Prison is no place to keep fit

September 28, 2007
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Prison health is public health, so goes the truism, since the released will soon be out spreading their germs among the general populace. Prisons are breeding grounds for disease, as are all locations where people congregate – aeroplanes, submarines, hotels and particularly hospitals. Thai prisons are particularly infectious, however.You have 100 or so people sleeping essentially in the same bed, sweaty body to sweaty body, and on their sides to save space. Many quench their thirst by drinking from a community cup. It’s paradise for microbes.

Upon entry into prison, inmates get a cursory physical examination. Height, weight, and blood pressure are noted and there are a few routine health questions. There is no blood test, no stethoscope employed and no qualified doctor present.

The three main concerns are: HIV/Aids, tuberculosis and hepatitis. Our new arrival could be bringing in all three and no one would ever know until symptoms broke out. This leaves open a large window for transmission. Unless he or she is obviously sick, there is no exit physical and the released convict could unknowingly be spreading prison ailments to the general public.

Upon entry, the Corrections Department has other things on its collective mind. The subject is, once again, fingerprinted and photographed. After being stripped, body markings, scars and tattoos are noted.

Perhaps for their own protection, Corrections personnel take a particular interest in fresh wounds, and these are duly photographed. The subject is asked to explain these blemishes and his or her response is noted for the record.

Hence, documentary evidence of police torture is in the dossier and subject to subpoena, but it is not acted upon unless a complaint is filed. There is little in the way of complaint reports that amount to anything.

“HIV blood tests are strictly voluntary,” said Dr John Lerwitworapong, director of the Medical Correctional Institution (MCI), “Swab saliva tests are less intrusive but are not accurate.”

However, should Aids symptoms break out, the patient will be persuaded to have a blood test. Persuasion is not difficult in a Thai prison, which operates like a military academy on a merit/demerit system. Merits minus demerits equal sentence reductions.

When Aids appears, patients are sent to the MCI to begin an antiretroviral therapy (ART) regimen and for physicians to observe side effects. After initial treatment, the patient returns to his original prison and is mixed in with his former cellmates.

Press reports from the recent Aids conference in Mexico City say the disease can be contagious for as long as 10 years before it shows itself. The good news is that HIV is difficult to transmit once ART begins.

The patient might look quite normal, but everyone knows he is HIV positive. Fortunately, very few co-inmates will discriminate, Dr John stated, but the sufferer is thoroughly lectured and must pass an exam on Aids hygiene.

In the past half-dozen years sex has taken over from needles as the chief mode of HIV transmission. In a 2007 report, Me’decins Sans Frontieres (MSF) wrote: “The greatest risk factor for HIV transmission within Thai prisons is unprotected sex between men. Sex, consensual or otherwise, is part of prison life. Condoms are not banned from Thai prisons, but the attitude of prison staff towards sex between prisoners influences condom distribution.”

If condoms are temporarily not available, Dr John recommends exercise, meditation or masturbation. Oral sex is not safe, he said.

According to prison folklore, katoey are very popular and the Corrections Department puts them together in separate cells by night. During the daytime they are relatively free to do their chores. In any event, katoey get special lectures on hygiene, as well as free condoms. They are also advised to have an HIV blood test but some, indeed, refuse, according to Dr John.

The jury is still out on tattooing. While against regulations, the practice continues to be widespread in men’s prisons. Unhygienic tools are used, and it is not clear how dangerous this is. There is a move to allow the practice with controls, but doubts still remain.

While HIV is a virus transmitted by blood-to-blood or blood-to-semen contact, tuberculosis (TB) is an airborne bacteria passed on in close proximity by sneezing or coughing, and so is much easier to pass on.

All prisoners get an annual chest X-ray, and if positive this is followed up by a sputum test to search for TB bacteria in the saliva. A patient who tests positive would then go to MCI for two months of isolation and to begin the “Dots” (Directly Observed Treatment Short-course) routine. This regimen should cure the TB in six months. In the meantime, it is unlikely he will transmit the bacteria and can more or less safely return to his old cellmates.

However, there is still time for contagion before the disease is detected. To complicate matters, a third of the world’s people have the TB bacterium in their lungs. It remains dormant unless activated by a weak immune system, as is the case with an HIV affliction. So, like many prison maladies it is difficult to find the source and fix the blame.

