Prisoners do not care about their health
Prisoners with HIV/AIDS Support Action Network (PASAN) works with prisoners, ex-prisoners, prison staff and community organizations.
About the author: Prisoners with HIV/AIDS Support Action Network (PASAN)
PASAN is a community-based organization in Ontario that provides support, education and advocacy services related to HIV/HCV and harm reduction with the prisoner and ex-prisoner populations and within the prison environments. PASAN is the only organization in Canada that exclusively works with prisoners and ex-prisoners around HIV/HCV and harm reduction. We strive to ensure that prisoners living with HIV are receiving the healthcare and support that they deserve and are entitled to; as well, to facilitate continuity of care when people are returning back into the outside community. Through education sessions inside prison, we provide opportunities for prisoners to learn about and discuss information related to HIV/HCV and harm reduction in order to equip people with updated and accurate information about high risk activities, sexual health, HIV/HCV/STI transmission, testing and treatments. We aim to engage Correctional Service Canada, Provincial correctional services in Canada, health services, and other important ministries and stakeholders to exchange information and to address correctional policies and practices that have a negative impact on people’s health by upholding stigma and discrimination for prisoners generally and especially those living with HIV. We carry out capacity building training and workshops in the community for agencies that work with people who are in and out of prison.
Stereotypes about people who are or were incarcerated
Some of the myths and assumptions that get in the way of accessing care
Prisoners are bad people and have hurt others, thus don’t deserve to have their healthcare needs met.
Deprivation of healthcare is part of the punishment, which acts as a deterrent for recidivism.
Prisoners are not to be trusted, have hidden motives, are manipulative.
Getting the particulars and facts of someone’s life, circumstances and health issues before trying to assess a prisoner is crucial to avoid treating that person according to stereotypes and assumptions we have about people who are or have been incarcerated.
Prisoners are often forgotten, undervalued, unconsidered, despised and deemed undeserving of quality and responsive health care. It is often assumed that prisoners don’t care about their health or are out to ‘trick us’, especially if they are people who use drugs. It is also often assumed that the deprivation of health care services is a part of the punishment of incarceration when in fact prisoners are entitled to receive equivalent or comparable health care as to what people receive in the outside community. If a prisoner has a health condition that requires treatment, they are entitled to maintain their health while inside as opposed to be subject to further suffering because they are sick, disabled or because of their HIV/HCV status.
Indeed, incarcerated people have a right to health, as recognized in sections 85-86 of the Corrections and Conditional Release Act, which requires Corrections Services Canada to provide essential health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community.
Who is in jail and how does it lead to health disparities in our communities at large?
Longstanding forms of systemic racism, and other types of discrimination, have resulted in the targeted profiling, policing and criminalization of marginalized populations in Canada. Racialized and Indigenous communities in Canada continue to experience the impact of racism and discrimination and it translates in high rates of incarceration. There is an over-representation of Indigenous peoples in federal prisons: [While] Aboriginal people in Canada comprise just four per cent of the population, in federal prisons nearly one in four is Métis, Inuit, or First Nations. Indigenous women make up 36% of all young women incarcerated.
In 2011, the Correctional Investigator of Canada reported an 80% increase in Black prisoners in federal jails over the last decade, making Black people the fastest growing prison population in Canada – despite Canada’s Black population representing just 2.5% of the total population.
Given the disproportionately high rates of incarceration among racialized and Indigenous populations, they are more likely to be given the mandatory minimum sentences, which, while it is being challenged in the courts, judges are required to impose on a range of offences.
Longer sentences increase the likelihood of poor health outcomes of those who are incarcerated, especially related to sexual and reproductive health. High rates of incarceration also deeply impact communities as a whole; research shows that the impact of incarceration extends beyond those individuals who are themselves incarcerated. In particular, incarcerating mothers is commonly associated with negative implications for her family and especially her children, including depression, anger, poor school performance, and environmental disruptions.
