. It should also be visited at other times, with a view to observing the preparation of food and the provision of meals, as well as discussing pertinent matters with cooks and the catering staff.

# Nutrition and food preparation
Processing and cooking procedures can drastically alter the nutrient content of food. For example, water-soluble vitamins can be lost in water during washing or boiling, and the vitamin content of fruits diminishes when they are dried.

# Occupational health and food preparation
Prison kitchens are workplaces and subject to occupational hazards, including burns and cuts, as well as ailments caused by prolonged exposure to high temperatures, humidity and smoke. Kitchens should be covered and well ventilated; they should also have a chimney and a regular supply of sufficient quantities of water.

# Hygiene and food preparation
Kitchens are potential sources of food-borne diseases, and these can lead to epidemics. Food may be contaminated by pathogens (disease-causing agents) while it is being prepared. Pathogens may come from contaminated water, insects (especially flies), animals (rats and cats are found in many prison kitchens), or from infected humans (cooks may carry bacteria). The handling and preparation of food must be regulated by rigorous hygiene practices. Prison health staff should ensure that people working in the kitchen are educated in food hygiene issues and adhere to basic rules of kitchen hygiene (see 'Kitchen hygiene rules' , below).
Other sensible precautions include encouraging food handlers to notify their supervisor before commencing work if they have experienced diarrhoea or vomiting in the last 48 hours or if they have skin infections, boils or burns, or ear, nose or throat infections. Routine health screenings for all food handlers may also be considered (screening for carriage of salmonella, tapeworm, etc.).
There is no evidence that TB, hepatitis B or C, or HIV/AIDS and other sexually transmitted diseases can be passed on via food or beverages. People with HIV/AIDS should not be prevented from working with food. The main foodborne diseases are: food poisoning, typhoid fever, salmonellosis, cholera, hepatitis A, leptospirosis and intestinal parasitosis.
When large numbers of detainees complain of gastrointestinal problems the prison health staff should have some idea of the possible causes and be able to suggest potential solutions. If prison staff are unable to define or resolve the issue, cooperation should be sought from the local public health office, health centre or hospital. This should not only lead to resolution of the problem, but also foster links between the prison and the community's public health system.

# Kitchen hygiene rules 24
Keep clean   Wash hands before preparing food, after visiting the toilet; do this frequently while handling food. Water stock in the kitchen 3 m 3 /1000 persons (ICRC)
Besides the recommended water stock and cooking pot capacity, sufficient fuel for stoves is required, so that meals may be cooked properly.
Remember that meals for detainees, while being safe and nutritionally balanced, should also look edible and be tasty. Efforts should be made to provide variety in the meals. 3.5. Access to food 'Access to food' refers to access to: a) the official rations prepared and distributed by the prison authorities, and b) additional sources of food, such as family visits or guards or prison shops.
The official distribution of prison meals should be equitable, but some detainees' access to food may be limited or influenced by the category or group to which they belong. For example, foreigners may be the last to receive the meals, and so may have less, and juveniles may get smaller portions because adults take more. The organization of food distribution (e.g. by cells or at a central point) should be assessed with these considerations in mind; the use of measures to ensure equal portions (e.g. food scoops) should be assessed as well. Prisoner hierarchies may influence access to food even after an equitable official food distribution, because lower 'classes' of detainee may have to 'donate' or 'pay' food to higher 'classes' .
Access to food from supplementary sources is likely to be uneven. Detainees without families, money, or employment (entitlement to work and earn a small income is often a privilege in prisons) will probably have less access to food. 

# SAMPLE QUESTIONS ON ACCESS TO FOOD

# Nutrition
The human body needs a diet of adequate quantity (sufficient amount of kilocalories, or kcal) and quality (balance among the various food groups) in order to maintain health.
Prison authorities are responsible for providing all detainees with an adequate diet. Because all the nutritional requirements cannot be met by only one meal, a minimum of two meals should be served each day.
The energy content of detainees ration should be 2,400 Kcal at least. Energy content should, however, be adapted according to detainees' profiles and their physical activities (see Table 3.2). Nutritional requirements vary according to: age, gender, physical activity, health status, and environmental temperature. However, the figures in the tables below provide useful approximations.
The nutritional balance of the prison diet and its energy content should be calculated during a prison assessment. These calculations should be checked against the recommendations for food groups outlined in   People may be insufficiently nourished even when a diet adequate in quantity and quality is available. This may be owing to illness altering the body's biological utilization of food. Certain diseases increase nutritional needs (especially AIDS, dysentery, TB, cancer, severe infections). At the same time, they may inhibit or decrease food consumption (for example, by causing nausea, loss of appetite, mouth ulcers, or problems in the digestive tract). Disease may also reduce food absorption (through 'malabsorption syndrome') and impair food utilization (among people suffering from diarrhoea, for instance, large numbers of bacteria in the small intestine can decrease the quantity of vitamins in food).

# SAMPLE QUESTIONS ON DIET
  Find out if the official daily/weekly menu is indeed provided to and consumed by the majority of the detainees.   Assess the quantity of food consumed: weigh individual meals provided to detainees. As a guide, take no less than 10% of a representative sample of the total population (the larger the variability expected between the portions served, the larger the sample should be) and measure the weights of cooked food provided. Select the meals randomly and make sure that your sample meals are collected throughout the distribution period, e.g. not just at the beginning or at the end.   Weigh also family food rations or self-prepared food if this is an important source for the detainee population. 

# Malnutrition
Malnutrition occurs in an individual when the quantity (energy in kcal) and/or quality (balance of food groups, presence of vitamins and minerals) of his or her daily food intake is insufficient over a period of time. This is often, but not always, due to lack of food. Malnutrition can be associated with other diseases as either a cause or a consequence. Malnutrition can cause disease because it impairs the functioning of an individual's immune system. Malnutrition can be a consequence of disease (and not only owing to lack of food), because many diseases increase the body's need for nutrients while impairing its ability to utilize those nutrients.
Broadly, adult malnutrition can be divided into two types: 
- Acute malnutrition -caused by an overall deficiency of nutrients 
- Micronutrient deficiencies -caused by lack of specific micronutrients.
The appearance and assessment of these two types of malnutrition are discussed separately below. However, the separation is artificial: in reality, an undernourished individual will often suffer from both acute malnutrition and one or more micronutrient deficiencies.

# Acute malnutrition
Acute malnutrition is caused by a deficiency of those basic food groups (carbohydrates, protein, fats) that are necessary for growth and general body metabolism. When these food groups are not consumed in sufficient quantities (and where the diet does not meet the energy requirements in Table 3.2), the body breaks down its own stores of proteins and fats. In adults, this very often results in wasting -loss of muscle mass and body fat. People with wasting look very thin and have little strength or energy. More rarely, oedema -accumulation of fluid, initially in the lower limbs -can be a second clinical aspect of acute malnutrition. People may look swollen and puffy; fluid accumulation may mask the loss of muscle and fat. In adults, differential diagnosis of oedema should be done for tropical oedema, hard oedema or oedema associated with kidney failure.
Acute malnutrition is associated with a very high mortality rate. BMI cut-offs for malnutrition are the same for all adults, irrespective of their age, sex, or height. However, BMI should not be used to assess the nutritional status of children and adolescents, pregnant women, or people with oedema. For assessing nutritional status in children and adolescents, use weight-for-height charts. For pregnant women, measure the mid-upper arm circumference (MUAC). There are no universally recognized MUAC cut-off levels for adults, but an MUAC of 230 mm has been suggested as the lower cut-off for an adult of normal nutritional status; below this level the individual may be malnourished.
For people with oedema, that alone may indicate malnutrition; an MUAC may provide further evidence. Examining for oedema involves applying pressure for three seconds with the thumb to the front of the patient's lower leg or the back of his or her foot. After three seconds the pressure is released; if a dent remains in the skin, pitting oedema is present. Pitting oedema due to malnutrition always affects both feet.

