Prison Health Care in the Czech Republic, Hungary and Poland

HEUNI Paper No. 16

Prison Health Care in the Czech Republic, Hungary and Poland

Morag MacDonald

The European Institute for Crime Prevention and Control,affiliated with the United Nations

Helsinki, 2001

HEUNI Paper No.16 2

This document is available electronically from:http://www.vn.fi/om/heuni/

HEUNIThe European Institute for Crime Prevention and Control,affiliated with the United NationsP.O.Box 157FIN-00121 HelsinkiFinlandTel: +358-9-1825 7880Fax: +358-9-1825 7890e-mail: [email protected]://www.vn.fi/om/heuni/

ISSN 1236-8245

HEUNI Paper No.16 3

Table of Contents

INTRODUCTION.............................................................................................................................................................5

BACKGROUND TO THE STUDY ........................................................................................................................................5DESCRIPTION OF THE STUDY ..........................................................................................................................................5

COMMON PROBLEMS FACING THE THREE PRISON SYSTEMS .....................................................................5

OVERCROWDING ............................................................................................................................................................5IMPACT ON HEALTH .......................................................................................................................................................7FOREIGN PRISONERS .......................................................................................................................................................7BUDGET CONSTRAINTS ...................................................................................................................................................7DRUGS.............................................................................................................................................................................8ALCOHOL......................................................................................................................................................................10SEX IN PRISON ...............................................................................................................................................................11

STRUCTURE OF THE PRISON HEALTH CARE SYSTEMS ................................................................................12

CONFIDENTIALITY ........................................................................................................................................................15STAFFING ......................................................................................................................................................................15EQUIVALENCE OF CARE ................................................................................................................................................16TREATMENT PROGRAMMES ..........................................................................................................................................17HEALTH PROMOTION ...................................................................................................................................................20

PRISON PRACTICES AFFECTING THE HEALTH OF PRISONERS..................................................................22

CLEANLINESS AND HYGIENE........................................................................................................................................22FOOD IN PRISON............................................................................................................................................................22ACTIVITIES AND WORK .................................................................................................................................................23

KEY ISSUES IN HEALTH PROVISION ....................................................................................................................24

HIV ...............................................................................................................................................................................24TUBERCULOSIS (TB)......................................................................................................................................................26HEPATITIS .....................................................................................................................................................................27SYPHILIS ........................................................................................................................................................................27TERMINALLY ILL PRISONERS.........................................................................................................................................27DENTIST AND OPTICIANS .............................................................................................................................................28

THE ROLE OF THE PRISON DOCTOR IN PUNISHMENTS ................................................................................28

CONCLUSIONS .............................................................................................................................................................28

REFERENCES ..................................................................................................................................................................31

HEUNI Paper No.16 4

Acknowledgements

The completion of this study would not have been possible without the support andassistance of a number of individuals. I would like to thank all the staff in the prisonadministrations in the Czech Republic, Hungary and Poland who participated in theinterviews and who provided statistical information and documentation and the prisongovernors for enabling my visits to their prisons.

I would also like to thank Otakar Michl from the Czech Republic, Karola Kovacs fromHungary, Miroslaw Nowak and Tomasz Wierzchowski in Poland who translated for meduring the interviews and visits in their countries.

The organisation of the programmes of visits and the data collection were facilitated bythe support and experience of Roy Walmsley.

HEUNI Paper No.16 5

Introduction

Background to the study

This study of health care in CentralEuropean penal systems wascommissioned by HEUNI and took placeduring January and February, 2001. Thethree countries included in the researchwere the Czech Republic, Hungary andPoland. These countries were selected tocomplement the work already done byRoy Walmsley (1996) and his currentfollow-up study of the prison systems asa whole in Central and Eastern Europeancountries. The link with Roy Walmsley’sresearch was important as a means ofsecuring access to appropriate keypersonnel in each of the countries and asa means of securing general informationabout the prison systems.

This study also complements the workalready carried out in Italy and Englandand Wales about the structure and keyissues facing the two prison systems inthe areas of health policy and morespecifically on HIV and drugs policy(MacDonald, 1999).

Description of the study

The purpose of the visits to the CzechRepublic, Hungary and Poland was toprepare a report that provides descriptivedata about the current health policies inprisons in the countries visited.Interviews were to be carried out withkey officials in each of the countries todiscover the extent to which internationalstandards are currently adhered to in theimplementation of health policy; thereasons for any lack of adherence; theconcerns expressed, and the state ofprogress.

It is the intention to return to each ofthese countries to undertake a more in-depth follow-up study in the area ofimplementation of health policy in theform of audits in a sample of prisons,which will also include interviews withprisoners.

Although this report is primarilyconcerned with the provision of healthcare services in each of the threecountries’ prison services it is alsorecognised that there are other factorsthat make a significant contribution to thehealth of prisoners. Therefore, a variety ofissues (overcrowding, budget constraints,drugs and sex in prison and so on) havebeen included in the report in so far asthey impact on prisoner health.

