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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


United States: sentenced to sickness

The US policy of mass incarceration with access to inept medical care but
without access to information, prophylactics or disinfectants) has led to a
steep increase in the number of prisoners with communicable diseases. By MEGAN

PEOPLE walking out of jail in the United States usually have up to $200 "gate
money" to get them started in their new lives, to buy some clothes and pay
the Greyhound bus fare to reach the city in which they must live. But they might
also come out with something less helpful and more perman ent: 1.3 million of
the 9 million released in 2002 were infected with hepatitis C, 137,000 with
HIV, and 12,000 had tuberculosis. These figures represent 29%, 13-17%, and 35%
respectively of the total number of Americans who have these diseases (1).

As public health researchers have warned for years, the mass incarceration
that has been happening across the country since the early 1980s has been
accompanied by the mass incubation of infectious diseases in correctional facilities
across the US (2).

The figures are dramatic but not really surprising. Much of the behaviour for
which people are sent to jail - such as injecting drugs, sex work, and
violence - leads to infection with blood-borne or sexually transmitted diseases. So
any police sweep of law-breakers means a round-up of the currently or
soon-to-be ill. Once behind bars, the practices continue, but without the protection
that people might have had on the streets: since homosexual sex, drugs and
violence are illegal in correctional facilities, syringes, needles, bleach,
condoms or latex barriers are considered contraband (and even clean water for
rinsing things is hard to come by).

The result is a make-do policy that results in scarce injection equipment and
a few coveted needles (perhaps actual needles, but what is used are more
likely to be ingeniously transformed ink cartridges, straws, or guitar strings)
that are widely shared. Unprotected sex is routine without access to condoms.
And even activities such as tattooing or skin piercing that are relatively safe
against infection from HIV or hepatitis C when performed in the outside world
become high-risk activities in prison. They are prohibited by law, and their
equipment banned; therefore everything connected with them is concealed and, of
course, shared.

Body decoration is an important and highly ritualised activity among
convicts, for whom "tattooing creates permanent representations of identity that
cannot be taken away by authorities; they represent positive affirmations of self
in an environment full of negatives" as well as a visual means of identifying
gang or group affiliation in a world full of strangers (3). While all
needle-related activities are illegal in prison and therefore go unreported or
underreported, researchers suspect that tattooing involves greater numbers of inmates
than does injection-drug use and could perhaps be the primary means of HIV and
hepatitis C transmission in correctional facilities.

This information surprises many inmates, since untold numbers of them do not
know the crucial facts about the transmission, prevention, or treatment of
infectious diseases; before their arrest they probably did not have access to
medical care. In the US medical care is contingent upon having an employer who
provides benefits (in the form of health insurance) at an affordable premium, or
having personal funds to purchase private insurance, or qualifying for public
aid, which is denied to those who are not impoverished enough and may anyway
specif ically exclude medication for drug addiction, mental illness and other
serious conditions. This is a problem.

Paul Farmer and Barbara Rylko-Bauer have written: "The US health system is in
fact a non-system, and what happens is the result of chance and a patchwork
of services: it is splintered, unsystematic, fragmentary and inefficient." So
people entering prison may not know that they are already carrying infectious
diseases if they have not already received treatment for symptoms, or they may
not know they are at risk of acquiring them.

Once inside prison inmates are tested for certain diseases, such as
tuberculosis or syphilis, but institutions do not automatically test for HIV or
hepatitis. But when procedures are not well explained (or when a prisoner does not
speak English) and blood is taken, some inmates think that they are being tested
for these viruses. Budget limitations often mean a no-news-is-good-news
policy, so only those whose results show infection receive a follow-up appointment
- and the rest assume that all is clear.

Inept or illegal medical companies compound the disorder. One California
laboratory faked test results for thousands of prisoners for years during the
1990s. Tipped off by concerned prison medical staff who had noticed spelling
mistakes and other errors in reports, officials from the California State
Department of Health raided the laboratory building in 1996 and "found a jumble of idle
equipment - a laboratory in disarray, with testing equipment that didn't
work, was out-of- calibration or lacked proper reagents for conducting tests of
blood and urine" (4).

By 2000, when the San Francisco Chronicle investigated this
affair, there was little evidence that the California Department of Corrections
had made any efforts to contact or retest inmates who had received wrong
information about their HIV or hepatitis C status, their cervical cancer exams or
any other life-threatening conditions. But in the meantime the manager of the
phoney lab had obtained a state licence to operate a new clinical testing

In another case a Michigan prisoner was accidentally shown medical records
from his previous incarceration and was stunned to learn that he had tested
positive for hepatitis C two years earlier and had never been told. His
girlfriend, with whom he had lived between his arrests, discovered that she too had the
disease (probably acquired between her partner's detentions).

