Withholding liberty, not the right to health
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2022)

The end of 2021 marked the passing of Archbishop Emeritus of Cape Town and Nobel Peace laureate, Desmond Mpilo Tutu—an anti-apartheid activist and moral leader who needs no introduction. In a Comment published in The Lancet in 2016, as part of a Series on HIV and related infections in prisoners, Tutu wrote about the right to dignity and compassion for everyone in need of medical care, including those behind bars, and appealed “Don’t forget the prisoner”. According to a report by the UN Office on Drugs and Crime, 11·7 million people were held in prisons globally at the end of 2019, an increase of over 25% since 2000, and 29–31% of these were pre-trial detainees without sentence. Prisons were operating at over 100% of intended capacity in 47% of the countries and territories with available data between 2014 and 2019. Prison population rates vary across continents and countries: the USA has the highest prison population at 629 per 100 000, followed by Rwanda with 580 per 100 000, while 53% of countries and territories included in the latest World Prison Population List have rates below 150 per 100 000. Despite these numbers, the health of prisoners receives little attention in research and policy. The United Nations Standard Minimum Rules for the Treatment of Prisoners (or the Nelson Mandela rules), state that “Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health-care services free of charge without discrimination on the grounds of their legal status.” The rules also state that prison health services should be managed in close relation to wider public health services to ensure continuity of care, including for infectious diseases and drug dependence. Notably, however, there was no specific reference to prisoners in the SDGs, despite the overarching promise to “leave no-one behind”. Prisoners typically come from marginalised sectors of society, experiencing poverty, poor access to health care, and unemployment before imprisonment. Overcrowding, injection drug use, unsafe sexual behaviours, and dynamic and changing prison populations can increase the risks of infectious diseases and exacerbate mental illnesses in this already vulnerable population. In a study that was part of the 2016 Lancet series, Dolan and colleagues found that the prevalence of HIV, viral hepatitis, and tuberculosis was substantially higher in prison populations than in surrounding communities. A systematic review and meta-analysis of prisoners in low-income and middle-income countries (LMICs) published in The Lancet Global Health in 2019 found that the prevalence of non-affective psychosis was on average 16 times higher among prisoners than the general population, while the prevalence of major depression and illicit drug use were both six times higher, and the prevalence of alcohol use disorders was twice as high as that of the general population. Studies on the health of prisoners in LMICs are scarce overall and the literature is dominated by research from high-income countries. In a linked Comment in The Lancet Global Health, Oye Gureje and Jibril Abdulmalik discuss the difficulties of conducting research in prisons, pointing to the significant ethical and security clearance needed, with bureaucracy and red tape complicating efforts, particularly in LMICs. In a further Comment published in The Lancet Global Health in 2020, Rosemary Mhlanga-Gunda and colleagues say that, in addition to bureaucracy, high rates of pre-trial detention, the “revolving door of re-incarceration”, and low testing uptake also contribute to poor routine data collection and disease surveillance in sub-Saharan African prisons. The authors cite lack of political will to invest resources in prisons and societal views on incarceration as punitive rather than rehabilitative as possible reasons for the lack of research on prisoner health in the region. This is further compounded by ethical concerns on research conduct, with “prison management influencing research data, structural obstacles to voluntariness, coercion of imprisoned people and prison staff, and embargoing of academic publications by management and government at a country level.” The challenges are clear to see. A greater focus and investment in research on the health of prisoners in LMICs will help guide the development of evidence-based solutions for this vulnerable and often forgotten population with complex health needs. A supportive architecture for prison health research and disease surveillance will not only benefit detainees and staff within prison walls but also public health of populations at large. As “the Arch” said, let's not forget the health and human rights of prisoners.