Also important to highlight is the impact of our punitive approach to drug use. When we consider what we have done in Canada to address problematic drug use, A review conducted in 2009 showed that law enforcement received the overwhelming majority of funding for the drug strategy (70%) while prevention (4%), treatment (17%) and harm reduction (2%) combined only received a quarter of the overall funding. Our punitive approach to drugs has been reinforced by new “tough on crime” laws, including legislation introducing mandatory minimum sentences for certain drug-related offenses despite health and human rights concerns. In the last decade, the federal government has actively worked to prevent the implementation of new harm reduction programs across the country.
It comes to no surprise that Canada’s “tough on crime” agenda has led to significant increases in incarceration in federal prisons with disproportionate impact on the most marginalized and vulnerable groups including people who use drugs. Upon admission, eighty percent of people incarcerated in federal prisons have a history of problematic substance use. Given the absence of harm reduction programs in prison, the incarceration of people who use drugs, or may have a greater vulnerability to initiating drug use have also deepened the threats to individuals and the public health crisis in Canadian prisons.
There are significant issues concerning sexual and reproductive health and rights in prisons. HIV and Hepatitis C rates are on the rise and the sexual and reproductive rights of incarcerated Indigenous persons, in particular, are often violated, including through the shackling of pregnant women also while in labor, coerced sterilization and sexual violence from prison staff and guards and the absence of effective facilities for incarcerated mothers.
Current patterns of incarceration put those who are more likely to become incarcerated, specifically Indigenous persons and racialized communities, more susceptible to contracting STIs and HIV. The rise in STI rates can be attributed to the lack of effective harm reduction policies, limited access to comprehensive sexual and reproductive health services, and information in and out of prisons. The Correctional Investigator of Canada has reported delays in inmates’ access to health services, cuts to essential health-related programs, unsupported harm reduction strategies, and the exacerbation of inmates’ existing health conditions. This is despite the fact that incarcerated people have a right to health and to all essential health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community.
 Native Youth Sexual Health Network, http://www.nativeyouthsexualhealth.com/january15172014.pdf
 Native Youth Sexual Health Network, http://www.nativeyouthsexualhealth.com/emrip2013item5.pdf
 Rabble. 2014. “Do Black Lives Matter in Canada?” http://rabble.ca/columnists/2014/12/do-black-lives-matter-canada and CBC. 2011. “Prison watchdog probes spike in number of black inmates.” http://www.cbc.ca/news/politics/prison-watchdog-probes-spike-in-number-of-black-inmates-1.1039210
 BC Civil Liberties Association. “More than we can afford: the cost of minimum sentencing.” https://bccla.org/wp-content/uploads/2014/09/Mandatory-Minimum-Sentencing.pdf
 Gadsden, V.L. [Ed.]. 2003. “Heading home: Offender reintegration into the family.” Lanham, MD: American Correctional Association.
 Enos, S. 2001. “Mother from the inside: Parenting in a women’s prison.” Albany, NY: State University of New York Press.
 Acoca, L. & Raeder, M. S. 1999. “Severing family ties: The plight of nonviolent female offenders and their children.” Stanford Law & Police Review, 11(1), 133-151.
 Native Youth Sexual Health Network. 2013. Presentation during 6th session of the Expert Mechanism on the Rights of Indigenous Peoples July 8-12, 2013; http://www.nativeyouthsexualhealth.com/emrip2013item5.pdf
 Brennan, S. 2014. “Canada’s Mother-Child Program: Examining its emergence, usage and current state.” Canadian Graduate Journal of Sociology and Criminology.
 Public Health Agency of Canada. 2013. “The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2013. Infectious Diseases – The never ending threat.” http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/sti-its-eng.php.
 Correctional Investigator of Canada. 2014. “Annual Report 2013-2014 of the Office of the Correctional Investigator.” http://www.oci-bec.gc.ca/cnt/rpt/pdf/annrpt/annrpt20132014-eng.pdf
 Corrections and Conditional Release Act (S.C. 1992, c. 20). http://laws-lois.justice.gc.ca/eng/acts/C-44.6/page-24.html#docCont
What impacts the health of prisoners and ex-prisoners?