Three days were spent in each country.Interviews were carried out with a rangeof key officials in the prison serviceadministration. At least one prison wasvisited in each country and furtherinterviews were undertaken with theprison governor and medical staffworking in the prison hospital/department.

Common problems facing thethree prison systems

Overcrowding

At the time of the visits all three countrieswere experiencing overcrowding in theirprison systems. This was considered to bea major problem in the delivery of healthand treatment programmes for prisoners.In Poland, overcrowding in the prisonsystem has resulted in the adaptation ofsome rooms used for cultural events to

HEUNI Paper No.16 6

increase the amount of cell space forprisoners. The 130% overcrowding of thePolish prison system means that there aresome problems with the care forprisoners where case managers1 have tocare for approximately 130 remandprisoners now instead of their usual caseload of 60 prisoners. Overcrowding isparticularly a problem in big cities and inpre-trial and closed prisons in Poland.The feeling in the Polish Prison Service isthat the prison population will continueto rise. This increasing prison populationis leading to more repressive regimes forprisoners. In a time of overcrowding, it ismuch harder to place women prisoners,near their homes, due to the smallnumber of women’s prisons. As theprison governor of Bialoleka Prison inWarsaw said, they have “had to limitsome prisoner rights and although thecurrent atmosphere is good,overcrowding is a time bomb waiting togo off”.

In Hungary, overcrowding in pre-trialprisons was considered to be a majorproblem for the prison service. There iscurrently 160% overcrowding insentenced prisons and 250%overcrowding in the remand houses. Asof 30 September, 2000 there were 15,778prisoners: 14,728 were male with 737 (5%)being foreigners; 1,050 female prisonersand 50 (5%) being foreigners.

In Hungary there is a new prisonbuilding programme in progress. Twoyears budget has been agreed to allow forthis building programme and

1 Case managers are key workers in the Polish prison

system. Case managers are normally graduates. Theywork closely with the security guard on the prisonsection. The role of the case manager is to look afterthe general welfare of prisoners and involvesprisoners’ personal problems, problems with theirsentence and the organisation of cultural events.

modernisation of old buildings toimprove the conditions for prisoners.

Increasing the number of places forprisoners does not solve the problem of agrowing prison population. TheHungarian Prison Service would like todecrease overcrowding, provide moreareas for cultural activities for prisonersand to be able to provide differentiatedregimes for prisoners. The rate of increasein the prison population has gone downthis year by 2% and by 7% compared totwo years ago. Some reasons given forthis were:

• that home detention had beenintroduced;

• that part of the sentence could beserved at home following theScandinavian example;

• that there had been a decrease in thenumber of people sent to prison andthat public opinion in Hungaryendorsed this.

The situation in prisons is considered tohave improved in the Czech Republicwith the Deputy General’s introductionof new management and new approachesto prisoner care that are nearer toEuropean standards. There have beensome disturbances in Czech prisons,which were a result of the currentovercrowding although the prisonpopulation has gone down betweenOctober and December, 2000 with adecrease in the number of both pre-trialand sentenced prisoners across the CzechRepublic. Consequently, the prisons arenot so crowded as they were a year ago.The Court proceedings and interrogationprocess have been speeded up and thereis more use of alternative punishments.This has resulted in a reduction in thelength of time a prisoner spends in pre-

HEUNI Paper No.16 7

trial detention. In May/June, 2000 aprisoner spent approximately 11–12months in pre-trial detention whereas thecurrent situation is approximately 5–6months.

Impact on health

Overcrowding impacts on prisoner healthin a variety of ways. When the number ofprisoners per cell is increased this placesa strain on hygiene, available washingfacilities and personal space. In all thethree countries the space per prisonerwas often less than the stated minimumin their legislation. In the Hungarianprison system, most cells are for twoprisoners but in reality there are fourprisoners per cell. Prisoners only haveone hour out of cell. It is considered to bean achievement that the Prison Servicecan ensure this one hour. There is anawareness that there needs to be moreprison programmes, for example, simpleunskilled work, which occupiesprisoners. This is considered to beimportant because it allows prisoners toearn some money, provides anoccupation to kill time, provides a newway of living and learning how to workand reduces the amount of time in cells.

In the Czech Republic, time out of cellsfor pre-trial prisoners is mostly one hourper day but there is a unit for 300 pre-trialprisoners with a changed regime wherecells are open for 12 hours, which allowsprisoners to walk about the wing. Theunit is not full, as some people are notsuitable for it because of concern aboutcollusion between prisoners in the periodbefore their court hearing.

There are a small number of single cellsbut usually there are three to fiveprisoners per cell in the Polish prison

system. In the diagnostic section2 ofprisons, the hours out of cells are three orfour per day.

