"It is said that no one truly knows a nation until one has been inside its jails.
A nation should not be judged by how it treats its highest citizens, but its lowest ones"
-Nelson Mandela
“[A] chronic disease [is] an illness or condition that affects an individual’s well-being for an extended interval, usually at least six months, and generally is not curable, but can be managed to provide optimum functioning within any limits the condition imposes on the individual” (CorrectCare, 2012). As an RPN for Corrections Service Canada (CSC), I encounter a multitude of chronic diseases and conditions in the vulnerable population that I work with. This post will discuss chronic diseases relevant to my practice and their prevalence, the primary determinants affecting these diseases, and how CSC handles chronic diseases in their population.
Chronic diseases relevant to my practice
Two chronic conditions that are frequently encountered in the federal correctional system are hepatitis C virus (HCV) and mental illness, including addictions. Adhering to a bio-psycho-social-spiritual approach to nursing, my goal is to offer treatment for all of the causes of suffering that a person experiences and encourage wholistic health.
Many of the health concerns that affect federal inmates disproportionately are communicable diseases such as hepatitis C. The potential for transmission of blood-borne pathogens is heightened by the generally poorer levels of health among inmates, many of whom also have a history of high-risk behaviours such as injection drug use, sex work, and unprotected sex with high-risk partners, and by the compromised health of those with chronic diseases (Government of Canada, 2007).
About 30% of those in federal facilities are infected with Hepatitis C (HCV). There is also evidence that some people contract HCV while in custody. Sharing needles and tattooing and piercing equipment in jails likely contributes to these high rates (Kouyoumdjian et al, 2016). These staggering numbers present an opportunity for nurses, like myself, to provide harm reduction education to offenders. Another opportunity is to build up the self esteem of inmates, through contact with primary care providers and mental health professionals and encourage them to treat their hepatitis C infections while serving their sentence.
The majority of inmates in correctional facilities have mental disorders as defined by the DSM-V. Men in federal detention in British Columbia in 1999 had lifetime rates 2 to 3 times greater than men in a community sample with respect to mood disorders, schizophrenia, anxiety disorders, substance use disorders, and eating disorders (Kouyoumdjian et al, 2016). As a member of the institutional mental health team, these individuals are my patients. My primary task is to identify and provide care to individuals with major mental illness through both psychological and pharmacological therapies. The most serious consequences of failing to adequately treat this population is suicide and the terrible truth is that more than 1 in 5 persons in custody have attempted suicide and many complete the act each year.
Causes & Concerns:
Social Determinants of Chronic Illness in Federal Inmates
Determinants of health are the broad range of personal, social, economic and environmental factors that determine individual and population health (Canada, 2001). Nurses working in federal institutions must address counterproductive aspects of the correctional setting such as fat-laden menus with few healthy alternatives, intimidating exercise yards, isolation from those who support lifestyle change and limitations on rewards or reinforcements for new behavior (CorrectCare, 2012).
The following section will discuss the social determinants of health as they apply to chronic illness in federal inmates.
Age- More than 50% of those admitted to sentenced custody are younger than 35 years of age, compared with less than one-third of the Canadian population (Kouyoumdjian et al, 2016). Among incarcerated offenders in 2012/13, 21.5% were 50 years or older. Older inmates generally require more health care services than younger inmates because they are more likely to have chronic diseases and disabilities and consequently have more specialized needs for care and assistance with mobility and daily living (Stewart et al., 2015).
Gender- About 1 in 10 adult admissions to federal, provincial, or territorial custody are for women, the other 90% are men (Kouyoumdjian et al, 2016). The genders are separated while in correctional facilities.