Some of the factors that impact the health of prisoners and ex-prisoners include: poverty, identity-based oppression (sexism, racism, homophobia, transphobia, etc.), negative attitudes and stereotypes about prisoners, misconceptions about who prisoners are, cycles of re-incarceration, loss of support networks and care providers, disconnection from community and the way their health was, or wasn’t, taken care of while incarcerated.
Some of the barriers to quality and comprehensive care in prison include: lack of access to a second opinion, criminalization of high risk activity, lack of harm reduction tools and programs both in correctional facilities and in the community (and bridges to the services that do exist in the community when someone is discharged), lack of, or restricted access to preventative care and dental care, lack of explanation of conditions and treatments, lack of confidentiality, vulnerability of requesting care from people who may also harm you, prisoner and drug-related stigma and discrimination, communication skills, literacy levels, lack of culturally-appropriate services, comprehension/cognitive capacity issues, language barriers, lack of available information and resources, lack of knowledge, lack of availability due to restricted treatments, lack of understanding of systems, stigma around sexual activity, fear of reprisals, lack of outside supports to advocate for prisoners.
The relationship between prisoners and health care providers, both inside correctional facilities and when discharged back into the community, is generally not positive. There is often mistrust due to poor treatment and/or previous negative experiences, including being labelled as drug-seeking, manipulative and/or criminals. When out of prison, some people have significant challenges around getting to and keeping appointments due to poverty, cognitive challenges and geographical location (i.e. rural, remote, underserved areas).
The criminalization of drug use, especially for people living in poverty has also meant that rates of substance use in people who are incarcerated are high, which can initiate or exacerbate physical health problems, while decreasing the likelihood of actually receiving care.
The prison environment also socializes people to tell authority figures what they think they want to hear in order to get their needs met which also gets in the way of trust building between patients and providers and in the health care provider having access to important information that can lead to a diagnosis or the proper treatment plan.
Offering the best care for people who are or were incarcerated
The lack of availability/accessibility of health care for prisoners and ex-prisoners results in compromised health care, a reluctance to address side effects and complications resulting in inconsistent treatment adherence.
Trauma, both in early life and throughout life, and how that impacts self-esteem, behaviour, decision-making and judgement.
Inform yourself on what a trauma-informed approach is and how you can implement it in your practice!
Behavior can be impacted by the complex ways prison subculture, range survival and institutionalization.
Reach out to organizations who work with this population, seek out resources, papers and information on prison and health to be better prepared to offer care, ask the right questions, notice important details, etc.
Both the stigma and the general feeling of powerlessness people may experience when incarcerated and post-release from prison can color people’s experience of health care settings and impact trust building with people who are part of their care team.
Know that you may have to pace yourself in getting information and avoid rushing disclosure of sensitive information. Accept the challenge to construct a therapeutic connection over time.
Navigating non-heterosexual sexualities/identities and gender diversity in prison and post-release from prison (especially when stuck in cycles of re-incarceration), can be very complex and, for many, threaten their security.
Keep in mind how this can impact the kind of care, including preventative care, people may have accessed, or NOT accessed and how you can assist in making sure they have the information and the tools they need to keep themselves safe and maintain their health.
Prisoners and ex-prisoners often normalize not feeling okay and minimize symptoms that they are experiencing.
Be thorough when assessing someone’s health history or current health issues, don’t assume you can skip over some questions, and explain why you are asking your questions.
People who are incarcerated or have been released and who feel ready (or the urgency) to address their health issues may need an anchor to navigate the health care system or to address health issues because they may have no idea where to start, what to tell or what to ask.
Take on that role or make sure you have a list of trustworthy organizations you can refer to and where they would be able to find ‘health navigators’ or people who could help them work through complex basic (housing, food, etc.) and health-related needs.
When people are released from prison, they usually do not have identification because it has either been lost in the prison or confiscated/destroyed by police during arrest or they were released from court without their personal belongings.
Find out how you can assist people in getting new identification documents or which agencies in your community is able to assist. Keep relevant forms handy. Know where in your community can be accessed without ID.