Foreign prisoners

In Hungary the number of foreignprisoners has been rising since 1993 with807 in (2001) spread across sentenced andpre-sentenced prisons. In Poland thereare 944 foreign prisoners in prison. Thesplit of Czechoslovakia gave rise to a highnumber of foreign prisoners in the CzechRepublic (especially Slovak gypsies).Currently, there are between 3000 to 4000foreign prisoners.

In the three countries foreign prisonersare offered the same treatment as nationalprisoners but this group do raise someproblems, for example, with languageand the prison budgets.

Budget constraints

In all three countries improvements toregimes for prisoners were constrainedby budgetary concerns. In Poland, thecurrent government are perceived as notunderstanding the problems faced by theprison system and prisons are low on thegovernment’s list of priorities. This wasconsidered to be a short-sighted viewbecause if Poland wants to be integratedinto Europe then society should notignore the need to ensure appropriateprison standards and the human rights ofprisoners. It was felt that money wasfound by the politicians as a response tocrises in the prison system and that as 2 The diagnostic Wings are for newly sentenced

prisoners where they undergo psychological testsprior to being moved to other areas of the prison. Thestaff on the diagnostic section consists ofpsychologists, a case manager and security staff.There is teamwork between case manager,psychologist, psychiatrist and security - they all worktogether.

HEUNI Paper No.16 8

long as the Prison Service maintains agood atmosphere in prisons thepoliticians ignore the situation.

The feeling in the Czech Republic echoedthe view in Poland. The key problem wasperceived as the lack of budget forprisons and a lack of interest from thestate towards prisons. The Governor ofPankrac prison in Prague felt thatproblems with the budget have causedstaff shortages (the number of employeesis fixed by the government) as Parliamentdid not increase staffing or the budget.There is a shortage of money for salaries.Staff in the prison did not get theirovertime payment and they have beenpromised that they will get it this month(February, 2001). The governor considersthat staff morale was previously good butthat some individuals are dissatisfied andif non payment of overtime happensagain it will not be possible to guaranteestaff attitudes.

Drugs

Drugs and drug addicts in prison wereidentified as a problem in each of thecountries. However, the extent of theproblem differed between the countries.

Hungary in the past has tended to be atransit country for drugs but now there isa growing problem with drug use in thewider society, which is gradually beingreflected in the prison population.Parliament is currently designing anational drug strategy and the prisondrug strategy will be developed fromthis. The Prison Service response to drugscurrently involves staff education,attempting to minimise the amount ofdrugs that get into prisons and theintroduction of drug free units. At themoment, there is not considered to be adrug problem in prison but they are

trying to solve any potential problems.The amount of drug addiction isincreasing and they are concerned that itmay increase in prison. The new criminalcode allows for more severe sentencingfor drug related crime.

The Hungarian statistics show a pictureof minimal drug use in prison. Therewere only three cases of drugs found lastyear during searches by staff using drugdogs in some instances. There is rare useof drugs and it is felt to be under controlso far but the Prison Service is aware thatthis is a growing problem.

There is no use of methadone fordetoxification in Hungarian prisons.Instead there is some possibility ofpsychiatric treatment. However, as mostpeople will have spent a considerabletime in police custody most detoxificationwill happen at that point.

In some circumstances the court maydecide that a drug addict can bepermitted to go for alternative treatmentand then return to prison. Some prisonershave been sentenced to alternativetreatment but also have to be in prisondue to the serious nature of their crimeand these prisoners have individualtreatment involving drug therapy inprison. In the new law, the health caredepartment would like to introduce adrug-free unit for prevention purposesbut this is problematic as all of the prisonshould be drug free! Attendance atpsychological or psychiatric groups isvoluntary for drug addicts.

Cleansing materials (for cleaning needlesand syringes) are not available inHungarian prisons. However, there isharm-reduction literature that has beentranslated for use with non-national

HEUNI Paper No.16 9

prisoners. Drugs involve a specialsentence and drugs in prison are a hiddenproblem. Testing for drugs will beintroduced soon but the tests are veryexpensive and there is not a legalregulation to force a prisoner to take thetest.

There is a national drugs strategy in theCzech Republic, which follows throughinto the prison drug strategy. There is agrowing drug problem in the communitywith cocaine being popular and anincreasing use of heroin. Drugs are also adeveloping problem in prison wheredrugs such as pervatin3, cannabis, pillsand, exceptionally, injecting drug useoccurs. Drugs are seen as a problem butstill not yet as a major problem in prison.The main problem regarding drugs is theuse of pills (medicines) distributed by themedical department. The medical care inprison is at a high level but they usemany medicines with prisoners and sopills are easily accessible. Prisonersshould swallow the pills when they aregiven them but this does not alwayshappen. There is also some abuse of theuse of painkillers that it is legal forprisoners to keep. The prison staffmonitor the consumption of certain legalmedicines in the prison to ensure they arenot being used to produce illegal drugs.