# Micronutrient deficiencies
Micronutrients are required for specific metabolic functions. They take various forms: for instance, the many vitamins and minerals found in fruit, vegetables, and protein foods. Micronutrients are stored in the body, often in particular tissues. When a micronutrient is absent from the diet the body's store is gradually depleted until, eventually, none of the micronutrient remains and the specific metabolic function that depended upon the nutrient can no longer occur. At this stage, specific physical signs and symptoms emerge, indicating the micronutrient deficiency. Such deficiencies have no direct effect on overall body mass or growth (except deficiency in iodine in children), but may nonetheless still result in death.
Signs and symptoms of some of the most important micronutrient deficiencies are described below. Clinical assessment of signs and symptoms remains important for diagnosing micronutrient deficiencies, because biochemical testing using blood or urine samples is often very expensive or simply impossible to arrange. 

# Assessing nutritional status in prison populations
Nutrition is an important issue in prisons. Assessing the nutritional status of detainees and the nature, extent and severity of malnutrition among the prison population may be an important part of the overall prison health assessment.
When considering the nutritional status of people inside prisons, remember that malnutrition normally affects a group or groups (signs of malnutrition in a single individual are more likely to suggest an underlying disease, which should be investigated). Also, malnutrition tends to affect vulnerable groups first (in prisons this may include the elderly, ethnic minorities, and detainees who receive few or no family visits).
Warning signs of a nutritional problem within a prison may include: Health staff may have data showing death rates and sickness among detainees. They may also keep records of the nutritional status of individual detainees (for example, weights documented in clinic records). However, these records may not be a reliable indicator of the nutritional status of the general prison population, because the data will refer only to those detainees who have accessed medical care, and they may not be representative of the general population. Also, nutritional data may not always be recorded and analysed accurately or systematically when health staff attempt to do this alongside their other clinical tasks.

# Nutritional surveys of the prison population
The rule is to carry out yearly nutrition surveys in prisons that could have a nutrition problem, and quarterly nutrition surveys in prisons with ongoing malnutrition problems.
A survey of this kind is, most frequently, a targeted assessment of the nutritional status of the entire prison population, and, when there are too many detainees for that to be possible, of a sample of that population.
Conducting a nutritional survey successfully requires time, effort and good organization. It will probably entail the clinical assessment of many detainees over several days. If a population sample (rather than the entire population) is being used for the survey, it must be ensured that this sampling really represents the whole prison population -including members of those vulnerable groups that may be most at risk of nutritional problems. Nutritional surveys can provide information about the prevalence and severity of malnutrition in prison. They may be conducted routinely, or in response to specific concerns about nutrition within the prison. (See Chapter 8 of Booklet 2: Assessment of the food and nutrition situation in detention.)
A comprehensive nutritional survey could include the following for each individual (see Chapter 8, The results of a nutritional survey should be interpreted carefully. The interpretation should include analysis of the prevalence and degree of malnutrition. For instance: Does malnutrition within the prison affect many detainees or only a few? Is it severe or moderate? Equally important is analysis of which groups within the prison are most affected. A nutritional survey will not reveal the underlying causes of a nutritional problem. Ultimately, identifying the causes is essential and will require consideration of the entire food chain (as outlined earlier in this chapter) and of any disease factors.

# HEALTH-CARE SERVICES

# Background principles
Imprisonment should not increase the risk to the health of detainees. In the context of health-care services this means that the principle of equivalence should apply. That is, the health care available in prison should be at least equivalent to that available in the surrounding community. For this reason, it is important that all detention visits include a visit to the local health facilities as well. Visiting the local health facility will give you a grasp of the levels of service available to the community. It will also allow you to study the provisions that have been made for detainees who may be referred to this facility for further care. It is important to see how detainees are treated at the facility and to discuss any specific concerns with local doctors.
It might be argued that even the principle of equivalence is inadequate in relation to prison health-care services. Prisons contain people who are often vulnerable to ill health because of their background, their environment, and their behaviour inside prison. Detainees are often socially, educationally and economically disadvantaged before entering detention -all of which increases their risk of ill health and reduces the likelihood of their having made use of health services before entering prison. Detainees are also more likely whilst in prison to be exposed to behaviour (physical and sexual violence, substance use, and other risky conduct) that increases their risk of contracting infectious diseases such as hepatitis and HIV, and that also increases the incidence of psychological disorders among them. As a result, the demands on the health services of prisons are greater than those on community health services; even so, prisons usually receive far less help, in terms of resources and funding. Consequently, health services for detainees are often of lower quality than those available to the community outside. One significant element of health care in the community for which there is rarely, if ever, an equivalent in prisons, is choice: detainees cannot choose their health-care provider. If detainees do not like or trust their health-care provider, or if they think the standard of care is inadequate, they can only very rarely choose another provider.
Ensuring the dignity, safety and security of detainees remains the responsibility of the detaining authorities. In relation to health-care access, current universal standards underline detaining authorities' obligation to provide access to health services (including preventive as well as curative services; addressing mental as well as physical illness; and providing for the special needs of certain detainees) free of charge and without discrimination, both inside and outside the prison as determined by medical needs (SMR Rule 27). Close cooperation with the general public health administration (and with other State institutions involved in public service delivery) is recommended to assure equivalence and continuity of care (SMR Rules 24 and 25), and to promote rehabilitation and successful re-entry into the community after release.

# Health staff Role and responsibilities of health staff
The level of health care provided in a prison will depend upon the number of health staff, their qualifications and training, and their motivation. These factors should be assessed during the prison visit.
In some contexts the role of health-care staff in prisons may be defined in the country's 'prison regulations' . These regulations may specify that prison health staff are responsible not only for running the health-care services, but also for other tasks such as oversight of hygiene, sanitation and nutrition. This is consistent with the ideal that health staff have duties that go beyond curative care: they must also be responsible for protecting and promoting health.

# Prison health-care structure and hierarchies
In many contexts, the authority in charge of the management and security of the prison (usually the Ministry of Justice or the Ministry of the Interior) also has authority over the prison health staff and responsibility for prison health.
Health staff may have no official connection with the Ministry of Health and may be entirely accountable to the Ministry of Justice. They may even have a police or military rank. This arrangement means that health staff in prisons often take no part in ongoing training and have no professional contact with their colleagues in the national health system, which can adversely influence the care that they are able to provide. The professional independence of health staff may also be compromised in these circumstances by 'dual loyalties' (see below), and this may have a further adverse impact on their performance.
In order to better understand the forces acting upon prison health staff, it may be useful to map the structure of health-staff hierarchies. This map should show who the health staff report to -within the prison and at the local health authority or ministry. It should also show the points of contact between health staff and community health services, district authorities, and relevant ministries.
Completing this mapping will help to ensure that any actions intended to bring about change are directed at the appropriate individuals or authorities, or at the proper level.

# Relations between health staff and detainees
Relations between health staff and detainees vary considerably in prison settings. Some health staff may carry out their work with empathy and compassion, treating detainees as they would any other patient; they may know each detainee by name and be willing to see anyone who wishes to have a consultation. Others may treat detainees impersonally, referring to them by their prison number, for example; and they may view detainees with suspicion, regarding their complaints as no more than malingering. Some health staff may seek to do as few consultations as possible, especially in contexts where salaries are low or where staff have been obliged to work in the penitentiary system.
During the prison visit, try to gauge the attitude of health staff towards detainees.

