Transcript Slide 1

HEALTH CARE IN PRISONS: AN
INTERNATIONAL CHALLENGE
IN PRVEVENTIVE MEDICINE
AND PUBLIC HEALTH
Anthony J. Silvagni, D.O., Pharm.D., M.Sc., FACOFP dist.
Professor of Family Medicine and Public Health
Nova Southeastern University College of Osteopathic Medicine
The WHY of Correctional Health Care
• Why treat inmates?
– Civilization is measured by how it cares for society’s
outcasts. (deToqueville)
– It is the ethical and humane thing to do
– In many countries it is the law (e.g. USA)
– Diseases will spread within the prison population
and when released, within the general population
– The cost of providing appropriate health care to
prisoners is most likely less than not providing the
care due to the greater spread of diseases.
World Population of Inmates
• Over 9 million inmates world-wide in prisons
and jails
• US, China and Russia lead the world in
incarceration rates. (Probably other countries
are high but data gathering is inconsistent)*
• In many countries- remand to PRISON while
awaiting trial- therefore people who are NOT
CONVICTED of anything are in prisons (not
jails)
•
Walmsley, R., Kings College London- International Prison Studies from
http://www.scribd.com/doc/328143/World-Prison-Population-List-2007
Incarceration: a global response to crime and disorder
USA Incarcerated Populations,
Midyear 2002
• >2,020,000 persons in prisons or jails
– 1,360,000 in Federal and State prisons
– 665,000 in local jails
Source: Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2002
Source: Bureau of Justice Statistics Publication #, NCJ 198877 April 2003
(4/2003) NCJ 198877
USA Incarcerated Populations,
Midyear 2007
• >2,299,116 persons in prisons or jails –
Approximately a 14% increase from 2002
– 1,528,014 in Federal and State prisons
– 766,010 in local jails
Source: Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2007
Source: Bureau of Justice Statistics Publication #, NCJ 198877 April 2003
(http://www.ojp.usdoj.gov/bjs/prisons.htm)
Note Slower Pace- (Slope more level)
Source: Bureau of Justice Statistics. Correctional Populations in the United States, 1997 and
Prisoners in 2004.
Typical Florida Prison (Jefferson Correctional
Institution)
United Nations - Seven
Standards For Medical Care
1. A medical officer with some knowledge
of psychiatry is to be available to every
institution.
2. Prisoners requiring specialized
treatment are to be transferred to a
civil hospital or appropriate facility.
3. A qualified dental officer shall be
available to every prisoner.
UN - Continued
4. Prenatal, postnatal and related care are
to be provided by women's prisons;
when nursing infants are allowed to
remain with their mothers, a nursery
staffed by qualified staff is needed.
5. Every prisoner shall be examined by the
medical officer shortly after admission;
prisoners suspected of contagious
diseases are to be segregated.
UN - Continued
6. The medical officer shall see all sick
prisoners daily, along with those who
complain of illness or are referred to his
or her attention.
7. The medical officer is to report to the
director
a. those prisoners whose health is
jeopardized by continued imprisonment
b. the quality of the food, hygiene, bedding,
and clothing
c. physical regimen of the prisoners.
An UN Rule Regarding Food
• UN requires wholesome food being
prepared daily for prisoners
• Not uncommon to see malnutrition in
prisons, similar to, but worse than the
malnutrition of the country’s indigenous
population
United Nations
Standard Minimum Rules for the Treatment
of Prisoners
Prison Cell in Austria
• “Where sleeping
accommodation is in
individual cells or rooms,
each prisoner shall occupy
by night a cell or room by
himself. If for special
reasons, such as temporary
overcrowding, it becomes
necessary for the central
prison administration to
make an exception to this
rule, it is not desirable to
have two prisoners in a cell
or room…”
Prison Cell in East Africa
Photo by New York Times
CARIBBEAN PRISONS
• Jamaica – Patient (prisoner) held in Tower
Prison infirmary without care. Doctors sent
to hospital but patient died in hospital prior
to being seen
• Haiti - Malnutrition commonplace (beriberi)
• HIV is frequent throughout the Caribbean
prisons
NSUCOM International
Medical Outreach in
Jamaica Prisons
NSUCOM Student Teaching in
Jamaica Prisons
Inside Towers
Removal of Bullet- Towers
Telemedicine
Linking Prisoners to Specialty Care
Telemedicine program at the Tower
Street Prison, Kingston, Jamaica
Tremendous Opportunities for
Education in Prison Health Care
1. Great Teaching Environment
1. Only environment where students can see
long term effects of disease
2. With or Without treatment - PATIENTS
HAVE TO COME BACK
2. Inexpensive to set up and run services
3. Tremendous wealth of pathology – some
advantages over a university-based
residency program
4. A truly needed area for care
5. Exponential effect on country’s public health
Why Bother Teaching
Students in US Prisons
•
One of the few environments that is NOT
dominated by reimbursement and
insurance policies
– 1. Write Orders
– 2. Progress Notes
– 3. History & Physical Opportunities
– 4. Triage
– 5. Really sick people
Universal Finding Among Incarcerated
Populations: High Burden of Disease
• Inmates typically have few economic resources and
little access to health care prior to incarceration
• They have disproportionately high rates of substance
dependence, mental health disorders, high-risk sexual
activity, prior violence-related injuries, head trauma,
and complications of chronic illnesses
• High rates of infectious
disease including HIV,
TB, STD’s, hepatitis, etc.