The Czech Republic drug strategy coversa three-year period. Last year, theprogramme for 1997–2000 wascompleted. The programme has beenseparated into three parts:

• reduction of supply into prison;• primary prevention and education in

prison;• treatment for hard drug users.

3 Pervatin is an amphetamine drug made in the Czech

Republic.

During the period 2001–2004, theemphasis will be on drug-free units. Theintention is to use the Austrian modelthat started in Austria in 1995 and wasbased on programmes that existed inHolland and England. It is a mixture ofdifferent strategies to meet the CentralEuropean situation.

Drugs are not routinely tested for inprisons in the Czech Republic. Registereddrug addicts are asked at the entry checkup if they are dependent on alcohol ordrugs. At the time of the entry check-up,urine tests monitor drugs likeamphetamines, opium, benzodiazapines,barbiturates, cocaine and cannabis. Thishas been done for the last four or fiveyears and, so far, about 20% of the check-ups were positive. During 2000, 5763people were tested and 1269 werepositive on arrival at prison

Despite the apparently high rate of druguse at entry, a recent research study hasquestioned the level of drug use in theprison. The study took place in tworandomly selected Czech prisons forsentenced prisoners. It found that, during1999, of 730 prisoners tested in the firstprison there were 12 positive (1.69%)drug tests. In the other prison, of 470prisoners tested 35 positive results wererecorded and none of these were usingprescribed medicines. Detection of harddrugs is exceptional and tends to berestricted to isolated individuals. Onlyeight of the positive tests at the secondprison in the research study, were cocaine(23%), 12 of the 35 positive tests wereusing Parvatin (35%). When needles arefound which are not used for officialtreatment, they are destroyed.

There is special treatment for drugaddicts in three prisons in the CzechRepublic. In one prison, there is a special

HEUNI Paper No.16 10

unit that can accommodate160 prisonerswho are drug addicted. Currentlyhowever, it is only operating for 100people.

There is now a wider use of drugs in thecommunity in Poland, including someheroin-injecting drug users. 70% of thesedrug users are also HIV-positive. There isrelatively little injecting drug use in thewider community, rather there is moreuse of drug cocktails and alcohol. One ofthe most popular drugs is UFO4 a drugparticular to Poland. Drugs are seen as agrowing problem in Polish society.

In 1994, after a trip to then English PrisonService, the Polish prison administrationwere advised that they would eventuallybe likely to have a drugs problem inPoland. The economic changes in Poland,trends and fashions have given rise to amarket for amphetamines and alcohol.Now there is also a problem as a wideselection of drugs are being smuggledinto the prisons including cocaine,cannabis, and heroin. Independentresearch is being done about the extent ofdrug use within prison with a grant fromthe Ministry of Health. There will be areport in 2002. All admissions to theprison are asked if they are using drugs(using an anonymous questionnaire) pluspeople in the special therapeutic wardswill receive a questionnaire. Informationfrom security guards about the drugsfound will also be recorded. There willalso be anonymous urine checks to findout what illegal drug use is happening inthe prison. There will be training forprison officers on how to detect drugsand drug dogs are being used to searchcells. The newest development isconsideration of using tests for detectingdrugs and training their own drug dogs

in the prison administration. It seems thatthe drugs in prison are mostly eaten notinjected, as syringes have not been found.

Methadone substitution is going to beintroduced in two Polish prisons. Thelocal Health Authority will support aproject in the two prisons. Methadonewill come from the National Centre forDrug Addiction. This project will startlater in 2001. There are about 1000 addictsin prison.

Alcohol

In Poland alcohol is seen as a moreserious problem than drugs. There aretreatment centres available for alcoholismin the community. There are 19 alcoholicsections in the Polish prison system,which use the same philosophy as theAtlantis project in Mokotow Prison. TheAtlantis project was visited. Prisoners onthis project have to attend the project , aspart of their sentence. They undergo bothindividual and group therapy and live onthe unit with five or three to a cell. Theywear their own clothes and have to eattogether. They are out of the cell from 6a.m. until 6 p.m. There are 49 prisonerson the programme and it lasts for threemonths. There is education available anda printing shop. The programme wasevaluated in 1993 and it was found that20% do not drink after one year.

Alcohol is not considered to be a seriousproblem in Czech Republic prisons. ThePrison Service is opening a unit foralcoholics for 30 people next year (2002).Before 1990 there were many units foralcoholics but they were closed as it wasthought that capitalism would solve allproblems and alcoholism would reduce.There is now a need for theirreintroduction.


Compared to Poland, the Czech Republicdoes not have a big problem with alcohol.The courts do not order many people tohave preventative treatment for alcohol(about 20–30 per year). Prisoners at entryto the prison are asked if they arealcoholics and if necessary medicines foralcoholism are used while in prison,where possible.