# Dual loyalties and health-care ethics in prisons
'Dual loyalties' commonly exist for health staff working in prison settings. The problem of dual loyalty for health professionals has been defined as "simultaneous obligations (...) to a patient and to a third party. " 25 The obligations may be expressed or implied, real or perceived. The third party may be an employer, an insurer, a relative of the patient, the State, or the authorities in charge of a prison. Dual loyalties are not the same as a conflict of interest: in a conflict of interest the health professional's self-interests vie with those of another individual or group; when dual loyalties are at stake, the health professional's self-interests are not necessarily involved, he or she has nothing personal to gain from the outcome, and the conflict is between two incompatible accountabilities. In practice, however, even when dual loyalties are clearly in play, as in a conflict between the patient's health interests and the security interests of prison authorities, the health professional will also experience a conflict of his or her own interests, since he or she will likely be dependent upon the prison authorities for employment and income, meaning that it is in his or her interests to align with, or be more loyal to, the authorities. Thus, in situations where the health professional's clinical independence is threatened by conflicting loyalties to prison authorities and patients, the risk that patients will suffer is considerable.
Nonetheless, it is important to recognize that health professionals working in prisons are bound by the same ethical obligations as their colleagues working in the community.
In prisons, health staff may be confronted with various ethical issues. The nature of these ethical issues and the frequency with which they arise, as well as the health staff's response to them, needs careful and sensitive evaluation. The visiting health professional should obtain information from various sources: direct observation, discussions with detainees, and discussions with health staff and authorities.  Relations between staff and detainees   How are relations between prison health staff and detainees? Try to form an impression based on observation of the daily clinical routine, treatment of inpatients, and discussions with staff and detainees.

# Examples of medical ethical issues in prison settings

# Medical facilities and equipment Clinic
All prisons and places of detention should have a clinic or health facility on site (it may be called the 'health post' or the 'outpatient department'). 27 The clinic area should include: a consultation room, an area for treatment, and a waiting area for patients. The consultation room should allow for discussions in confidence and for privacy during the examination of patients. It must be equipped with an examination couch and basic medical equipment (thermometer, stethoscope, sphygmomanometer, etc.); absence of these items suggests that medical examinations cannot be performed properly.
The situation of the clinic should be noted. It may be situated beyond the main security perimeter if it is the local community clinic or if health staff are unable to enter the prison premises (for security or other reasons). If the clinic is beyond the perimeter, detainees' access to it may be impaired (especially if guards obstruct passage or demand bribes); it may also mean that health staff do not regularly enter the prison to check the hygiene condition of cells, kitchens, toilets and other shared premises or to assess the food and directly observe the health of detainees.

# Sick ward/ Hospital
Large prisons might have a hospital or sick ward, which allows detainees to receive continuous monitoring and treatment, to be isolated from the general prison population, and to recover from their illness in a quiet environment with easy access to sanitary facilities.
Whether or not a prison has a hospital or sick ward may depend on: the criteria for hospital construction set out in the country's Prison Act or prison regulations, the facilities available to the community, and the structure of the national health service. Prison hospitals have the advantage of being 'within the system' , meaning that transferring a detainee to hospital involves less red tape, and no issues with transport or custodial staff. However, there is this disadvantage attached to prison hospitals: they may become liabilities at some stage: in a system that is hard pressed for funding, there may not be enough money available for maintenance and supplies, and for keeping a permanent staff on hand at all times.
Acceptable standards for a prison hospital or sick ward may vary, depending on: the standards of the medical facilities available to the community outside; the seriousness of illnesses treated inside the prison; and possibilities for referring seriously ill detainees to hospitals outside. As a minimum, though, inpatient wards should have: good levels of hygiene; suitable sanitary facilities; good ventilation and a heating or cooling system (adapted to the local climate). The ward must also be staffed by a team with appropriate levels of training and supplied with all necessary medical equipment and consumables.
All larger prisons should be equipped with an isolation room or ward to separate detainees with contagious diseases, in order to prevent the spread of disease among the entire prison population. As a minimum, there should be a spare room that can be rapidly converted into an isolation ward if the need arises.
On-site laboratory facilities, if there are any, should be evaluated for such things as: state of repair, supply of parts and reagents, and knowledge of staff regarding the use of lab items. 

# SAMPLE QUESTIONS ON MEDICAL FACILITIES AND EQUIPMENT

# Access to health care INSIDE the prison
The level of the health infrastructure does not necessarily reflect the kind of health care that detainees actually receive: in other words, there is no guarantee that the existence of a comparatively well-developed health infrastructure will result in high-quality health care for detainees. Assessing ACCESS TO HEALTH CARE is important: that is, assessing the degree of access that inmates have to health staff, consultations and treatment. Access must be considered at two levels: access to health care within the prison (covered in this section) and access to health care outside the prison (see Section 4.5. below). Access to care outside prison will be necessary when medical needs go beyond the capabilities of the prison health staff and facilities.

# The role of prison health staff in ensuring access to health care
Health care available to people in prison should at least be equivalent to that available to people in the community outside. In large prisons, or in contexts where the community outside has relatively easy access to health care, one or more doctors may work full-time in the prison. In small prisons, or where the surrounding community has only limited access to health care, a doctor working part-time may visit the prison intermittently. Nurses or health assistants may be more available and they may be able to take on many health-care tasks in prisons: for example, performing the initial detainee health screening and treating sick detainees for common or minor ailments. However, these first-line health personnel must be able to refer patients to a doctor if further care is required, and they must be capable of recognizing cases that require referral. The working hours of these first-line health staff (and their availability) will reflect the health-care situation in the community. Irrespective of contextual variations, the degree of access to health care is acceptable only if: detainees with acute symptoms are able to have them reviewed by a member of the health team on the same day (sooner if possible or necessary); and if detainees with chronic or complex illnesses are able to receive medical follow-up regularly.
Within the prison, all detainees should have equal access to health services. Health care is often a scarce resource; any rationing of health care should be done according to clinical need, as determined by a member of the medical staff. Non-medical staff should not screen detainees or limit their access to health care. This is for several reasons: first, non-medical staff lack the expertise to determine the health-care needs of individual detainees; second, they may make choices or impose restrictions based on non-health-related reasons (political affiliation, bribery, etc.); and third, because the principle of medical confidentiality dictates that a detainee should not have to divulge the state of his or her health to non-medical staff. Ideally, detainees should be able to report their names and health complaints directly to a member of the health staff, either at the clinic itself, or during rounds of the prison made by the health team. In reality, however, non-medical prison staff often draw up the list of detainees who wish to see the doctor or nurse: particular attention must be paid to ensuring that there is no discrimination in this process.

# Non-medical determinants of access to health care
Difficulty in getting access to health care is a common problem inside prisons. It may affect the entire prison population, or only certain groups or individuals. Where the entire prison population is affected, a number of factors may be responsible: geographic or demographic factors that limit the supply or availability of staff or medical consumables; insufficient budget for salaries of medical staff, medical supplies or medicines; or negligence or lack of will on the part of the prison authorities.
Specific groups or individuals may find their access to health care limited by hierarchies or 'gangs' within the prison. One group of detainees may not want another to get medical care. Vulnerable groups might include: women, minors, the elderly, minority groups, those with mental-health problems, and detainees in particular categories or locations (e.g. those on 'death row' or in solitary confinement). These groups may suffer discrimination because they are thought to be inferior and less deserving or, in the case of political or security detainees, because they are regarded as 'enemies' or 'traitors' .
Corruption involving the prison authorities (and even other detainees) can also impair access to health care. Some form of corruption or bribery exists in almost every prison in the world. This is a complex and delicate issue and often difficult to assess, let alone respond to. But a response strategy must be formulated, in case corruption hampers access to basic services for all or even some detainees.
Information on access to health care can be obtained from the health staff, the administration, the detainees themselves, and from direct observation. Medical registers may also be a useful source of information in this regard, as they may contain a record of the days on which the clinics are open, and on the number of consultations and the reasons for them.

