People in prison experience health inequalities

The protests against and criticism of medical care and the handling of medication by people in prison in Denmark have shed light on a key issue: Are they receiving the healthcare they are entitled to?

In her PhD dissertation, Mathilde Carøe Munkholm from the Department of Law at the University of Southern Denmark has examined this very issue in depth by investigating how people in prison experience access to health care while incarcerated.

The PhD dissertation is based on both a legal analysis and qualitative research in the form of observations and interviews with people in prison and healthcare staff in multiple prisons. Her research shows that healthcare provision in prisons is characterised by a number of challenges, including security considerations and institutional frameworks that may limit incarcerated people’s access to treatment.

May deviate from the principle of equality

Postdoc Mathilde Carøe Munkholm points out that on the one hand, there are legal issues relating to the principle of equality, which is a key element within the Prison Service.

- The principle of equality is intended to ensure that people in prison enjoy the same conditions and rights – in this case, the right to the same healthcare services – as other citizens. However, the legislation allows for exceptions to the principle of equality where security considerations apply, and it will always depend on a discretionary assessment of when security-related considerations can justify such an exception, she says.

A sense of powerlessness is a recurring theme

A recurring theme in the interviews with people in prison is that they expect to be treated fairly, but find that this is not the case.

- Many people in prison report being met with distrust and feeling powerless because they have limited opportunities to influence their own treatment, for example because they are unable to contact their own GP or an out-of-hours GP themselves.

A concrete example is the prescribing of medicines:

- When healthcare staff prescribe medication in prisons, their decision is based not only on a clinical assessment but also security concerns aimed at preventing misuse and avoiding the creation of a black market for medication within the prison. For people in prison, it may seem as though the assessment is based on factors other than the medical assessment, which they believe should be the sole determining factor. This therefore undermines the experience of equal treatment, the SDU researcher says.

When health deteriorates in prison

According to Mathilde Carøe Munkholm, health plays a major role for people in prison. Many already have substance abuse-related diagnoses and mental health conditions when they enter prison, and health issues often arise as a result of the imprisonment itself.

These include depression, anxiety and insomnia, as well as physical health problems, due to the lack of the same opportunities for activity and exercise as outside prison.

- Many people in prison say they sleep poorly on the mattresses provided. And if they already have injuries, for example following accidents, they find that their condition worsens because they do not have the same access to equipment and treatment as they would outside prison. In other words, there is a group of people in prison whose physical and mental health deteriorates during their time in prison, and it is important to be aware of this, says Mathilde Carøe Munkholm.

Healthcare staff are caught between a rock and a hard place

She points out that it is not only people in prison who are under pressure, but also healthcare staff, who work in conditions in which security considerations play a major role where they are required both to provide treatment and take risk and security assessments into account.

- Their duty of loyalty to patients is challenged by the institutional context, where the primary aim is not to help people get better, but to enforce a sentence. This means that they must always take risk considerations into account when deciding on treatment. How many prison officers are required to escort a prisoner if we send them to hospital? Is there a risk that this drug could be misused? And is a person in prison allowed to inject themselves with diabetes medication using a needle? the researcher asks.

Treatment closer to the healthcare system

Against this backdrop, Mathilde Carøe Munkholm points out that there is a need to rethink the way healthcare is organised in prisons.

Today, healthcare provision is anchored within Danske Fængsler (the Danish Prison Service) under the Ministry of Justice, rather than within the regional and municipal healthcare system that the rest of Denmark’s healthcare system falls under. She instead proposes a model based on imported healthcare, drawing on the positive experiences of countries such as Norway and Finland.

In those countries, healthcare is integrated into the mainstream health services under the Ministry of Health, with healthcare staff visiting prisons to provide treatment.

- It could promote equality if healthcare staff worked more across the wider community and within prisons, so that they are better informed about treatment practices in the wider healthcare system, rather than the current situation where prison healthcare staff are solely based within the prison and fall under the Ministry of Justice, says Mathilde Carøe Munkholm, continuing:

- Working as a healthcare professional in a prison is, of course, a specialised role, and one must be properly prepared for the task. However, in my view, anchoring the staff under the Ministry of Health would ensure greater consistency in treatment, as it would be brought closer to the practice provided to the general public.

Greater use of GPs outside prison

According to Mathilde Carøe Munkholm, another area in which action could be taken is to give people in prison – particularly those on remand – better access to private practitioners, ideally their own GP.

- Under current legislation, remand prisoners are allowed to consult their own GP, but this option is rarely taken up. It would make sense for them to receive more support from doctors and perhaps even continue seeing their own GP if they are remanded in custody close to their home, so that they are seen by a doctor who is familiar with their medical history and treatment, the SDU researcher says.

Consequences for individuals and society

Finally, she points out that limitations in access to healthcare can often be perceived as an additional punishment that makes time in prison more difficult and potentially creates a sense of being viewed with suspicion.

At the same time, inadequate treatment can have societal consequences following release.

- By ensuring appropriate and timely treatment during imprisonment, we also increase the chances that those released will be able to lead a life free of crime after serving time in prison, she concludes.