In Hungary there are some programmesavailable for prisoners who have aproblem with alcohol.

Sex in prison

In the Hungarian Prison Service sexbetween men is not considered to be aproblem as the perception is that it rarelyoccurs. However, there is considered tobe a higher incidence of sexual relationsbetween female prisoners. If homosexualsex is consensual and discreet then thereis a lenient attitude.

There are no conjugal rooms available forvisits to Hungarian prisoners at themoment. The prison service wants tointroduce ‘intimate rooms’ for conjugalvisits or for whole family visits. Thiswould be very useful especially now asshort-term leave from the prison has beendisallowed. It should be possible toimplement these rooms but the prisonadministration are waiting for thelegislation to come from the Ministry ofJustice. The legislation is currently in theprocess of being developed and may startthis year (2001) and the main problemwill be to find the necessary space in theprison to provide conjugal rooms. Dr.Laszlo Huszar, Director of BudapestCentral Prison reinforced the view thatsex was not considered to occur in prison.

Condoms are not available in Hungarianprisons. There were plans to install

condom machines but there was notconsidered to be a need for them.Prisoners can ask the doctor or health-care staff for condoms. Juveniles getcondoms prior to release via a project notfunded by the prison service.

Sex in Czech prisons is a hidden problemthat is difficult to investigate.Exceptionally, there are incidences ofviolent sex. Sex in prison is against therules. Sex is not tolerated if it is abusivebut if it is consensual it is difficult to doanything about it. In prisons there is amonthly committee (psychologist, headof the unit, social worker, inspector ofprisons) that identifies vulnerableprisoners, who may be violent or whomay be at risk from sexual violence. Sexamongst women prisoners is moretolerated and there are only about 200women prisoners. The hidden nature ofsex between men in prison is reflected inthe wider society in the Czech Republicas was demonstrated by the rejection ofthe proposal to legalise homosexuality.

In prisons in the Czech Republic it ispossible for prisoners to buy condomsfrom the prison canteen but nobody buysthem.

There are some signs of sex occurring inCzech Republic prisons. Medicalexamination sometimes reveals signs ofviolent penetration or the spread of adisease, such as hepatitis C, is indicativeof sexual activity. People do not like tospeak about sex in prison. It is rare that aprisoner will complain about sexualviolence, due to shame. Usually theauthorities find out indirectly.Overcrowding makes the incidence of sexworse.


Gay male prisoners in the Czech Republicare put into special areas, usually singlecells, for their protection.

Aggressive sexual behaviour amongstprisoners is recorded by prison staff. Atentry to the prison, prisoners are told toinform security if they see any oddbehaviour of a sexual nature.

Condoms are available for Polishprisoners when they go on home leavefrom the prison. Condoms can beobtained from the medical staff andothers but no one asks for them in theprison. Condoms are supplied by theHealth Ministry. Some staff feel thatproviding condoms in prisons raisesethical issues as Poland is a Catholiccountry.

Structure of the prison health caresystems

The Hungarian Prison Medical Servicecan provide nearly all the inpatient andoutpatient treatment that is required. Inthe thirty one prisons, there are basictreatment sections with a full-timedoctor5. There may be more than four fulltime doctors in the bigger prisons andmany nurses. In remand prisons, wherethere are between 100–200 prisoners,part-time doctors are used and 2–5nurses. These doctors may have retiredand are returning to work for the PrisonService on a part-time basis. Health carefor prisoners is financed in two ways:from the central budget and from publichealth insurance.

5 If there are more than 500 sentenced prisoners there

must be one full time doctor provided.

The central budget for health in Hungaryis based on the number of prisoners andmost of the budget is allocated to thecentral prison hospital. The Departmentof Finance defines the amount of moneyeach prison receives. The same process isused for medicines and medicalinstruments. Public health insurance ispaid through work but prisoners areconsidered in the same way as students.There is some controversy because non-national prisoners get free treatmentwhile in prison but after they are releasedinto the community they have to pay forany continuing treatment.

In the Czech Republic, prison health careoperates on the same principles as thenational health care services. Czechcitizens are covered by health insurancelegislation. If a prisoner is not employedthen 60% is paid by the state (up to 20euros) per month. Every new prisonerhas a full medical check up at the time ofadmission to the prison. This entry checkup is the same as in public healthregarding physical health. One differenceis that an X-ray of the lungs (for TB) andin the case of foreigners a skin test for TBis done as well.