# Consultation rates
The number of medical consultations carried out in a prison may disclose information on such matters as: detainees' access to medical services; availability of health staff and their willingness to see patients; and the overall health status of the prison population. However, these findings must be interpreted cautiously.
Reference or 'baseline' values for the number of health consultations expected to take place in prisons do not exist. References to displaced populations (including refugees) provide some guidance, but these too must be interpreted cautiously.
It is expected that in a population of 1,000 displaced people, 10 consultations will be performed daily (representing about 1% of the population). 28 Higher figures may indicate poor health in the population. When the number of daily consultations exceeds 3% of the population, the patterns of morbidity must be studied carefully. It is important to find out whether the higher numbers of consultations are related to minor ailments such as headache or back pain, or to serious illnesses. While studying the consultations consider also whether the patients seen by medical staff represent new cases of sickness, or whether these are detainees with chronic diseases attending the clinic several times a week.
Remember the other important tools for assessing detainee health and access to health care: discussions with the health staff and with the detainees themselves, and direct observation of sick detainees. The presence of obviously sick detainees who have not attended the clinic, or of detainees with chronic diseases or injuries who have not had any medical follow-up, suggests a potentially significant problem affecting access to health care in the prison.

# Medical assessment of new arrivals
Prisons should have a system for the medical assessment of all newly arrived detainees. An individual's medical history should be documented, and an examination conducted, as soon as possible after arrival, preferably within 24 hours. Ideally, a doctor should perform the initial medical examination, but where this is not possible, a qualified nurse can fill in. An initial medical examination is not always feasible in police stations, but a medical consultation should be available on request of the detainee, or if the authorities have reason to think one is needed. All medical information obtained during the initial medical examination is confidential and should be stored accordingly.
It is important that newly arrived detainees undergo a medical assessment.
There are a number of reasons for this:
1. Detainees may have immediate medical needs that require treatment. This may include treatment for an acute condition (a wound, broken limb, or acute infection, for example), or for a chronic condition (a diabetic may need to continue his or her insulin regime, a person with a mental-health problem may need to continue taking his or her antipsychotics, etc.).
2. Detainees may have contagious diseases when entering a prison, and may have to be isolated until their disease has been treated, or until it is no longer contagious. It may be appropriate to isolate newcomers temporarily, until an initial medical assessment has confirmed that they pose no risk to the general population. The isolation ward should be of the same standard and as comfortable as the rest of the prison so that detainees who have to be isolated for a contagious disease do not feel that they are being punished. Isolation should end immediately after the contagious stage of a disease has passed (e.g. detainees in the continuation phase of anti-TB treatment should not be kept in isolation once their sputum test has come up negative).
3. Detainees may bear physical or psychological evidence of ill-treatment that needs to be documented. For example, if detainees arriving from interrogation centres or police stations have been abused, the fact must be recorded and any scars described. Such documentation can be beneficial both to the detainee and to the prison authorities. Medical documentation of evidence of ill-treatment may help the detainee in the event of future legal action against those responsible; and recording evidence of injury or psychological distress at the time of their arrival at the prison may help to prove that these occurred prior to the detainees' arrival and were not caused by the current detaining authority.

# Medical involvement with persons in solitary confinement
There is as yet no international agreement on the definition of solitary confinement in places of detention, let alone its prohibition. However, extreme forms and prolonged or indefinite periods of "involuntary separation from the general population" are, increasingly, considered unacceptable, as are their application to certain categories of detainee (particularly those considered 'vulnerable'). The revised SMR provide definitions, list restrictions on application, emphasise both prison authorities' responsibility to alleviate "potential detrimental effects", and guide health-care professionals regarding their response to detainees facing such sanctions. 29 The UN Basic Principles for the Treatment of Prisoners (1990) encourage efforts to abolish or restrict the use of solitary confinement. 30 The revised European Prison Rules ( 2006) recommend that solitary confinement be used only in exceptional cases and for short, pre-specified time periods. 31 The Istanbul Statement on the Use and Effects of Solitary Confinement (2008) states that "solitary confinement should only be used in very exceptional cases, for as short a time as possible and only as a last resort"; it also sets out the circumstances in which solitary confinement should be "absolutely prohibited. " 32 Nonetheless, while the use of solitary confinement is banned in some countries, in others a judge may authorize its use; and in certain other countries, prison superintendents can decide whether to put detainees in solitary confinement.
This can be a delicate issue for doctors who work in detention. It is unethical for a doctor to be involved in 'medical certification of punishment' , and since solitary confinement may be used as punishment, a doctor certifying someone as fit for it would be behaving unethically. However, it is a doctor's duty, and therefore expected, (1) to tend to the health of someone in solitary confinement. 33 , (2) to report any resulting adverse effect on a detainees' physical or mental health to the prison director, and (3) to recommend changes to the regime (including its termination) to prevent or address them (SMR Rule 46).

# SAMPLE QUESTIONS ON ACCESS TO HEALTH CARE INSIDE THE PRISON
Procedures for getting access to health care 

# Access to health care OUTSIDE the prison
Prisons mostly provide only basic health care; a link to medical institutions outside is therefore essential. Detainees may need to make use of health services outside the prison for a variety of reasons: urgent hospitalization, medical investigations, specialist consultations, and medical and surgical procedures. As with referrals from the community, detainees may be in hospital as outpatients (the hospital visit covers a single day, as for an appointment at a clinic -sometimes called 'ambulatory' care) or as inpatients (the patient is 'admitted' overnight).
The number of referrals made to a hospital outside will depend on: the level of medical care available within the prison, the availability of health services outside the prison, the general health status of the prison population, and the ability and willingness of the administration to transfer cases. Detainees' access to health services outside the prison may also be impaired by other factors, such as: security regulations, transport, hospital restrictions and financial constraints.
Transport and security logistics may be a problem. There may be no vehicle to transport detainees from the prison to the hospital; or, if a vehicle is available, the space in it may be limited. There may also not be enough security guards to escort patients, or these guards may not be available on a regular basis. In some contexts, it is not the prison but the police or army who must provide security for detainees outside the prison, and this can create problems related to communication and coordination. The necessity of appearing in court may also complicate hospital visits for detainees, as it might be difficult to find a suitable day.
The hospital may set limits on when detainees may attend clinics, the number of detainees that may attend, and the length of time that detainees may spend in hospital as inpatients. These limits may be explained by concerns for security, or by perceptions that the presence of detainees disrupts hospital routine.
Financial constraints can also limit access to medical care outside. Detainees may be excluded from health insurance coverage, and the detaining authorities may have only a limited and insufficient medical budget. Corruption may be involved at all levels. Since conditions in hospital are usually more favourable than in detention (fewer security restrictions, better food, better access to families in some instances), influential detainees may pay to stay there far longer than they need to, or sometimes even when they are not sick. Some detainees may also feign illness in order to be hospitalized.
Visiting the referral hospital will lead to a better understanding of the difficulties faced by the prison, the hospital and the detainees; and that will help to formulate effective responses where they are needed to ensure access for detainees to health care outside the prison. The condition of any detainees receiving inpatient care should be assessed, as should the treatment they are being given; the attitudes of the hospital staff towards the detainees should also be noted.
There is one final aspect of access to health services outside prison that should be assessed: the mechanism for ensuring communication between hospital and prison. Prison health staff should communicate their requests and concerns to hospital staff (in a referral letter), and in return, hospital staff should communicate investigation results, diagnoses, management plans and any further followup required to the prison health staff (in a clinic or discharge letter). These communications should be kept confidential, and there should be a system in place to ensure that they are acted upon or followed up where necessary.   Are there any clear-cut cases of corruption in connection with hospitalization (threats to hospital staff, detainees paying to stay longer than they need to or feigning illness to gain admission, etc.)?