Aboriginal- 1 in 4 admissions are for aboriginal persons, while they make up only 4% of the general population. About 15% to 20% of aboriginal persons in federal facilities have attended residential schools. (Kouyoumdjian et al, 2016)
Early Life- Most persons in custody have experienced substantial adverse events in childhood, such as witnessing family violence, having 1 or more parents absent, or being involved with the child welfare system. At least half report a history of childhood physical, sexual, or emotional abuse. (Kouyoumdjian et al, 2016)
Disability- Mortality rates are higher for persons in custody than for the general population. In Ontario between 1990 and 1998, the crude mortality rate for men in federal facilities was 420.1 per 100000, compared with a rate of 187.5 per 100 000 in men with a similar age distribution in the general population. This is remarkable, as persons in custody are protected from many types of unintentional injuries, which are the leading cause of death in the general population for persons aged 25 to 44 (Kouyoumdjian et al, 2016)
Housing- One-fifth of men in provincial custody in Toronto, Ont, in 2009 and 2010 reported being homeless at the time of admission,54 and more than half of youth in custody in British Columbia in 2012 and 2013 had been homeless at some time. (Kouyoumdjian et al, 2016)
Income and income distribution- The socioeconomic status of this population is low, as indicated by a lack of housing, low employment rates, low educational achievement, and low income status. (Kouyoumdjian et al, 2016)
Education- Most adults in custody have not completed high school; More than 55% of people admitted to federal custody in 2011 had less than a grade 10 education, whereas only 19% of all Canadian adults have not obtained a high school diploma. (Kouyoumdjian et al, 2016)
Race- On any given day in 2002, there were approximately 12,500 (12,492) offenders incarcerated in federal facilities in Canada. Offenders are culturally diverse. About three-quarters (71%) of offenders were Caucasian (8,787). A further 12% were First Nations (1,523), 6% were Black (773), 5% were Métis (628), and approximately 1% each were Inuit (92), Asiatic (88), South East Asian (88), and Arab (71). The remaining were other visible minority groups—Other (154), South Asian (50), Chinese (45), Latin American (44), East Indian (27), Hispanic (19), Filipino (19), Korean (4) and Japanese (2). (Government of Canada, 2007)
Employment and working conditions- There is a lack of relevant and meaningful skills training for federal offenders. Inmates earn between $1-$6.90 per day.
Social exclusion- In some cases, incarceration itself, with the increased exposure to individuals with higher rates of infection and continued risky behaviours while in correctional facilities, may contribute to the generally poorer health status of inmates. Inmates are separated, as a consequence of incarceration, from their family, friends and most meaningful relationships in their life.
Food insecurity- Meals are provided however, spending cuts in 2014 resulted in a fixed daily food budget of $5.41 per inmate resulting in smaller portion sizes, less protein and few fresh fruits and vegetables (Harris, 2017).
Social safety- Rates of suicide and homicide are particularly high compared with the general population,63,64 with suicide rates of 70 per 100 000 in federal custody and 43 per 100 000 in provincial custody compared with the overall Canadian rate of 10.2 per 100 000, and homicide rates of 22 per 100 000 in federal custody and 2.3 per 100 000 in provincial custody compared with the overall Canadian rate of 1.6 per 100 000. (Kouyoumdjian et al, 2016)
Net health services- The health of persons who experience detention or incarceration in provincial, territorial, and federal facilities is poor compared with the general Canadian population. (Kouyoumdjian et al, 2016)
Unemployment and job security- Less than 10 per cent of inmates are gainfully employed at any given time, and too many are engaged in menial institutional jobs rather prison industries that will lead to viable work after they are released. Opportunities to acquire apprenticeship hours towards a trade certificate are scarce and women prisoners are most often put to work on gender stereotypical work like sewing, textiles and laundry (Harris, 2017).
Making Progress: CSC’s Public Health Strategy
Standards for health care in federal facilities are defined in the federal Corrections and Conditional Release Act. This is the legal framework within which CSC provides public health services to offenders. As an employee of CSC, I am expected to have a good general understanding of all guiding legislation applicable to my practice.
Below is an info-graphic on CSC’s Public Health Strategy (2007). The Objective of CSC's Public Health Program is “to provide public health services to federal offenders in order to prevent and control disease and promote good health within federal institutions.” The strategy provides CSC with a framework to guide the development of public health activities, including the collaboration that will be required with internal partners and external stakeholders. In addition, it will provide a stronger focus for public health activities, along with expressed goals for improving offender health in order to contribute to the safety of Canadians (Government of Canada, 2007).