The Czech Prison Health Care Service ismore integrated into the National HealthService than it was seven years ago. Thishas been a deliberate policy and it wasemphasised that the controls for publichealth in the community also controlprison health services. The areas coveredby these controls are accommodationcleanliness, nutrition and epidemiology.Prison health care is considered to becomparable with the Czech RepublicNational Health Service. It is sometimesbetter as it can be quicker to getappointments and care in prison than it isin the community. The availability of


medicines is good in the prisons and thedoctor decides which medicines areprescribed and there is the same access asthere would be in the community. In thecommunity medicines are divided intothree groups and certain medicines haveto be paid for. As in the community,those prisoners who can afford to payhave to pay for some medicines.However, most prisoners cannot pay, asthey have no money, so they get all theirmedicines free. The prison medicalservice makes no profit and if they needto they will prescribe and provideexpensive drugs. Foreign prisonersreceive the same medical care as Czechnationals. However, as in Hungary, whenforeign prisoners leave prison they haveto start paying for any medicines.

In the Czech Republic each prison has itsown medical centre with at least one full-time doctor. There is no formal rule butthere is an unwritten rule that thereshould be one doctor and three nursesper 500 prisoners in pre-trial prisons.However, normally it is more. Whenthere is an emergency and there is nophysician the prisoner is escorted to thenearest emergency hospital. Every prisonhas a dentist who is either a full-timeprison dentist (there are 10 of these) orwho is contracted by the prison service.The health-care staff who are contractedare psychiatrists, ear, nose and throatspecialists and opticians. Every prisonusually has a consulting room forexternal doctors. Each prison has abudget to pay for contracted staff. Thereare only four psychiatrists employed bythe Czech Republic Prison Service.

New admissions to Czech prisons go toone of 22 prisons where there is a specialcheck up for new prisoners. A blood testis offered to all prisoners. It is possible to

refuse but prisoners are isolated untilthey do take the test. In reality, mostprisoners take the test. An x-ray of thelungs is mandatory every year and beforerelease from the prison if the prisoner isin the prison for longer than threemonths. From these measures, the prisonmedical staff are able to detect TBeffectively. HIV and TB are notfinancially covered by health insurance sothis comes out of the prison health carebudget.

New legislation, in the Czech Republic,that covers the community and prison,stipulates that there has to be amandatory blood test before anoperation.

In Hungary, a doctor is available eachday to see prisoners. In some institutions,there may not be a doctor’s surgery everyday but if a doctor is needed the prisonercan go to another prison or theemergency services will be used.

If it is an emergency a prisoner will see adoctor at once. The prisoner does nothave to say why he or she wants to see adoctor. The evaluation of the urgency ofthe prisoner’s request is evaluated by thenurse who is in the prison until 7pm inremand houses and in sentenced prisonsthere is 24-hour cover. If there is not anurse in the remand house, the prisonerasks an officer who will then call anambulance. What constitutes anemergency is defined by law set down bythe Ministry of Health Care.

In the central prison hospital in Budapestthere are specialists and medical experts.There are 297 beds for in-patients andfacilities for out patients. A wide range ofspecialisms are covered such as,pulmonary, gynaecology, internists, x-ray, intensive care, ear, nose and throat,


dermatology and dentistry. Prisoners cango to outside hospitals in the communityif another specialism is required. There isa psychiatric clinic (within the grounds ofthe central prison) which provides 311beds. Neurological psychiatry isprovided. There is an after care sectionwith 80 beds.

There are three prison hospitals in theCzech prison system. In Prague thehospital is 100 years old and can hold 139patients, 60 for internal problems and 79surgical beds. The optimal occupancy is89. Specialist surgeons come from outsidebut the nurses and equipment areprovided in the hospital. The hospital canalso provide x-ray and laboratory servicesand also has the facilities for out-patients.At the time the hospital was visited it was80% full, in order to meet the demands ofseparation of pre-trial prisoners, maleand female and the four securitycategories. There were about 10% femalepatients and a few juveniles in thehospital. Although most prisoners aretreated in the prison hospital, someprisoners are taken to public hospitals butthis poses security risks. Last year therewere 800 escorts from the prison hospitalfor check ups, examinations and someoperations. The most frequent illnessestreated in the hospital are cardiology andasthma.

The head of this hospital identifieddealing with foreigners as a seriousproblem as they have no healthinsurance. Some of the costs for theirtreatment comes out of the prison budget.Therefore, if a prisoner comes to thehospital in Pankrac from another prisonthe cost for treatment comes out of thePankrac prison budget. The hospitalbudget is part of the overall prisonbudget. The chief doctor liaises with the

deputy governor and they meet everytwo weeks.

The hospital director has all themedicines that he requires. There are staffshortages in the hospital where they aretwo nurses, one physician and onemedical assistant short.

The prison hospital in Brno was openedin 1997 and is very modern and wellequipped and there have been somecomplaints that the hospital is of a higherstandard than those in the community. Ithas 170 beds. It is not fully used as thereare only two psychiatrists employed atthe moment. It has an internaldepartment, intensive care, remedial andresuscitation and 28 beds for infectiousdiseases.

The third hospital is for dealing with TBonly. It has 65 beds. Some patients havelung tumours and after diagnosis,prisoners with this are released. Thoseseriously ill (terminal) are released butthe decision is made by the court and insome cases prisoners may die in prisonwhile awaiting the decision.