# SAMPLE QUESTIONS ON ACCESS

# Individual patient records
Individual patient records -also known as 'case notes' , 'patient charts' , 'medical records' , or 'clinical files' -should be a standard component of most healthcare systems. They contain information relating to one person's health: for instance, that person's medical history and documentation of various medical encounters, test results, diagnoses, treatments, progress notes, and care plans.
Individual patient records allow the health status of individuals to be managed and followed properly over time. In prisons, however, individual medical files often do not exist; where they do, they may be messy and disorganized.
When assessing individual detainees' medical records it is important to confirm two points. First, that detainees' health issues are accurately and honestly recorded: you may need to confirm this by taking a random sample of detainees' records and going through them. It is not unknown for prison authorities to force health staff to update or falsify records in preparation for a prison visit. Second, it must be confirmed that the information in medical files is kept confidential and handled only by health staff, without interference from the administrative detention staff. This also applies to individuals and organizations visiting prisons: only health professionals should have access to detainees' medical files. For inpatient records   Is a discharge summary kept in the prison? What about other records of inpatient treatment? How does the record-keeping system affect the course of follow-up (e.g. can records be easily retrieved for later appointments)?

# SAMPLE QUESTIONS ON INDIVIDUAL PATIENT RECORDS

# Clinical registers
Clinical registers are generally used to record activities in health-care settings. These registers are generally not intended to serve as the primary repositories or sources of clinical information on individuals. Keep in mind that medical registers will likely contain patient-identifiable medical information. This information is confidential and must be treated as such -meaning that the registers must be stored appropriately and must be accessible only to medical staff.
If a prison has no clinical registers, a basic system should be introduced. This could be based on the system used in the community, if it exists. The registers should be a record of consultations, deaths, significant infectious diseases, pharmacy stock and budgetary developments. Some examples of clinical registers that might be expected to be in use in prisons are described below.

# Register of initial medical examinations
Prisons seldom have a register of the initial medical assessments of newly arrived detainees. Results are recorded in the detainees' individual medical files, in the main register, or in the detainees' individual administrative files.

# Consultation register
Consultation registers should indicate the name of each detainee seen in the clinic, the date of the consultation, the nature of the health complaint, the diagnosis, and the treatment prescribed. Accurate recording of information in health registers is important because data extracted from the registers may shed light on: the attendance of health staff; the number of daily clinical consultations; patterns of morbidity (illness) and mortality (deaths) among detainees; referrals to hospital; patterns of prescribing and dispensing drugs; and sometimes, the occurrence of ill-treatment. These indicators can be used to monitor the performance of prison health services and the overall health status of the prison population.
If patients' symptoms, and the treatment for them, are properly recorded, the consultation registers can also indicate the quality of care -by showing the link between diagnosis and treatment.

# Pharmacy stock and dispensing register
The pharmacy stock register records the number and types of medicines received and stocked. It can serve to justify budgets and to prevent (or detect) corruption associated with medicines and other medical supplies.
A separate dispensing register should record medicines that are used in the clinic. Drugs listed in the pharmacy stock register minus those listed in the dispensing register, and minus stock wastage due to expiration or damage (which should also be recorded), would be expected to equal the quantity of drugs currently in stock. Where the quantity of stock drugs is less than expected, the matter should be investigated: theft or corruption may be the explanation.

# Medicines and health budget Pharmacy stock
The stock of medicines available in the prison clinic should be sufficient for treating all diseases commonly occurring among the detainee population.
Medicines should be unexpired and of proven efficacy and good quality. They should be in accordance with the 'national list of essential medicines' that exists in most developing countries. The types and the quantities of medicine that a prison's stock should contain varies from one country to another, and may depend on: local patterns of morbidity (e.g. endemic disease); the general health status of the prison population (e.g. a malnourished population will have high morbidity rates); and the level of training of prison health staff (especially in prisons where only a health assistant is available, oral medicines should suffice for treating the most common illnesses; injectable drugs should be available only to staff trained in their use).
Difficulties related to budgets, supply, corruption, security or inappropriate use might lead to shortfalls in medicines within the prison. Prison authorities should be encouraged to address these issues. Bear in mind that few other goods are as valuable as medicines within a prison: they may become a 'parallel currency' , exchanged for goods or services.
During prison visits, health professionals should attempt to assess whether medicines are prescribed and used properly.

# SAMPLE QUESTIONS
Pharmacy stock and dispensing   Is it possible -by examining the pharmacy stock and the consultation or treatment registers -to draw any conclusions about the prescribing habits of staff? Do they seem to be acting as they should?
Make a brief list of the types of medicine stocked in the prison. A more detailed list may be obtained from the pharmacy stock register and can be included as an annex if necessary. 

# Supply of medicines

# Health budget
Information on budgets for medicines and for health activities in prisons is often difficult to obtain. Detaining authorities may be reluctant to release figures, and often the budget is mixed up with other 'spending lines' (for food, sanitary materials, salaries, etc.). Nonetheless, it may be necessary to obtain access to information on health budgets, particularly if there are serious health problems among the detainees that may be related to budgetary restrictions, and also if such budgetary problems are related to corruption within the detention system. Prison health staff are often an important source of information regarding deficiencies in health spending and corrupt use of the health budget.
The health budget must be explored with officials at the particular prison and with the detention service or ministry responsible. Action on prison health budgets would usually involve the entire detention system; so, information from all the prisons in question must be compiled to create a composite picture and to identify common problems and points for action. 

# SAMPLE QUESTIONS ON HEALTH BUDGET

# Health care for women in prison
Women in prison have specific health issues and specific health-care needs. However, prisons and prison regimes are usually designed by men and for men: the women among prison authorities are usually not in a position to make decisions; and women make up less than 10% of the prison population in most countries. Consequently, arrangements for health care, security, family contact, work and training opportunities within prisons are all likely to prioritize the needs of men, and neglect the needs of women. Women detainees are often left vulnerable and comparatively unattended. The UN Rules for the Treatment of Women Prisoners (the Bangkok Rules), 34 adopted in 2010, include provisions to ensure that the specific health-care needs of women in prison are met. 

# Pregnancy in prisons
Ideally, pregnant women should not be imprisoned unless there are truly compelling reasons for doing so. If there are pregnant women in a prison, it must be ensured that they have access to additional water for washing and a diet that meets their nutritional needs (including protein, fresh fruit and vegetables); and access also to all necessary health checks and antenatal 

# Promoting health in prisons
Health promotion refers to activities that enable people to have greater control over their health and its determinants. Health promotion should be carried out in prisons, and should include health education and measures for preventing disease. Its aim is twofold: to ensure that people in prison do not acquire diseases or health-defeating habits; and to ensure also that they adopt healthpromoting attitudes and practices that enable them to remain healthy whilst in prison, and after leaving.
The World Health Organization has stated that providing detainees with health information and education, as well as the means of preventing disease, is vital for protecting and promoting health in prisons. 35 However, detainees also need to be given the sense that they are in control over their health, so that they can make decisions and act on them. Clearly, this requires the prison authorities to demonstrate a commitment to health and well-being by implementing supportive policies and practices. Prison health staff also have a key role in assessing the health needs of the prison population and individual detainees, and in ensuring that health promotion programmes meet the needs of detainees.
Examples of health promotion in prisons include: education in aspects of health and hygiene, such as prevention of HIV and sexually-transmitted diseases; training in food hygiene and nutrition; and drug and alcohol counselling, including harm-reduction education. Smoking cessation and exercisepromotion activities can also be undertaken in prisons.

