There is a range of risks occurring in prison because of the special secluded and secured environment. All these risks can affect the health and/or social situation of the prisoners.
y overcrowding
y discontinuity of care and treatment (post and pre)
y psychiatric co-morbidity
y drug free orientation
y discrimination
y violence (against minorities)
y mothers and children
y sexual violence (US-Act)
y food and sport
Worldwide over 9.25 million people are held in penal institutions – almost half of these in the US, Russia or China (Walmsley 2006). In the 27 European Member States more than 600.000 people are incarcerated in prisons on a given day. The prison population in the member states of the European Union comprises 558.025 prisoners (including pre-trial prisoners) on 1st September 2004, while 40.085 persons in Romania and 10.935 persons in Bulgaria, were in prison at that time (Council of Europe 2004). The turn over rate is estimated to be at least threefold, which means that around 2 Mio people pass EU-custodial institutions annually. In average, the prison population rate per 100.000 inhabitants in the European union is 121,6 (with large variations between 56,4 in Slovenia and 337,9 in Estonia). In average, more than 5% of the prison population are female prisoners (for details see chapter 3).
Prison conditions are integrally linked to the physical health and mental well-being of prisoners. Poor living conditions can contribute to an increased risk of HIV transmission in prisons and a decline in the health of prisoners living with HIV/AIDS. First, substandard conditions can increase the risk of HIV transmission by promoting and encouraging drug use, (which usually involve unsafe injecting practices) to escape boredom or stress. They can also contribute to the increased risk of prison violence, sexual coercion and rape. Secondly, among prisoners living with HIV/AIDS, poor conditions can increase vulnerability to a decline in health by exposing them to contagious diseases and opportunistic infections; placing them at risk for dual infection with either TB or hepatitis; housing them in unhygienic and unsanitary environments;
confining them in spaces that do not meet basic needs for size, natural lighting, and ventilation; failing to provide them with proper diet, nutrition and/or clean drinking water; and housing them in overcrowded, high-stress environments. Minimum standards for the housing and treatment of prisoners are defined by international agreement, yet many prison systems in Europe – whether in high-income countries or countries in economic transition – fail to meet these standards, due to strained financial resources and/or a lack of political and public interest in the well-being of prisoners. Failure to improve such confinement conditions can undermine the effectiveness of HIV/AIDS programmes and strategies (Lines et al. 2004a; MacDonald 2005).
The discrepancy between treatment need and receiving of treatment is an issue underlined in several studies. Most details on treatment assessments are provided by the report of the Home Office (Home Office 2003). 40 % of the total sample received help for drugs in prisons mainly detoxification and counselling. In addition 42 % of the women sought help for emotional or mental health problems by a prison doctor or psychiatrist. Not even half of those women in need received treatment and a number of
those who did were not satisfied with the help they got. The most common cause of dissatisfaction was the length of time to see the doctor or to receive treatment. In the European study of Dünkel, Kestermann et al. (Dünkel et al. 2005) did 17 % to 29 % of the women prisoners undergo drug treatment. The need for this kind of treatment reported 20 % to 35 % of the women. This gap is even more alarming regarding psychological treatment needs. Only 11-20 % of the women received psychological treatment although 14-37 % of the women said to be in need for this treatment. Women with drug problems and severe depression showed an even higher need for psychological treatment which was up to 56 %.
The results clearly demonstrate that treating of mental illness is inadequate as psychiatric services do not meet the extent of the women’s need.
International literature shows that the number of ex-prisoners relapsing after release and becoming re-imprisoned is high and even increasing. Most studies found gender differences in terms of fewer women than men who re-offend after release but evidence suggests that reconviction rates for women tend to be the same proportion as adult males (Commission on Women and the Criminal Justice System 2004).
As regards gender differences a study from Finland reveals that of 30.000 individuals 59 % returned to prison during five years after release. Men re-offended more often (59 %) than women (45 %) (Hypén 2003). Similar recidivism rates for men and women are reported from Queensland, Australia (Walsh 2006).
Re-offending rates seems especially high for drug using prisoners. A review of seven studies on imprisoned drug users found that levels of re-offending post-release were significantly higher for drug users (62 %) than for abstainers (36 %) (Ramsay 2003b).
International research identified several reasons for the consistent fact that a majority of the prisoners re-offend after release. When summarising the main given reasons, relapses after release are related to
y substantial minorities of drug-using prisoners that received treatment (Ramsay 2003b),
y an insufficient preparation for release and the lack of someone who meets the prisoner at the gate upon release (Walsh 2006) and
y a persistent drug problem and a low self-efficacy to remain abstinent in high-risk situations(Pelissier and Jones 2006).
In addition deprived living conditions increase the likelihood to relapse after release.
According to a recent study on gender differences in predictors of criminal recidivism (Benda 2005) childhood and recent abuses, living with a criminal partner, selling drugs, stress, depression, fearfulness, and suicidal thoughts are stronger positive predictors of recidivism for women than for men.
The findings highlight the importance of a health and social policy addressing the women’s lives by providing drug treatment, mental health care, welfare benefits, housing, education, and employment. Addressing the realities of women prisoners through gender-sensitive programmes is fundamental to prevent relapses and to improve their resettlement in community (Bloom and al. 2004).
Last not least the destructive impact of imprisoning mothers underline the need for new pathways in handling female offenders (Zurhold et al. 2005).
5.3.1. Overcrowding and the over-representation of risk groups
Despite several attempts to improve the situation, nearly all prison services in the EU Member States are reporting overcrowding (Walmsley 2003; Walmsley 2006). A majority of 16 countries plus Bulgaria and Romania show a prison density per 100 places between around 90 and about 120. The highest rates can be found in Cyprus, Greece and Hungary (160,6 to 144,9) and the lowest in Malta (62,6). The EU average prison density is 109,6, indicating a general tendency of overcrowding in the prisons throughout the European Community (Council of Europe 2004). This represents institutional/environmental risk factors for prisoners.
Prisoners are a vulnerable group coming from vulnerable sectors of society with high unemployment rates, low levels of education and poor health (Møller et al. 2007).
Generally in many countries the number of prisoners has dramatically increased over the two last decades (Stöver and Weilandt 2007). The EMCDDA estimates that at least half of the EU’s prison population has a history of drug use, many with problematic and/or injecting drug use (EMCDDA 2003b). Only limited data are available about the exact percentage of injecting drug users. As already informed, the EMCDDA estimated in 2006 that the prevalence of injecting drug use among prisoners in Europe is between 7 % and 38 %, which shows that the spread of problematic drug use is varying widely throughout the countries and differs even within the country from one prison to the other. Drug use is seen as one of the main problems of the current prison system that threatens security measures, is dominating the relationships between prisoners and staff and leads to violence and bullying for both prisoners and often their spouses and friends in the community (Restellini 2007).
Research has demonstrated the detrimental impact of overcrowding in prisons, in relations to security issues and also on prisoners’ health and access to other services such as education, work and visits from family members and other external organisations. With regards to prisoner health, overcrowding presents additional risks for prisoners with HIV or other infectious diseases, as they often experience poor nutrition, limited access to treatment and are also often engaged in high risk behaviours such as injecting drug use, sexual activity and tattooing (Tkachuk and Walmsley 2001;
Lines et al. 2004a; WHO 2005b). Overcrowding in prisons has also been shown as a key factor in increasing levels of self-harming and suicide among prisoners, higher
prevalence of mental illness among prisoners and also as having a detrimental impact on resettlement and rehabilitation strategies (Howard League for Penal Reform 2001).
6. Prevention, treatment, care and support of drug users in prisons