In Poland, as prisoners are not requiredto pay medical insurance, medical care inprison is financed from the state budget.The budget for the prison service is worsethis year than last year and health carewas considered to be the lowestbudgetary priority. The head of prisonerhealth care considers there to be good co-operation between prison health andpublic health services. The prison healthservice employs a range of specialists andconsultants and has hospital facilities.However, the prison service is not able tocover all branches of medicine nor able toprovide 24-hour care for prisoners in allthe prisons in Poland. Urgent


consultations, surgical interventions andspecialised medical procedures areprovided by the public health service andpaid for from the prison health-carebudget.

There is an out-patients’ health centre inall Polish prisons and in some prisonsthere are some hospital beds. Each sectionhas a doctor and several nurses. They alsouse outside consultants. Most prisonshave X-ray facilities.

There are two large women’s prisons inPoland with maternity facilities but therehave not been many deliveries this year(2001). The mother-and-baby houses aregood. The child can stay in prison withthe mother up to three years of age.

There are 14 prison hospitals in the PolishPrison System with 41 special wards. Inthe hospitals there is physiotherapy andrehabilitation available for disabledpeople. There are two wards forrehabilitation (one operating and one willbe later). The Mokotow prison hospitalwas visited. It has 155 beds, facilities forrehabilitation and X-ray and is primarilyfor remand prisoners. I was shown theshowers that were very clean and modernand gave prisoners privacy.

It is argued that throughcare in Poland isgood because in the Polish prison systemthe therapeutic staff are obliged to helpprisoners to continue their treatment afterthey are released. In Hungary, it is thedoctor’s role to keep in touch with thecommunity and a prisoner’s notes goboth ways.

Confidentiality

In Hungary the general rules in thecommunity, which govern medicalconfidentiality, have been adopted for the

Prison Medical Service. A prisoner’srecord is only available to medical staffwith two exceptions, the prison governoror the information officer, but it is keptsecret. Prisoners who are HIV-positive donot have this marked on their medicalfile. The result is kept in a sealedenvelope that is only opened by thedoctor.

There is not a problem withconfidentiality between the medical staffand the guards in the prison hospital inPrague. The same guards work in thehospital all the time. When a case is takento court, for example, if a patient has aterminal illness, the papers are notspecific, about the illness. Prisoner’slawyers can only have access to medicalrecords if the prisoner gives consent. Themedical staff wanted medicalexaminations to be done without guardsbeing present. No guards are presentduring examinations now and this isconsidered to be an improvement.

Staffing

In Poland the salaries for nurses arehigher in the prison than in thecommunity. The same was true for manyyears for doctors but this is changing asdoctors are earning more, since 1999,working in the community. The futuremay be problematic when trying torecruit doctors. One strategy is trying totrain prison doctors as generalpractitioners (GPs) as it is not easy to getthis specialist training (outside). It is anew idea in Poland to have GPs ratherthan specialists. The Polish Prison Serviceis taking a long-term view of recruitment.

The Czech Republic also has concernsabout the future recruitment of doctors tothe Prison Service. At the moment theyare experiencing staff shortages. For


example, the Prison Service employs 134full-time doctors and there should be 143.Currently, approximately 45% of theprison physicians have retired andreturned to work for the prison service.Plus working for the prison service is notan attractive career for young doctors.This is despite the opportunity forupdating skills, which is very good fordoctors as there are many courses duringthe year where they can meet withcolleagues in the health service. Prisondoctors have the same status as doctorsworking in the community. However,there is perceived to be no advantages towork in the prison service and sometimesthe behaviour of the patients is difficult. Itis also considered to be important thatprison doctors have a certain level ofexperience before being able to work inprisons. Many doctors in the PrisonService are reaching retirement age or areretired and replacing them will bedifficult because of salaries. A healthinsurance agency doctor can command asubstantially higher salary than a doctorworking for the prison service.

Nurses in Czech prisons are required tohave had three years’ experience ofpractice prior to being employed by thePrison Service. However, there are novacancies for nurses as the salary in thePrison Service is twice as much as that inthe community.

In Hungary, there are also staff shortages.The Prison Service employs 95 full-timedoctors and there should be 105 and 387nurses are employed and there should be410. Health-care staff can receive moremoney if they are classified as uniformedstaff, that is, part of the military. ThePrison Service tries to have as manydoctors as possible classified as military

staff as a means of keeping the doctors inthe prison service.