# Challenges to promoting and protecting health in prisons
Promotion and protection of health may be neglected in prisons. A prison health assessment can put this subject on the agenda of prison authorities. Nonetheless, there are many challenges to effective promotion and protection of health in prisons. Detainees may be in poor health, have bad healthrelated habits, and know very little about health when they arrive at a prison. Detainees may also find it difficult to involve themselves in health education and promotion. They may find it hard to change their habits whilst in prisonfor various reasons, including loss of independence and lowered self-esteem. Meanwhile, conditions in prison, such as overcrowding, widespread smoking and drug use, inherently compromise health. Prison staff and authorities might not acknowledge the need for action, and there may be a lack of commitment to protecting and promoting health.

# Benefits of promoting and protecting health in prisons
Initiatives to protect and promote health in prisons should generally be planned to be of immediate and long-term benefit to detainees. However, there are other benefits that can be emphasized while promoting initiatives among interested parties. Prison staff may benefit indirectly from health promotion efforts aimed at detainees, since healthier detainees will result in a healthier workplace for staff. Health promotion efforts in prisons should also aim to promote the health of staff directly, for their own well-being and because a healthy and motivated workforce will be more able to promote the health of detainees. Health promotion in prisons can also benefit the wider community by eliminating or drastically curbing the role of prisons as breeding grounds for infectious diseases that are then released into the world outside. Improved health in prisons also means that detainees will require less health care after their release. By these means, protection and promotion of health in prisons can reduce the health-care burden on society. 

# HEALTH STATUS OF DETAINEES

# Assessing health status and collecting measurable indicators
To assess the overall health status of detainees, information must be collected from a broad range of sources and through various means: discussions with the health staff and detainees; review of detainees' medical records; direct observation of clinics and health-care procedures; and analysis of certain measurable health indicators for this population.
The following end-point indicators should be collected systematically during prison visits: 
- Mortality -i.e. deaths within a population. The mortality rate can be calculated. Causes of death can be recorded. The number and proportion of deaths by cause can be noted and the most common causes identified.
- Morbidity -i.e. ill health or disease within a population. The prevalence of illnesses among detainees can be observed. The most common causes of morbidity can be recorded.
Other useful health indicators are: ratio of health staff to detainees; number of daily health consultations; number of referrals to hospitals or clinics outside; any deaths that occurred among detainees referred elsewhere; number of visits to the prison under specific health-care programmes (e.g. HIV, TB); and number of visits to external specialists. Also, disease-specific treatment indicators include: number of detainees enrolled in treatment programmes; number of detainees receiving the full course of appropriate treatment for selected indicator diseases; and stock of drugs available for treatment of selected indicator diseases.
Health professionals visiting prisons should ensure that a data gathering system exists to collect these indicators.
The systematic collection of basic health indicators should be an integral part of any prison visit. It establishes baseline data and allows for the subsequent recognition of changes and trends in the overall health status of the prison population and in the health-care delivery system. Trends may be observed at the level of individual prisons, or in a country's detention system as a whole. Findings from systematic monitoring may also serve as a basis for the planning of visits and assistance programmes. In prisons where medical assistance programmes (e.g. HIV prevention, provision of medicines, feeding programmes) have been introduced, the systematic collection of relevant indicators should be incorporated in the programme from the beginning. This will allow the effectiveness of the programme -its contribution to achieving pre-determined results -to be evaluated, and may enable changes to be made if objectives are not being met.

# Mortality
The number of deaths occurring in a prison population over a given period of time is an important indicator of the health of a prison population.
The crude mortality rate (CMR) is defined as the number of deaths in a population at risk during a specified time period. It can be readily calculated.

# Calculating the Crude Mortality Rate 36
Number of deaths in a period of time Crude mortality rate =
x Population unit Population at risk of death x Duration of time period Mortality rates are often expressed in units of 'deaths per 1,000 individuals per year' . In this case, the time period is one year and the population unit is 1,000. The 'population at risk of death' is usually an estimate of the mid-year population size. The calculation is then as follows:
Number of deaths in one year CMR (Deaths/1,000/Year) =
x 1000 Population at risk of death x One year For example, during one year, 18 people die in a population that has an estimated mid-year size of 241 persons. The crude mortality rate is calculated as follows:
18 CMR (Deaths/1,000/Year) =
x 1000 = 74.7 Deaths/1,000/Year 241 x 1 Deaths per 1,000 individuals per year is a useful measure for relatively stable populations. However, in acute emergency situations involving large numbers of deaths and rapidly changing mortality rates, it makes sense to use a shorter time interval and a larger unit of population in the calculations. In these situations the mortality rate is often calculated as 'deaths per 10,000 individuals per day' .
For example, over 120 days, 440 deaths occur in a population with an estimated mid-year size of 18,000. The crude mortality rate is calculated as follows: 440 CMR (Deaths/10,000/Year) =
x 10000 = 2.04 Deaths/10,000/Day 18000 x 120 Mortality rates can also be calculated for each month and this may be useful if analysing monthly reports. Monthly rates are usually reported as 'deaths per 1,000 individuals per month' .
For example, over two months, nine people die in a population with an estimated mid-time-point size of 1,300. The average monthly CMR is calculated as follows: 9 CMR (Deaths/1,000/Month) =
x 1000 = 3.46 Deaths/1,000/Month 1300 x 2 For reference, 1 death per 10,000 per day = 3 deaths per 1,000 per month = 36 deaths per 1,000 per year. It is important to note that the units in these calculations differ, but the maths remains essentially the same. Conversion from one format to another is an exercise in arithmetic.
When calculating mortality rates it is usually preferable to use formats and units that are consistent with those already in use, so as to allow easier comparisons of data. The mortality rate should be calculated during every prison visit. This will provide useful baseline data. Global mortality data for prison populations do not exist and national prison mortality rates may be unavailable or unreliable; making accurate baseline calculations is therefore often very important. An increase in mortality above the baseline rate may reveal deterioration in overall prison population health or the outbreak of disease. Comparison with baseline mortality rates will enable you to judge the severity of the problem. Mortality rates may show seasonal trends; it may be useful to calculate baseline mortality rates for each month or season.
While studying mortality in prison populations it is important to analyse not only the rate, but also the causes of mortality. Causes of death may suggest unsatisfactory detention conditions or shortcomings of the medical services, particularly where detainees have died of curable diseases. It may be useful to count the number of deaths and then calculate proportions by cause.
Causes of death may reflect local population patterns to some extent, and it may be useful to obtain community health and mortality data from local health officials. However, community mortality rates and causes may not be a reliable source of reference for prisons because of the generally higher prevalence of HIV, TB and other diseases among detainees.
An immediate and thorough analysis is indicated when: mortality increases above the prison baseline mortality rate; mortality is due to curable diseases; or mortality exceeds the regional reference value. Determinants of the high mortality must be identified and measures negotiated with the authorities. Close monitoring and follow-up visits should be planned. 