This raises a little-known issue: a sizeable percentage of the 9 million
people released from jail each year in the US carry infectious diseases back into
their communities and risk transmitting them to their sexual and
needle-sharing partners - and anyone else who comes into contact with their bodily fluids.

People do not see prisons as particularly risky to their health and so do not
avoid unprotected sex or needle-sharing with someone who has recently
rejoined society (5). In fact, since the correctional facilities do provide regular
meals, sheltered housing and some degree of health care (however inadequate),
the poor and homeless in the outside world may view prisons as quite healthy
environments, especially when they see someone return to the streets well
rested, nourished and even buffed up from long hours of exercise in the gym. The
decline in the US welfare state to the point where the penal institution "has
increasingly become America's social agency of first resort" (6) means that, for
the most marginalised, the harsh grip of the punitive state also functions as
the steadying hand that keeps their heads above water.

Even so, errors, neglect and incompetence can prevent adequate medical care
for detainees and prisoners. Doctors and other medical personnel who have been
sanctioned for poor standards of practice may have their general licences
revoked but can continue to be allowed to work in correctional facilities. Inmates
who require medication for HIV or hepatitis C may receive out-dated
treatments that are modified according to correctional policies (for instance, inmates
may be required to prove compliance with single-drug regimens before being
allowed to receive more advanced multi-drug therapies) or improperly
administered, as in the case of a Florida prisoner who was routinely given his pills with
his meals, despite the interdiction on eating two hours before and one hour
after taking his HIV medication. Such blunders endanger lives and well- being,
and they also help create drug-resistant strains of viruses.

But whatever health care someone receives in a correctional facility may be
better than that which he or she can scrounge when not behind bars. The US
Census Bureau reports that, in a nation that still rejects implementing a system
of universal coverage for its citizens, 41 million people found themselves
uninsured in 2001, meaning that they were responsible for paying in full any
medical costs they incur. Meanwhile the price of malpractice insurance for doctors
and hospitals translates into bills that are three to five times higher than
in Europe; prices for prescription drugs are prohibitive; and bills for
prolonged stays in hospital can cost hundreds of thousands of dollars.

Those who cannot afford these costs must rely on unpredictable and
bureaucratic state aid, underfunded and often shoddy public services (free or low-cost),
or the hospital emergency room - which the poor often use for primary
health-care since hospitals are required to treat people if they arrive in bad enough
shape. Ironic ally, prisoners are the only group in the US who are entitled
to medical treatment, for as long as they remain under state supervision. No
wonder some people "deliberately return to incarceration because they feel that
they can obtain better care there than in the community" (7).

The alarming prevalence of infectious diseases among the incarcerated
ratchets up the costs: sky-high rates of illness and infection translate into equally
high prison medical costs, which is a difficult issue to pitch to taxpayers
who already have seen engorged correctional budgets dwarf allotments for
education and social welfare spending during the past decade. The combined policies
of hypertrophic incarceration for the poor and commercially based
laissez-faire medical coverage for citizens are causing a public health nightmare in the

* Megan Comfort is a sociologist at the London School of Economics

(1) The Health Status of Soon-to-Be Released Inmates, National
Commission on Correctional Health Care, 2002.

(2) This situation is not confined to the US: for information about
healthcare in French prisons, see Claude Veil et Dominique Lhuilier, La
prison en changement, Editions Eres, Ramonville Saint-Agne, 2002. For Spanish
prisons, see "Sida y Carcel" in PANPTICO, N° 1, Nueva Època,
2001, Virus Publications. For Russian prisons, see Paul Farmer,
Pathologies of Power, University of California Press, 2003.

(3) Susan A Phillips, "Gallo's body: decoration and damnation in the life of
a Chicano gang member", ???I class=spip>Ethnography 2:357-388, 2001.

(4) Farmer Sabin Russell, "State Fumbles Prison Lab Testing: Company's Fake
Results May Never Have Been Corrected," San Francisco Chronicle,
6 July 2000.

(5) See Megan Comfort, Olga Grinstead, Bonnie Faigeles, and Barry Zack,
"Reducing HIV Risk Among Women Visiting Their Incarcerated Male Partners", class=spip>Criminal Justice and Behaviour, Thousand Oaks, California, 2000.

(6) Elliott Currie, Crime and Punishment in America, Henry Holt
and Company, New York, 1998.

(7) Theodore M Hammett, "Health-Related Issues in Prisoner Reentry to the
Community", in Reentry Roundtable, The Urban Institute, Justice
Policy Centre, Washington, 2000.

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