Prisoners in Thailand
Infectious Diseases in Prison
• BRING THEM IN WITH THEM
• Despite the movies- the HIV in prison is
NOT prisoner-prisoner transmission- less
than 0.032% in FL-DOC and 0.033% in
FBOP for P-P transmission
• Hepatitis C- 20-65% of inmates infected
primarily due to IVDU on the outside
• FDOC had not had a TB death (12 total
cases in 2002 all from the outside)
Translating Infectious Disease
Treatment into Correctional Practice
• Correctional physicians care for a population with a
burden of infectious diseases disproportionate to
their numbers in the community.
• For example, the prevalence of hepatitis C among
releases' is approximately ten times that among the
general population, and one-third of all hepatic C
disease is born by those leaving prison and jails.
However, the prevalence of infectious diseases does
change time over time. Best practices for the
management of specific infectious diseases also
change, so an update on the medical management
of communicable diseases is essential!
Prison HIV Prevention
Harm Reduction Strategies
• Prison Condom Availability
– Examples: Australia, Brazil,
Canada, most European
Countries, South Africa, and
more
• Prison Needle Exchange
– Examples: Switzerland,
Germany, Spain, Moldova,
Kyrgyzstan, Belarus, and Iran
Tuberculosis Behind Prison Walls
• “Prison walls curtain the
freedom of prisoners, but not
the freedom from spread of
tuberculosis. Prisons form a
reservoir of tuberculosis which
threatens not only prisoners,
but also prison staff, visitors,
and the wider community.”
WHO and ICRC
Guidelines for the Control of Prisons, 1998
Tuberculosis in Russian Prisons
• Over one million prisoners
• In the 1990’s, approximately
one in ten with active TB
• At least 20% sick with
MDR-TB
The Global Impact of Drug-Resistant Tuberculosis. Harvard
Medical School. 1999
OTHER DISEASES AND
CASES
• Acute & Chronic cases and FREQUENTLY
SEVERE
• Hypertension; Seizure Disorders; Cardiac
Disease; Asthma; Cancer; Diabetes;
Hepatic Disease; Psychiatric; Behavioral;
Trauma (including self-inflicted); Etc.
• It is the only setting where you can see the
natural course of untreated disease- WHY?
Rights of inmates and close monitoring
Intentional Trauma
• The following slides are from one inmate
who has a compulsive swallowing disorder
and exacerbated by sticking things into his
wounds
• HE HAS NO AXIS 1 PSYCHIATRIC
DIAGNOSIS
• He does have an anti-social personality
disorder
Special Care Unit for HIV Positive
Inmates in Florida Prison
Crop Garden at Same Prison
Correctional Medicine
Fellowship
PROGRAM DIRECTOR:
David Thomas, MD, JD
2 Year Fellowship Program
• 15 months in various correctional facilities
as a fellow (post-residency)
– Prison Hospital
– Reception Facility
– Women’s Facility
– Jail
– Private Facilities and Public facilities
• About 9 months in administrative and
legal experience and field experience for
the MPH Degree
• Only 1 year if fellow has an MPH Degree
Requirements to Finish
• Successful completion of two year program
including completion of MPH Degree
• Competence in:
– QM/QA- Quality driven programs
– Mortality Review
– Systems Design
– Hands on Patient care
• HIV; Hepatitis; Seizure Disorder; Acute
Detoxification; Chronic Illness clinics;
etc
Admission Requirement
• Board Eligible or Board Certified in a medical
or surgical specialty
• Acceptable to Federal, State, and Private
partners
• Dedication to underserved and/or corrections
• Desire to get or have the MPH Degree
• Desire to become Competent in Correctional
Health care and Correctional Systems and be
a Board Certified Correctional Medicine
Physician
Goals of Fellowship
• Create a cadre of physicians competent in
all aspects of correctional care
– Public sector - State and Federal
– Private Sector - Contract or owned
– Jails
– Prisons
– Systems Approaches
• Raise the Quality and Efficiency of
Correctional Healthcare
At Conclusion of Program
• Graduating Fellows should:
– Be readily employable at the senior
levels of large systems (Regional
Medical Director or Executive Director of
a large and complex facility)
– Be readily employable as the Medical
Director of a smaller system with
system-wide responsibilities
• All of our partners have agreed to give
preferential hiring to graduated Fellows.
Sample Resources on
Correctional Health
www.icpa.ca
• International organization dedicated to
advancing professional corrections with a
mission to contribute to public safety and
healthier communities.
• Newly formed Health Care Committee
• 2007 Conference attended by 300
delegates from more than 50 countries