N°5-6 de la Revue Santé Publique : un article co-publié en français et en anglais
A retrouver dans la rubrique "Afrique, Santé Publique et Développement" du dernier numéro de la Revue Santé Publique (Volume 32 - N°5-6) : l'article Épidémies et Covid-19 dans les prisons africaines : l’occasion d’une approche de la santé vraiment globale est également disponible dans sa version anglaise Epidemics and Covid-19 in African prisons: Towards an inclusive approach of health
L'article a été co-rédigé par Frédéric Le Marcis et Fanny Attas.
Healthcare remains largely neglected among prisons systems across the world (1) and the SARS-COV-2 epidemic, which has had significant consequences in prisons, highlights this phenomenon even further. The spread of Covid-19 in prison has been amplified by the difficulty to organize large-scale tests for prisoners in a short amount of time, as well as to determine comorbidity factors within the incarcerated population. Furthermore, the effects of the pandemic in prisons have been exacerbated by prisons’ inability to protect inmates or administrative personnel from the virus. This has been largely due to prison overcrowding, lack of appropriate equipment, and limited medical wards to isolate patients with positive cases. Moreover, security procedures such as suspension of family visits and group activities in prisons have been imposed without consideration of prisoners’ rights, wellbeing, or respect of their basic needs (2). This situation has raised alarm at a global level, with researchers and institutional actors specialized in prison system denouncing these abuses in media (3, 4).
These difficulties in the management of Covid-19 crisis during confinement are mainly due to specific characteristics of the prison system that impact health provision in prisons and constitute a favorable ground for the development and propagation of epidemics: overpopulation, difficulty to reduce risk of transmission in confinement (be it through sexual interactions or through drug injections), and a strong presence of comorbidity factors within the prison population. Furthermore, in African prisons, prison infirmaries are rarely integrated within the prison system. Administrations provide little for prisoners’ basic needs. Nutritional deficiencies are frequent (5), skin diseases are recurrent (6), and prisoners largely depend on their families or NGOs’ support to access healthcare—especially when the medical consultation is outside the place of confinement (7). The social illegitimacy of the prison population, associated with the reluctance of the States to provide for prisoners what they cannot guarantee for their wider population, are two arguments used by institutional actors to justify the implementation of a necropolitics (8). Moreover, international actors intervening in prisons mainly focus on epidemic pathologies, as their funding comes from institutions such as UNAIDS and world funds which tend to support global health politics and strategies. Unsurprisingly, the response to the Covid-19 epidemic focuses more on constraining the virus within each detention center rather than on directly addressing prisoners’ health needs and rights.
The social illegitimacy of the prisoners in African countries, as well as the fact that health programs exclusively address epidemic pathologies, are reflected in the management of the current pandemic. Consequently, I aim with this paper based on the Ecoppaf (Economies de la Peine et de la Prison en Afrique) program to shed light on COVID-19’s dire consequences regarding healthcare in detention centers, and to propose an inclusive approach, at a global level, to healthcare in prison systems. Considering healthcare’s multiple aspects, the first goal is to consider healthcare beyond the unique objective of epidemic control. Secondly, in a context of increasing risks of terrorism in African countries and public distrust of governments, recognizing healthcare as a priority and a right for all citizens legitimizes the social contract with the State. Lastly, beyond the recognition of individual medical experiences and epidemic concern, approaching healthcare in prisons as a global priority reaffirms the dignity and rights of imprisoned individuals, which is a necessary condition to maintaining citizenship rights even within prison.
Prisoners’ health, an illegitimate question?
In Africa, imprisonment has replaced banishment, which was historically a common form of punishment for socially rejected individuals during the pre-colonial period. Its legacy still prevails, as evidenced in the local names used for “prison”. For example, the Bété word Diéboudou or “the house of the infamous” is used in West-Center Ivory Coast (9), and the Baoulé word Bi soua or “the garbage house” in East-Center Ivory Coast (8), are used when referring to prisons. This social illegitimacy of prisoners in African societies translates in the political sphere into a difficulty to impose political programs to improve prisoners’ living conditions, especially with regard to their healthcare, food security, overcrowding, and water and sanitation.
Prison infirmaries, whatever their size, correspond to first-level healthcare centers as they tend to only possess essential medications and, in most cases, psychiatric care is inexistent. Referring patients to healthcare structures “in town” (outside the prison) is not a functional practice due to lack of material and economic resources, the unwillingness on behalf of prison administrators to secure the necessary healthcare services, and the reluctance on the part of healthcare structures “in town” to receive and treat prisoners.
A social illegitimacy with political and structural consequences
The lack of interest for health to the profit of security from institutional actors concerning prison is visible in the status of healthcare actors in the prison system. Although this situation varies from country to country, with differences on whether a prison is located within an urban or rural area, healthcare provision in prisons typically depends on:
- Ministry of Justice (with security being more important than health) (Venters Homer (2019) on sanitary questions in Riker Island…)
- Ministry of Health: they are “delegates” and are little integrated into supervisions or trainings. Sometimes, they spend only few hours per day in prison, with negative consequences on the quality of care provided.
As different professional grades coexist in the same prison structure, tensions may arise between the healthcare actors, mainly related to income difference—civil servants from the Ministry of Justice receive a risk premium whereas those from the Ministry of Health do not. Moreover, when political actors are questioned about prison needs, a “competition of causes”—general population versus prison population—is invoked to justify inaction.