There is little trustee monitoring of the Thai prison system’s 150 known TB patients. Medication is taken at a clinic during daytime hours where a nurse watches the pill go into the mouth. For that reason, cellmates are generally unaware of TB carriers among them.

On the other hand, everyone is quite aware of the Thai prison system’s 240 Aids carriers currently under ARV.

Also well-known are another 30 psychotics who must be prevented from saving up their dosages of psychotropic medications for a weekend bash. Subjects are carefully monitored by trustys with alarm clocks going off at pill time. The trustys do a good job, said Dr John.

CROWDED NIGHTS

Inmates spend the twelve hours after evening in crowded cells. Three hours are for watching TV and other recreational activities and nine are for sleeping. Cells are locked all night and opened only in a dire emergency. If necessary, medication will be passed through the bars.

Disease rates run higher in prisons. Some studies have shown TB is two to five times more prevalent in Thai prisons than on the outside. HIV/Aids is even worse, with MSF reporting 25 per cent of symptom-free male inmates at Klong Prem Central were HIV positive in 2003. The figure for the general population is only around 1.5 per cent.

Hepatitis is of less concern these days, according to Dr John, because there is less heroin and less drug injection. Sharing toothbrushes is a no-no. Drinking from community cups will spread hepatitis, flu, mouth diseases and a number of other ailments, but not HIV or TB.

The common cold is not a serious enough problem to separate prisoners, according to Dr John. However, some other maladies like conjunctivitis (red eye) might require temporary isolation.

Minor irritants like lice, scabies and fungus infections abound. Some prisoners refuse to bathe because of parasites in the water.

Female convicts nursing babies are provided special quarters. Those pregnant on admission will have their babies delivered at a local government hospital. The infants stay with their mothers for a full year to complete nursing. They will then be sent to relatives.  If no one is willing to care for them, they may remain with their imprisoned mothers as long as three to four years before being handed over to a welfare agency.

There are currently just over 30 babies at the Women’s Correctional Institution at Klong Prem and a somewhat smaller number at provincial prisons

There are special cells for VIPs, who Corrections euphemistically refers to as high-profile cases. In a recent publication they say: “These people are prominent prisoners who have high status in Thai society.” A Corrections official told this writer that the segregation was strictly for security and not for comfort.

A convicted medical doctor, for example, might have a semi-private cell. His medical licence would be voided and he would not be permitted to practice or even act as a medical assistant. He could, however, be very helpful with paper work, Dr John indicated.

Others separated from the general population are violent offenders who are forced to wear leg irons. “Paedophiles are generally tolerated in the prison community, but inmates are not so forgiving when it comes  to offences against religion or His Majesty the King,” Dr John said.

Conjugal visits were stopped over ten years ago. “It did not work out,” Dr John explained. “The programme was only for short-term prisoners and there was the ordeal of transporting them to open prison. We now rely on family visits.”

Officials assume that all those dealing with drugs are addicted and persuade them to sign up for a 3 to 12 month, in-house programme called Therapeutic Community (TC). This is a take on the 12-step Alcoholics Anonymous  programme.

Participants sometime engage in tear-jerking confessions before their peers, but there is little research on the Thai programme’s effectiveness.

Overcrowding is fundamental to the health problem. Thai standards allow 2.25m of sleeping space per prisoner. This works out to a national prison capacity of 110,000.

There are currently some 170,000 prisoners, so the system is 55 per cent over capacity. In the past crowding has been far worse. The international standard is 7.5m per person, making Thailand five times less generous than acceptable norms. The consolation is  that daytime activities take place in a larger arena.

There are no published figures on recidivism, but it is assumed to be well above 50 per cent for drug cases. Uneducated and unemployed convicts return to the same environment and naturally continue with what they know best.

In addition, many repeaters have grown accustomed to jail-house living and may well prefer its protective and controlled environment to life on the streets

There are no reports of released convicts suing the Corrections Department for prison maladies, although Dr John indicated there have been complaints from families. He said such a suit would bring publicity and further stigmatise the convict as a health hazard.

Some inmates with long sentences prefer to end their lives; hanging is the most common method. Official statistics show 18 suicides in Thai prisons for 2007, or 10.8 per 100,000 inmates.

The suicide rate amongst the general Thai populace for 2007 was 5.7 per 100,000. Rates are always higher in prisons. The figure for US prisons in 2002 was 14.0 suicides per 100,000 inmates.

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