The waiting room can be a place of high anxiety due to being in close proximity to people when people may easily feel judged or paranoid, feel nervousness about the interaction with the healthcare provider or find the act of waiting stressful.
When possible, do not involve security staff when someone starts showing signs of anxiety, find ways to deescalate stressful situations, have a quiet room where people can take a breather, see how you can inform people you know may have trouble with waiting how long they may have to wait so they can step out if needed.
Healthcare environments or any place that can feel institutional can resemble the prison environment in overt or nuanced ways. When people are spoken down to or belittled, this can trigger past experiences with prison guards.
Make sure everyone on the team is well-trained and well-aware of how to ensure affirmative and inclusive care for all patients, an experience that is not limited to the physician or nurse’s office. Take/Offer regular staff trainings and adopt policies that promote a better understanding of diverse experiences of the health care system and of anti-racism and anti-oppression principles and practices.
Many HIV & HCV risks occur in immediate post-release period as result of disrupted social networks of support and survival strategies.
Inform yourself on the specific risks people face during that sensitive time, on what harm reduction tips can be shared, on the resources available in your community where you can refer people who are about to be release or is often in and out of prison. Advocate for the implementation of naloxone programs in your community.
Quick Tips: Identifying Key Moments
While there are many challenges, solutions do exist. Here are some possible scenarios and suggestions to help build positive relationships for healthy bodies, healthy communities and healthy partnerships.
People seem like they are over-emphasizing one aspect of their health or seem like they are not forthcoming with information
As part of being institutionalized, prisoners learn to prioritize one thing and highlight it as a way to get their needs met. Understand the series of events that have occurred in a person’s life by allowing time for a person to give a brief biographical narrative and pay specific attention to traumatic areas of their narrative. People are often seen as prisoners only which leaves out significant historical information, which may be relevant to their current health issues. Ask open ended questions, help them paint a more thorough picture of who they are and what are important issues affecting them. Keep in mind that trust may be long to build.
People often present as non-communicative and non-cooperative while interacting with healthcare staff
Be sensitive to the reality that the person may have a heightened sense of anxiety and mistrust due to their past experiences. Understand the fear of being judged and the fear of being criminalized when disclosing information, notably if they discuss their drug use. Always use a non-judgemental approach, outline confidentiality and emphasize that the more you know, the more you can help the person. Take the time to walk the person through why you are asking your questions and how exams will go.
People may not be consistent with showing up for appointments
Inform yourself of what could make follow-up care challenging for your patients. If possible, ensure you can offer accommodations for people who may have a hard time making it to appointments – stock up on bus tickets, make arrangements with off-hour clinics or strike up partnerships for regular visits to drop-ins or organizations that may be easier to get to, where people go already, or where they may feel safer accessing services. Make sure that you take the time to explain procedures, diagnoses, treatments and results and ensure the person understands the information and their options. Outline what is important information to know if they are unable to stick to a treatment plan or get a test done (when to call with symptoms, what to be on the look-out for, etc.).
The dynamic of incarceration often includes short stays and frequent movement between prison and community.
This can be destabilizing, contribute to the risk of reincarceration and to the breakdown of important relationships with health care providers and support networks.
Make sure to maintain these important relationships with people who may be in and out of jail by also focusing on providing support services for their non-medical challenges (via referrals, partnerships, etc.). See how you could help people navigate complicated health systems (prepare some info-sheets, find out if there are health navigators in your area, insist on robust information exchange with the person’s circle of care – via programming from organizations people are connected to, with health care providers inside or outside of correctional facilities, and see to address or assist the person in addressing both transitional and primary health care needs.
Many people who are or were incarcerated report that the Emergency Room is often their main source of health care
Primary healthcare can often be a gateway to other services and so the failure to connect with a GP has consequences for people’s health and well-being. Disconnection and not knowing where to go to get health care is a big barrier to people maintaining good health.
When a person is receiving medical care that needs to continue after discharge and does not have an external GP, help them to register with one prior to discharge. Similarly, health care staff must arrange follow-up appointments.
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