Reform strategy of medical care for prisoners
The state of medical care for convicts (especially those serving sentences of physical isolation from society) is extremely poor today. The incidence of dangerous diseases among convicts, including infectious ones, can pose a danger not only to other convicts, but also to free people, because convicts communicate with staff, visitors, and they are released and through them the diseases can spread among the free population. An example is the evidence of studies showing that the incidence of tuberculosis among detainees/convicts is 22 times higher than among the general population.[1].
All this indicates that medicine in the State Penitentiary Service needs systemic and comprehensive changes, the ultimate goal of which should be to create an appropriate and functional system of medical care for convicts sentenced to physical isolation from society, and detained persons. This system should be focused on providing medical care and support to sick people.
The aim of the strategy is to formulate the main issues and the ways to resolve them in the field of medical care and assistance to convicts sentenced to physical isolation from society and the detained persons.
The main issues that require resolving:
1. Subordination of medical staff to the administrations of penitentiary institutions, and penitentiary medicine – to the purpose of punishment. The problem is that today there is a deep tradition, the content of which is the provision that a convict is, first of all, a punished person who does not “deserve” a normal human attitude. Accordingly, if the convict is ill, this circumstance is perceived as part of the punishment, i.e. part of the suffering that the convict must experience. Thus, the medical staff is in no hurry to provide medical care, given that the convict must be punished, and care for his physical condition is an optional element of the process of serving the sentence.
2. Inadequacy of the infrastructure of penitentiary institutions and pre-trial detention centres for the provision of medical care and treatment. The problem follows from the previous one: by not perceiving the convict as a person, the state does not take care to create humane conditions for the detention and provision of convicts. That is why penitentiaries are adapted to provide suffering, but do not have the appropriate infrastructure to care for a person. Especially one that needs medical attention. There are no proper premises, equipment or conditions for medical care.
3. Insufficient number and even lack of medical staff. Nowadays, the State Criminal Executive Service is experiencing a significant shortage of officers to enforce criminal penalties, including the need for medical personnel. Especially for qualified medical workers who are able to diagnose the patients, prescribe and monitor the treatment of patients, as well as make operational competent decisions during the course of the disease. The staffing of penitentiary institutions with such employees is a significant problem.
4. Insufficient provision of medical units with medicines and equipment for diagnosis and treatment of convicts and prisoners. Underfunding of SCES in general and HC of SCES and medical units of institutions in particular creates a state of chronic inability to provide medical services within the system. Lack of medication, lack of necessary equipment, inability to provide timely and complete medical care lead to the fact that even the efforts of medical staff become illusory due to their ineffectiveness.
5. Inconsistency of actions between the structural subdivisions of the SCES and between the HC of SCES and the Ministry of Health of Ukraine in providing medical care and treatment of convicts. The lack of clearly defined functional priorities in the implementation of criminal penalties (for example, the lack of a clear indication that human safety, life and health are the main criteria for the effectiveness of SCES) leads to the fact that even within SCES there are no consistent and clear algorithms of interaction, especially in the field of medical care. Numerous decisions of the European Court of Human Rights indicate that very often medical care is provided too late, not in full, with long breaks, and so on. All this indicates that the structural units of SCES are not able to make operational managerial and executive decisions and interact with each other.
6. Failure to comply with medical treatment protocols during the provision of medical care to convicts, failure to provide continuous and uninterrupted treatment of convicts, lack of efficiency and timeliness of medical care. This problem is cumulative, as it is related to all the previous ones, which together lead to the negative consequences that develop in practice in the provision of medical care: lack of interaction between medical staff of SCES and MoH specialists, understaffing and lack of necessary equipment, priority of implementation of punitive (executive) function ultimately lead to non-compliance with medical protocols for treatment of convicts and detainees, incompleteness, interruption and untimely assistance. This circumstance is not only a violation of medical regulations, but also an ethical and legal problem, as it is related to the state’s failure to protect human rights, failure to ensure the security of society. This situation makes it normal to leave a person in danger and endanger the health of both the convict or detainee and the people around him.
7. Mutual mistrust between the convicts/detainees and the staff of SCES. In the context of medical care for convicts and detainees, the problem is that the administration of the institutions has a negative attitude towards those convicts who complain about their health, perceiving them as simulants.: those who evade the regime, those who want to be released early, or to receive some mitigation in detention or to go to hospitals. For their part, convicts distrust staff and doctors, trying to maintain a balance between maintaining health and reducing their own vulnerability as a patient and one in need of additional care.
Given that convicts and prisoners are under the full control of administrations, we consider it necessary to formulate the following ways and directions for solving problems in the field of penitentiary medicine:
1. To solve the problem of subordination of medical personnel to the administrations of penitentiary institutions, and penitentiary medicine – to the purpose of punishment, it is necessary to put an end to the issue of transferring the entire medical service of the SCES to the Ministry of Health of Ukraine. We believe that in this process it is necessary to realize that the issues of administration should not be replaced by issues of managing the property of medical institutions of SCES. First of all, the process of transferring all medical staff of the SCES to the Ministry of Health of Ukraine should take place. This applies to the registration of labour relations of medical staff, as well as its provision, financing, social security, certification, etc. As for the property now owned by the HS of SCES, its fate should be decided by the SCS, but with due regard to the fact that medical staff, in addition to financial and social security, must have the material and technical base necessary to provide medical services. Therefore, it is expedient to transfer the relevant property (or part of it), which will provide a real opportunity to provide medical services to convicts, to the MoH of Ukraine.
The second important point is that the perception of the convict as a stigmatized punished person actually leads to the perception of the convict’s illness as part of the suffering, which, in turn, is the norm for the convict. Therefore, such treatment of the convict must be eradicated. And it is cooperation with civilian doctors that increases the chances of overcoming such a stereotype about convicts.