General health, which includes many chronic diseases, is screened for on admission and transfer to federal institutions, with the consent of the inmate. In federal facilities, “screening rates for blood-borne infections are high, with recent data revealing that more than 70% of persons were screened for HIV, hepatitis C virus (HCV), and tuberculosis during their current incarceration” (Kouyoumdjian et al, 2016). To highlight the effectiveness of CSC’s public health strategy, consider the seven years prior to the implementation of this strategic plan compared to the seven years following its implementation in terms of HCV testing: HCV testing among new admissions increased steadily from 37% in 2000 to 78% in 2014 (Government of Canada, 2002). The numbers of inmates initiated on HCV treatment also rose with the implementation of the Public Health Strategy from 91 in 2000 to 328 in 2007.
Part of intake screening includes a primary mental health assessment and suicide risk assessment by a health care professional. Inmates are also invited to participate in more in-depth screening for a variety of mental health concerns, learning disabilities and cognitive concerns called CoMHISS. Referrals to the mental health department are made based on these initial assessments.
The success of this strategy is based on a collaborative interdisciplinary approach and appropriate communication. “Reinforcing the close relationship with our colleagues in clinical services and mental health services will help weave health promotion and health education into their activities” (Government of Canada, 2007). In my practice, this is a huge part of my daily work. The inmates with the best outcomes are those that are supported by a team which includes mental health professionals, like me, primary health care professionals and other intervention professionals including program facilitators, institutional parole officers, and spiritual advisers. In my personal practice, I have found that the institutional mental health team is often at the center of this communication. This collaboration also ensures that a bio-psycho-social-spiritual approach is being taken and that individualized patient centered care is being achieved, per best practice. Time in custody provides health care providers a unique opportunity to offer services and information to persons who are often disengaged with public health and other primary health services due to criminogenic lifestyle and improve their overall being, not just their prosocial behavior, prior to release.
References:
Canada, P. H. A. of, & Canada, P. H. A. of. (2001). Social determinants of health and health inequalities [policies]. Retrieved February 9, 2019, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
Canada, P. H. A. of, & Canada, P. H. A. of. (2004, July 23). Chronic Diseases [navigation page]. Retrieved March 6, 2019, from https://www.canada.ca/en/public-health/services/chronic-diseases.html
Canada, P. H. A. of, & Canada, P. H. A. of. (2017, August 8). At-a-glance - The 2017 Canadian Chronic Disease Indicators [education and awareness]. Retrieved March 6, 2019, from https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-37-no-8-2017/at-a-glance-2017-canadian-chronic-disease-indicators.html
Contenu, E. name of the content author / N. en anglais de l’auteur du. (2011, November 29). Canadian Best Practices Portal – CBPP. Retrieved March 6, 2019, from http://cbpp-pcpe.phac-aspc.gc.ca/
CorrectCare Archive. (2012). Retrieved March 7, 2019, from https://www.ncchc.org/correctcare-archive
Government of Canada, C. S. of C. (2002, September 1). The Federal Offender Population Profile 2014. Retrieved March 8, 2019, from https://www.csc-scc.gc.ca/publications/005007-3038-eng.shtml
Government of Canada, C. S. of C. (2007, July 11). Research Reports. Retrieved March 8, 2019, from https://www.csc-scc.gc.ca/research/r144-eng.shtml
Government of Canada, C. S. of C. (2007, July 11). Suicides and Prisoner Suicide: A Review of the Literature. Retrieved March 6, 2019, from https://www.csc-scc.gc.ca/text/pblct/health/phs-eng.shtml
Harris, K. (2017, October 31). Hungry inmates pose security risk, watchdog warns CBC News. Retrieved March 7, 2019, from https://www.cbc.ca/news/politics/correctional-investigator-zinger-report-1.4379823
Kouyoumdjian, F., Schuler, A., Matheson, F. I., & Hwang, S. W. (2016). Health status of prisoners in Canada. Canadian Family Physician, 62(3), 215–222. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984599/
Stewart, L. A., Nolan, A., Sapers, J., Power, J., Panaro, L., & Smith, J. (2015). Chronic health conditions reported by male inmates newly admitted to Canadian federal penitentiaries. CMAJ Open, 3(1), E97–E102. https://doi.org/10.9778/cmajo.20140025
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