Health Issues in Prisons and Jails

Lerner BH. Subjects or objects? Prisoners and human experimentation. N Engl J Med. 356(18):1806–1807. Gostin LO. Biomedical research involving prisoners, ethical values, and legal regulation. JAMA. 297(7):737–740. Both of these articles describe the history and the current state of thinking regarding research using prisoners. The Lerner article gives a description of the shameful history of research that was ultimately believed to be fundamentally exploitative and unethical. These revelations led to a series of government restrictions, including the Nuremberg Code, the Belmont Report and the Common Rule. These have been followed most recently by a reexamination by the Institute of Medicine, which published a report in August 2006. Dr. Lerner supports the recommendations of this report, which include lessening the restrictions on research involving prisoners, but increasing ongoing oversight. He states “It is even possible that research studies, by providing a window into prison life, would focus needed attention on deficiencies in prison health care.” The Gostin article covers much of the same history with some additional detail, including the fact that prior to the 1970s, “..90% of all pharmaceutical research was conducted on prisoners...” He also points out that the correctional environment has changed dramatically with a fivefold increase in the correctional population between 1978 and 2005, and points out that “The U.S. currently has the world’s largest incarcerated population and highest incarceration rate, accounting for one quarter of the world’s prison population.” Mr. Gostin also concludes by supporting the implementation of the Institute of Medicine recommendations stating that “near-absolute prohibitions on research based on the sordid history of exploitation would leave prisoners without the benefits of modern science that could improve the quality of their lives and conditions unique to prisons.” COMMENTARY The dramatic examples of unethical research involving prisoners, including Nazi doctor experiments and the Tuskegee study of untreated syphilis in black men has led to a climate in which research on prisoners is viewed in a very negative light. However, as noted in these two articles and in the Institute of Medicine Report, there are many benefits that can occur through biomedical research, if done properly. The type of oversight described in these two articles, as well as in the Institute of Medicine Report, are likely to yield the benefits to incarcerated populations and minimize the risks of abuse. Given the dramatic increase in incarceration in this country (and the larger number of people affected by the epidemic of incarceration) and the tendency of society not to scrutinize what happens behind bars, perhaps among the most important benefits would be the increased transparency of medical care behind bars. This, by itself, would likely lead to improvement in medical care of prisoners. In addition, it may lead some individuals to question why are we incarcerating so many people. Some may conclude that we can find better ways to address untreated addiction and mental illness than mass incarceration. Sherrard J, Boss I, Law L. Experience of setting up a genitourinary medicine in-reach clinic in a male prison. Int J STD AIDS. 18(4):228–230 This article is a description of a new genital urinary medicine (GUM) clinic, set up in 2005 at the Bullingdon Prison in Oxfordshire, England. This clinic was set up in response to a 2004 change in health care provided to prisoners in England and Wales from the prison health care system into the National Health Service (NHS) in order “to provide prisoners with access to the same quality and range of health-care services as the general public...” The article describes many of the practical obstacles, including limited time, clinic space, and one interesting situation related to the name of the clinic. It turns out that many inmates showed up to the “GUM” clinic seeking oral health care. In spite of this, the numbers of inmates seen annually increased from 219 to 366. The number of people who underwent STD and HIV testing and hepatitis C testing increased, and the response has been to increase the funding and the scope of the program, including outreach to inmates with education about STDs. COMMENTARY Prior to the change to have National Health Service specialists provide STD care of prisoners, care was provided by in-house providers. With sexually transmitted diseases (STDs) and blood-borne pathogens, the diagnosis, treatment, and prevention of STDs and blood-borne pathogens are particularly important among incarcerated populations given the dramatically increased relative prevalence. If done properly, in addition to the impact on individual inmates, proper treatment and prevention can also have an impact on the entire correctional population, as well as the community at large, as nearly all prisoners eventually return to their communities. Another advantage in addition to the potential for improved specialty care is the possibility of continuity of care after release. This is especially true for chronic diseases. Even though there is no National Health Service in the U.S., there is both a network of community health centers, as well as a large number of academic medical centers that provide care. A model of having specialists from the outside of corrections enter to provide care, particularly for those who are preparing to leave the correctional setting, and also provide care in the community upon reentry, is a model that should be explored in the U.S.