2. Inadequacy of the infrastructure of penitentiary institutions and pre-trial detention centres for the provision of medical care and treatment. The problem is solved by updating the material and technical base of places where convicts and detainees receive medical care. In addition, it is necessary to re-equip penitentiary institutions and their individual premises and the medical units themselves in order to create the necessary conditions for the provision of medical care. We are talking about the allocation of premises for the isolation of patients with infectious diseases, the proper arrangement of the premises of medical units, diagnostic rooms, wards for temporary or permanent accommodation of patients in need of inpatient care. Solving this problem requires adequate funding and changes to the architecture and formation of the internal space of penitentiary institutions.
3. Insufficiency and even lack of medical staff. Problems need to be solved comprehensively in cooperation with the MoH of Ukraine. Of course, working with convicts and detainees is intense and has increased levels of stress and danger. Therefore, health care workers who work in such conditions should receive appropriate compensation and benefits that are associated with overload. It is necessary to introduce a system of allowances and surcharges for work in penitentiary institutions, as well as to provide for mandatory rotation of medical workers and opportunities for their rehabilitation. Such working conditions will make it possible to attract more qualified medical workers to penitentiary institutions and replenish their staff. Additional financial support for medical employees working in penitentiary institutions solves an additional task – prevention of corruption and reduction of corruption risks in working with convicts.
4. Insufficient provision of medical units with medicines and equipment for diagnosis and treatment of convicts and detainees. This problem is solved by comprehensive long-term planning and forecasting of activity of medical institutions, as well as by providing them with the necessary minimum of medicines and equipment that will allow at least the initial examination and diagnosis of most diseases, as well as to perform basic, including urgent, manipulations and research. The solution to this problem can be achieved through constant adequate funding of penitentiary institutions and, in particular, their medical units and institutions.
5. Inconsistency of actions between the structural subdivisions of the SCES and between the HC of SCES and the MoH of Ukraine in providing medical care and treatment of convicts. Settlement and elimination of such condition is possible by means of normative regulation and joint work by the specified structures, in developing the order and algorithms of interaction in certain circumstances and in connection with diagnosis of the corresponding diseases. It is necessary to determine the main course of action in certain situations, which would allow to promptly and quickly respond to the painful conditions of convicts and detainees in order to prevent untimely and incomplete medical care, as well as to effectively interact with other medical professionals.
6. Failure to comply with medical treatment protocols during the provision of medical care and treatment of convicts, failure to provide continuous and uninterrupted treatment of convicts, efficiency and timeliness of medical care. The solution of this problem requires the consolidation of the imperative requirement of mandatory compliance with medical protocols during the treatment of convicts, including compliance with deadlines for examination of convicts, the obligation to provide them with assistance and other mandatory algorithms. This should be complemented by the formulation of a doctrinal provision on the priority of the life and health of the convict over the achievement of the purpose of punishment. This means that the provision of medical care and treatment to sick convicts and detainees must be unquestionable. The rule on optimal continuity of medical care, in particular, ensuring such continuity during the staging of convicts, their transfer from institution to institution, etc., requires imperative consolidation. Compliance with the requirements for consistency, timeliness and intensity of treatment should be the main norm in matters of medical services for convicts and detainees. Normative legal acts regulating the procedure and peculiarities of providing medical care to convicts and detainees should be deprived of excessive discretion, which is inherent in many by-laws in the field of execution of criminal punishments.
7. Mutual mistrust between convicts/prisoners and SCES staff. Overcoming this mistrust, unfortunately, cannot be achieved in a short time. Only the creation of a positive climate in penitentiaries, humane treatment of convicts, giving them the opportunity to communicate in confidence with psychologists, medical workers, religious workers, guaranteeing the existence and preservation of medical secrets, secrecy of confession, etc., can gradually remove the obvious general confrontation. setting up a proper atmosphere inside penitentiaries.
The above problems are systemic and inherent in the penitentiary service of Ukraine since ancient times. But the most worrying factor is that over the last twenty years, during which the penitentiary system has been in a state of permanent reform, the situation in the field of health care has not changed.
The world practice of ensuring the right of convicts to medical care has developed the following criteria for adequate medical care:
1) clear delineation of competencies of medical staff and administration of institutions, prevention of influence of the administration on medical staff in matters of providing medical care to prisoners and recording of their bodily injuries;
2) ensuring unimpeded access of prisoners to medical staff;
3) strict observance of medical secrecy concerning the state of health of prisoners, in particular in relation to the administration of institutions, and on the other hand, the right of prisoners to receive reliable and complete information about the state of their health;
4) providing detailed documentation of the prisoner’s state of health and treatment during detention;
5) promptness and accuracy of diagnosis and treatment;
6) regular and systematic supervision and availability of a plan of therapeutic measures to treat the prisoner’s illnesses or prevent their complication;
7) creating the conditions necessary for the actual provision of the prescribed treatment;
8) the duty of the state to cure a seriously ill prisoner is the duty to take the means, not to achieve the result (criterion of due diligence).
When reforming penitentiary medicine, these criteria should always be in the field of view of both SCES staff and medical staff involved in the treatment of convicts and prisoners.
Project “Promoting freedom from torture and prisoners’ right to a medical care in Ukraine based on international human rights standards”
EU project “Resisting Torture, Ill-Treatment and Impunity in Ukraine”
[1] Report on the results of the study "Barriers to the diagnosis and treatment of tuberculosis in pre-trial detention centres, penitentiary institutions and specialized tuberculosis hospitals of HC of SCES of Ukraine". – URL: https://phc.org.ua/sites/default/files/users/user90/ZvitTB_Full.pdf