# Morbidity
As in any other population, people in prisons may experience a broad range of illnesses. However, infectious diseases and mental-health problems are especially common in prisons.
In many contexts, people in prisons come from social backgrounds in which certain infectious diseases, such as HIV, hepatitis, and TB, are more common.
The general conditions of detention may encourage the spread of infectious diseases through poor hygiene, poor water supply or sanitation, and poor food hygiene. Overcrowding, and the resulting strain on resources, may further promote the spread of disease. Drug use, sex and violence (including sexual violence) among detainees may also add to health risks.
People with mental-health problems may be at greater risk of imprisonment. They may be imprisoned because their mental-health problems contributed to their committing a criminal act. Or they may be imprisoned simply because they have a mental-health problem, particularly in contexts where 'unusual' behaviour is not tolerated or where no proper mental-health-care services are available. In societies where conditions are bad for people with mental-health problems, the situation in prison will be even worse. Imprisonment can also cause or contribute to the development of mental-health problems. Conditions of detention that can have an impact on mental health include: reduced contact with the world outside, including friends, family and social support networks; reduced opportunities for exercise and leisure activities; disruption of personal ties to work, education, or religion; internal hierarchies and violence; and the loss of freedom and independence. The consequences of imprisonment for mental health can manifest themselves in unexplained or psychosomatic symptoms, low spirits or anger, and an increase in psychiatric disorders and in the incidence of self-harm and suicide.
Although this is not restricted to detention, resorting to hunger strikes -for personal reasons or in protest against a regime -is more common in prisons. Clearly, this too will have an impact on health.

# Diseases commonly associated with detention conditions
Skin diseases -e.g. fungal skin infection, scabies, lice. May be due to lack of water, poor hygiene, overcrowding.
Eye illnesses -e.g. trachoma, conjunctivitis. Associated with lack of water and poor hygiene.
Respiratory tract illnesses -e.g. TB, upper respiratory tract infections. Associated with overcrowding, damp conditions, and poor nutrition.
Gastrointestinal diseases -e.g. diarrhoea, typhoid fever, cholera, intestinal parasitosis. Faecal-oral transmission through polluted water, improper human waste disposal or presence of vectors.
Hepatitis A -faecal-oral transmission.
HIV, hepatitis B and C -associated with intravenous drug use, consensual sex, and sexual violence.
Sexually transmitted infections -through sexual violence and consensual sex.

# Vector-borne diseases
Mental illnesses -associated with overcrowding, detention regime, ill-treatment, pre-existing condition.
Unexplained symptoms -psychosomatic complaints may be an expression of suffering.

# Measuring morbidity
Epidemiologists may use two different measures of morbidity: incidence and prevalence. Incidence tells us how many new cases of a disease emerged during a particular period of time. It tells us about the rate at which a disease is spreading or being diagnosed. Prevalence tells us how many people actually have the disease at a particular moment. Prevalence does not differentiate between old and new cases; it tells us about how common the disease is at a single point in time.
Calculations for rates of incidence and of prevalence, as percentages, are given below:
Incidence rate (%) = Number of new cases of a disease during a specified period of time / Size of the population at risk of the disease x 100
Prevalence rate (%) = Number of people with disease at a particular time / Size of the population at risk of disease x 100
These two measures provide very different information, but both may be useful. Prevalence may be more useful than incidence as an indicator of the impact of the condition within the community, and of the health services that will have to be provided. Incidence may be useful for assessing the risk of contracting the disease. A chronic disease like HIV/AIDS may have a low rate of incidence, but a relatively high rate of prevalence. A short-duration condition such as the common cold may have a high rate of incidence, but a relatively low rate of prevalence.

# Outbreaks of disease in prison
An outbreak or epidemic is said to be taking place when there are more cases of a particular disease than expected in a given area, or among a specific group of people, over a particular period of time. The cases are presumed to be related to each other or to have a common cause. 37 During a prison visit, if it is apparent that many detainees are suffering from a particular disease, the number of cases should be quantified. This can be done by studying the clinic consultation book and by discussing the matter with the prison health staff. If necessary, the exact prevalence rate of the disease can be determined by screening the prison population, or a representative sample of detainees, for the disease. 38 Remember, an outbreak is not defined by the number of cases meeting a specific numerical threshold; it is defined by an unusually high number of cases. This obviously depends upon what is thought to be an acceptable or usual number of cases. Having reliable baseline morbidity data is therefore essential. 

# Torture and other forms of ill-treatment
Where torture or ill-treatment of other kinds is known to be a problem within a prison, a doctor should always be on the prison visiting team. There are no exceptions to this rule. Allegations of torture can be collected by non-medical visitors, but the detainees in question must then be seen by the doctor.
It is the duty of doctors trained in this work to supplement the general documentation of cases of ill-treatment done by non-medical persons with clinical documentation of the medical consequences of ill-treatment and, where relevant, with forensic documentation of the alleged acts. Medical personnel are the only people authorized to conduct this type of assessment and to request access to patients' files. The support of a doctor is therefore required in all situations where severe-ill treatment is frequent or systematic.
As someone with special access to medical personnel in the place of detention, and to the authorities in charge of medical matters, the visiting doctor is also responsible for analysing the roles and responsibilities of medical personnel and the part they may have played in the ill-treatment, and for working, where necessary, to promote the independence of health workers and respect for medical ethics.
The role of the doctor when detainees allege torture or other forms of illtreatment is to assess health-care needs and, as appropriate, to address them in coordination with the authorities. The visiting doctor should ensure that people needing treatment are adequately cared for, and should support and encourage prison health staff to record the allegations and the physical and mental consequences of the alleged ill-treatment in the detainees' medical files. Where the prison health staff are unwilling or unable to do so, the visiting doctor should record the alleged ill-treatment, taking great care to explain to the detainee the use to which the recorded allegation may be put, and to obtain his/her informed consent to it.
Issues of ill-treatment should be given special attention, always bearing in mind the 'do no harm' principle. The visiting doctor may provide a degree of solace to victims of ill-treatment by listening sympathetically as they describe their experiences, and by informing them, not only of the possible repercussions of the ill-treatment they have suffered, but also of means of remedying them. Detainees may place their trust in the independence of the visiting doctor, and may appreciate the medical opinion and comfort provided by a professional from outside the prison.
The visiting doctor and the prison health staff must respect medical ethics while conducting assessments, providing care and documenting findings.
During conversations with victims of torture or other forms of ill-treatment, it should be kept in mind that most detainees in such circumstances will find it difficult to communicate or to give expression to their suffering; particular care should therefore be taken in approaching them. Remember also that people from different cultures deal differently with this issue. Some feel the need to 'open up' to others and to 'work through' reactions; others may wish to internalize their thoughts and feelings and not share them, out of guilt or shame. The doctor should gain the trust of the detainee and create an atmosphere conducive to the sharing of difficult or painful information; there must be no witnesses to the interview. The role of the visiting team with regard to ill-treatment should be explained to the detainees concerned, as should the limits within which the team has to work.
The steps in the medical documentation of torture or ill-treatment of detainees are fully explained in a number of publications. 39 Medical documentation should include information on: what was done, by whom, when and where; medical attention received; healing of any injuries suffered; clinical findings at the time of examination by the visiting physician and whether they match the allegation of ill-treatment.
It may be prudent when dealing with the authorities involved, and when writing reports that they might read, to refer to legal definitions of torture and other forms of ill-treatment. Be clear about the allegations to be sent on to the authorities, and, if explicit consent is not obtained, ensure that the source of allegations or evidence is not identifiable.
There are essentially three stages in the medical documentation of torture or other forms of ill-treatment:
1. A description of each form of ill-treatment. This should include: when it occurred; what the victim was wearing; whether he or she was sitting, standing, lying, or strapped to a table; and also whether she was blindfolded, tied up, handcuffed, etc.
Remember, ill-treatment includes psychological abuse (verbal threats, insults, oaths, shouting) as well as physical abuse, and that should be documented if it occurred.
Ill-treatment may also include the conditions under which the person was detained, if these have physical and psychological consequences and if they were imposed with the intention of breaking the person down. For example, it may be relevant to document conditions of detention, including hygiene, the state of the toilets, the size of the cell, and any withholding of food or medical care that would count as aggravating factors.
Any allegations of participation by health personnel must also be documented. This participation may be: direct (taking an active part), indirect (advising on methods or refinement of techniques), and by omission (falsifying medical examinations or reports).
Note that ill-treatment is most common in the immediate arrest-anddetention phase; it can also occur in prisons, but that is more likely to be related to disciplinary rules and punishments (official and unofficial).
2. A description of consequences, physical and mental, immediately after the events in question. This should include an account of open wounds, bruises, and loss of limb function, as well as any adverse consequences for the detainee's mental or emotional state during or soon after the ill-treatment. Detainees should also be asked about medical treatment and recovery (sequela) after the abuse. This is a key part of the documentation because corroboration of ill-treatment can be obtained even in the absence of any lasting consequences. In other words, even though the person may not show physical evidence of ill-treatment by the time of documentation, his or her description of events can provide significant clues and support for his or her allegations.
3. The last part of the process involves: determining whether there are any chronic physical or psychological consequences of torture or ill-treatment; enquiring about any recent treatment received; and conducting a physical and mental examination.
Ill-treatment before arrival at the prison Always use the standard three-stage process for medical documentation of torture/ill-treatment.