From an epidemiological point of view, public health researchers insist on the risk represented by the failure to address questions of health and insist on the opportunity to address them in prison (14). However, by doing so, they paradoxically reinforce the function of the prison as a “camp”: detaining individuals representing a risk to society (be it social or sanitary) and putting them to work. The contemporary prison system echoes that of penal camps from the colonial period (15). The infected body is “put to work” when placed under medical treatment in prison or when placed in quarantine, as it was the case during the Ebola epidemics (16, 17). The link between healthcare and confinement is old: for example, in 1917, the colonial governor of Guinea authorized for medical reasons the maintenance in detention of prisoners that served their sentences (National Archives of the Republic of Guinea, Conakry. 1H31…)—as they were treated by the medical officer and doctor Henry for “cerebrospinal meningitis” in Kindia. This function of the ill body is visible in the way in which health in prison is discussed in global health arenas.
Prison: when epidemic risks and social risks merge
Prevalence of HIV and HCV is higher among the prison population than in the general population, mainly in reason of the prisoners’ biographies and of the higher risk of contamination in detention (due to injections, unprotected sexual interactions, tattoos, blade exchange, etc.) (18). The link between prison and epidemics (HIV, HCV, tuberculosis) is described as a “Perfect Storm” in preparation (14), which is confirmed by the Covid-19 situation.
The prison is thus a place of exposure to and spread of a viral risk, but it is also open to the wider world through the circulation of prisoners and prison staff. Therefore, the implementation of a universal health coverage that includes prisoners is crucial for the protection of the general population, and it is one of the UN’s sustainable development goals (SDGs) in relation with health (19).
To act for the control of epidemics (HIV, HCV, tuberculosis, Covid-19) in prisons located south of the Sahara is a major stake for the health of prisoners and communities to which they return after their detention. Ensuring the continuity of care for prisoners, from their entry to after their release of prison, is an efficient way to fight against the development of therapeutic resistances (20). Considering risk at a global scale, the individual experience of health—be it from prisoners or from healthcare actors—appears less important than the contamination risk at a society level. This logic governs the attribution of global financial resources funding healthcare in prison. Thus, prisoners’ health needs in relation with pathologies that are not associated with epidemic risk at a global level are not recognized, as well as the isolation of healthcare agents in front of pathologies for which they do not have appropriate treatments. This logic also does not reflect the determining elements of health and hygiene in prison.
Determining elements of health and hygiene in prison
Structural and geographic characteristics of power in prison largely determine the way in which individuals—men or women, young or old, rich or poor—face illness. They produce inequalities in how people experience illness or access healthcare.
Recognizing these determining characteristics implies thinking of health and hygiene as elements at the core of a complex and unequal system of resources and power. For a prisoner, accessing healthcare—beyond the question of products availability—implies navigating hierarchies and negotiating with a multiplicity of normative frames within which health value is relative. In prison, health is simultaneously a common good, a universal right, a resource for a prison manager establishing the list of sick individuals, a way to obtain favors from prison agents that authorize exiting the structure, a possibility to go into the main prison court to get some air or negotiate a transaction (21).
Health beyond epidemics
When approached from the actor’s point of view, health issues reveal a dimension absent from healthcare programs implemented in prison: non-epidemic diseases and afflictions. Prisoners present recurrent signs of beriberi due to the low quality of the food rations provided by the prison administration. In Burkina Faso, “the daily amount used to buy food and condiments and to cook them is approximately one-hundred-and-sixty-five (165) francs CFA (165 francs CFA = 0.25 euros) per prisoner” (22), and prisoners largely depend on food packages from their families. Prisoners also suffer from recurrent skin problems that are not treated or poorly treated, and that vary depending on the level of overcrowding, type of cell and conditions of prison walk. Among other pathologies are present diseases linked to faecal hazard and directly due to the lack of hygiene and unsanitary, as well as diseases linked to mental health and addictions. These pathologies do not present epidemic risk and therefore are most often not taken care of by international sanitary and health programs implemented in prison (except the punctual interventions of urgency by the CICR for example).
Security and health: two parallel logics in the prison system
The impact of conjugated epidemics of HIV, tuberculosis and hepatitis on population’s health in prison is well known. The Covid-19 epidemic highlights the extreme vulnerability of the prison system structure. Globally, the risk reduction supposes to act on the length of preventive detention, the quality of healthcare and prevention offer, and the detainment conditions (23).
However, in sub-Saharan countries, researchers currently observe a prison inflation caused by the intensification of the fight against terrorism (13), whereas the trust of the populations toward the State and political elites is low. Funds aiming to improve justice operation and to reinforce rule of law are provided by international organizations (24). Nevertheless, both sanitary interventions and security interventions are deployed independently from each other. It is necessary to de-compartmentalize them. The inability for institutional and prison actors to take into account prisoners’ basic needs, as well as to respect the length of preventive detention, reflects the poor quality of the social contract binding the State and its citizens through rights and duties. Refusing to consider health needs in prison is missing the occasion to reinforce this social contract and serves as a support for individuals promising a better future in a new social contract.
Thus, prison constitutes a denial of rights whereas it is supposed to re-establish the social contract between citizens and their society. An advocacy addressed to the general population is therefore necessary in order to make health and Rights in prison legitimate subjects within the public space. Furthermore, in the light of questions raised by epidemics, it is necessary to consider health as a global question, including both the medical and Human Rights dimensions.