# Individual medical cases
The visiting prison doctor should conduct medical interviews and examinations among a sample of detainees. The purpose is to gain information on the general state of health of the population and on the quality of the medical care provided by the detaining authorities. The sample of detainees should include healthy people from different areas of the prison, as well as sick people identified by other detainees and the authorities, or by direct observation.
It is important to make clear to detainees and prison staff that visiting health professionals conducting prison assessments will not provide medical care to the prison population. If the visiting health professional encounters seriously ill detainees who have not received proper medical attention, he or she should alert the authorities to this fact, either at the end of the visit or immediately if the need is urgent. Such cases should be used as examples to illustrate the shortcomings of the health-care system, so that improvements can be made for the prison population as a whole. The objective is not to produce a list of all detainees who need some form of medical attention: detaining authorities are more likely to follow up lists containing only serious medical cases, rather than lists of people with minor ailments.

# Requests for release on medical grounds
Requests for the release of seriously ill detainees may sometimes be considered. These requests must not be made routinely and should be reserved for serious cases; otherwise such interventions will begin to lack credibility. Release in these circumstances may be described as 'compassionate' , 'humanitarian' , or simply 'medical' . Not every country has a legal basis and procedures for releasing people from prison on medical grounds. Release on medical grounds may be requested for a number of reasons, such as: the detainee is suffering from a serious, chronic and debilitating disease or handicap for which suitable care and attention cannot be provided in prison (e.g. permanent paralysis, severe mental-health problems, or dementia), and/or that continued detention would lead to the deterioration of such a condition, which might be preventable in other circumstances; the detainee is in the latter stages of a terminal illness and release would permit him or her to die with dignity at home or in some other appropriate setting. Other factors that may be considered include the detainee's age and vulnerability, the risk of recidivism, the danger to the public posed by him or her, and the overall conditions of detention.
From detainees spoken to in private   Assemble a picture of the health of the prison population. Identify ill-treatment or torture. Identify any problems in the prison's health-care system.
  Are there cases that illustrate particular failings in the health system? Are there cases of seriously ill detainees that warrant discussion with the authorities, with a view to securing urgently needed access to health care, or release on humanitarian or medical grounds?
  Cases brought to the attention of prison authorities must be followed up during subsequent visits.
Remember that medical confidentiality has to be respected at all times by visiting health professionals. Access to the diagnoses and medical histories of sick inmates must be secure and restricted; individual patients must remain anonymous when data related to them are presented in internal reports. Sick detainees may be recommended to the authorities for medical follow-up, or for release on medical or humanitarian grounds, only after they have given their consent.

# ADDITIONAL RESOURCES
The following is a list of some further resources relevant to health in prisons. The list of is far from exhaustive. A comprehensive guide to health and health-care issues in detention. Includes chapters on: primary health care, communicable diseases, non-communicable diseases, dental health, ethical challenges in detention health care, and drug use. Although its focus is on health care and the provision of quality services, the WHO guide encourages a whole-prison approach, promoting the health and wellbeing of people in detention. See also WHO Europe's Health In Prisons Project.

# Health in

# Good governance for prison health in the 21st century A policy brief on the organization of prison health
ICRC documents Describes the principles and purpose of the ICRC's work in detention; the characteristics and constraints of the ICRC's approach; and the legal and historical background explaining why the ICRC works in the way that it does.
The role of the physician in ICRC visits to prisoners. Hernan Reyes. ICRC, Geneva, 1994.
Available at:  A brief (3,000 words) overview of the ICRC detention doctor's role.
Policy on torture and cruel, inhuman or degrading treatment inflicted on persons deprived of their liberty, adopted by the Assembly Council of the ICRC on 9 June 2011. International Review of the Red Cross, Vol. 93, No. 882, 2011, pp. 547-562. Available at:  A reaffirmation of the ICRC's commitment to tackling torture and an explanation of its policy and practices.
Guidelines for Investigating Death in Custody, October 2013. 

# United Nations documents
The UN has produced many documents of pertinence to the ICRC's work in prisons. Many of these can be accessed via the Refworld website (www.refworld. org) of UNHCR (the UN refugee agency).
Standard Minimum Rules for the Treatment of Prisoners (SMR) were originally adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders held at Geneva in 1955. Their revision was mandated by GA Resolution 65/230 of 21 December 2010 which called on the UN Commission on Crime Prevention and Criminal Justice to establish an Expert Group to exchange information on best practices, national legislation and existing international law, and to revise the existing SMR to reflect advances in correctional science and best practices. The ICRC (JUR, DET, ASSIST) was actively involved in the Expert Group's meetings called by UNODC on behalf of States. The revised SMR (the "Nelson Mandela Rules"), adopted unanimously by the UN General Assembly in 2015, are a key source of inspiration and guidance concerning the sorts of solutions that should be applied in places of detention, and the types of provisions that need to be incorporated into national laws, regulations and practices in order to guide prison administrations and other State bodies responsible for managing places of detention, and to ensure that international law and universally acknowledged standards concerning the protection of prisoners continue to provide up-to-date guidance on how to maintain respect for detainees' inherent dignity and value as human beings. For an explanation of the SMR and their implications for policy and practice, see also: Women's needs in prison are often overlooked; this document provides evidence of that and calls for change. It highlights the high levels of mental illness, drug and alcohol dependence, and sexual and physical abuse and violence among women in prisons, as well as the gender-specific health-care needs and family responsibilities of women. Provides evidence of the health effects of solitary confinement and the harm done by it; describes the role of health professionals; and sets out ethical guidelines and human rights case law. Covers the same subject matter as the Istanbul Protocol, but more accessible and user-friendly.

# Other registers
Other medical registers may exist: to record night emergencies, transfers in and out of hospital, deaths in custody, etc. Enquiries should be made and the contents of these registers reviewed.

# Health statistics
Health data (number of consultations a month, number of contagious diseases, number of deaths, etc.) may be recorded regularly and reported to external authorities (prison medical services, district medical officer, department for health statistics, etc.). Some prison regulations or jail manuals may specify the types of register that a prison is obliged to keep. The national health authorities may also require the recording of certain kinds of data (e.g. mandatory reporting of contagious diseases such as TB and leprosy). For instance, in the Middle East or North Africa, any prison mortality rate above 0.3/10,000/day (corresponding to 3 deaths a month in a prison with 1000 detainees) indicates a serious health crisis.

# SAMPLE QUESTIONS ON MEDICAL REGISTERS