Equivalence of care

According to the Council of Europerecommendation R (98) concerning theethical and organisational aspects ofhealth care in prison:

Health policy in prisonshould be integrated into,and compatible with,national health policy. Aprison health care serviceshould be able to providemedical, psychiatric anddental treatment and toimplement programmes ofhygiene and preventivemedicine in conditionscomparable to those enjoyedby the general public.(Appendix toRecommendation No. R (98)7:b)

All three of the countries appear to bemeeting this recommendation as far as ispossible given the staff shortagespreviously mentioned. In Poland, theywant to get prisoners onto the nationalhealth insurance system as in thecommunity to make access to outsidefacilities easier. In Poland, prisoners getall the specialised care available in thecommunity. The cost per prisoner perday is higher than allowed for the ill inhospitals in the community. The feeling isthat prisoner health care is better thanstaff health care.

In the Czech Republic, the professionalcontrol of doctors is regulated both by thehealth department in the Prison Serviceand by the Public Health Medical Service.Prisoners are dealt with in the same way


as in the community and have access tothe same services. It was argued thathealth care was better in the prisonbecause there are more facilities andmedicines are free. For example, falseteeth are expensive but if a prisoner haslost 50% ability to bite then they will getfree false teeth in prison.

The professional skills of prison doctorsare maintained and updated in the CzechRepublic by ‘professional’ days fordoctors and experts when they can workin the community health institutions. Theupdating is regulated by the Ministry ofHealth.

In Poland, they have conferences onparticular subjects at which a variety ofhealth care staff share the good practicesof the different prisons and also shareexpertise with the community. Thisworks both ways, for example, how totreat people who have swallowed things,which happens a lot in prison, is usefulfor doctors working in the communitywhere it occurs less frequently.

Treatment programmes

A wide range of treatment programmeshave been introduced across the threeprison systems. Many prisoners haveunhealthy lifestyles outside prison: theyare more likely than the generalpopulation to smoke, drink, and to takedrugs. Prisoners are more likely to havesuffered mental illness.

In Hungary, there are programmes forpsychopathology, alcohol abusers andinformation about HIV is delivered insmall groups to prisoners. There is also aspecial project for job finding after releasefrom prison. There is a mental healthcourse. There are problems with suicide

and ideas about prevention are beingdiscussed during this year (2001). Thenumber of suicides has remainedconstant over the last two years with ninesuicides in 1999 and 8 in 2000. The nextstep that the Hungarian prisonadministration wishes to develop is toprovide programmes for sex offendersand for drug addicts. There are alreadysome small programmes in these areasbut they want to expand them.

In the Czech Republic, for standardtreatment programmes there should betwo pedagogues6, one social worker, onepsychologist and eight educators7 whomake up a multi-disciplinary team. Thereshould be two teams in each prison forevery 160 prisoners. In the case ofspecialised treatment for youngoffenders, there should be one educatorfor every 10 prisoners, one pedagogue for20, one psychologist and one socialworker for every 40 prisoners. They arealso trying to introduce an instructor toprovide physical education andvocational training for these groups.

The teams work in a multi-disciplinaryway and they have regular meetings. Theprison governor is not practicallyinvolved in the meetings but he or shehas to approve the programmes. Inreality, the methodology for theprogrammes comes from the prisonadministration and the prisons thenprepare their own programmes using theframework. The programmes are thenapproved and controlled centrally. The

6 Pedagogues are teachers who work with prisoners in a

range of activities. They have similar qualifications tothe educators.

7 Educators have responsibility for between 40-60prisoners who they are expected to get to know well.The educator deals with welfare issues and torespond to prisoners' problems. They need to have atleast secondary education and more usually auniversity degree.


teams are required to meet once permonth, but actually meet morefrequently, and they have to keep writtenrecords. However, this multi-disciplinaryway of working is still being developed.The teams also have an influence onpolicy and changes have been made tohealth policies. There will be training towork in teams starting in 2001.

In prisons in the Czech Republic there is aspecial unit available for those withmental health problems, for example, forpsychopaths, psychiatric patients and soon. In 2000 they had nine suicides in theprison system.

The Czech Republic prison doctors trynot to use methadone in detoxificationtreatment of drug addicts. However, aprisoner can continue to use methadone ifthey were on it in the community. Duringdetoxification, the prisoner is left in thepublic hospital for three weeks, wherethey will receive benzodiazepines.Prisoners who say that they are drugusers are asked to go to the drug unitwhere they are treated by psychologists,psychiatrists, social workers and nurses.Being on the unit involves mandatoryattendance at group work and individualtreatment. The quality of the treatmentdiffers but it is good in Pancrac prison.Currently, drug addicts do not have toaccept treatment and this is perceived asa problem.

The Czech Prison Service is trying tointroduce preventative health care. Forexample, a special department forprisoners who have committed sexualcrimes, used drugs or alcohol andpsychiatric treatment is being introduced.The court orders this preventativetreatment but it is to start after releasefrom prison. However, the prison service

is starting some treatment before release.The prevention is mostly forpsychopaths. Preventative measures(from the Czech Penal Court) includetreatment and prevention. This treatmenthas to be decided by the court, forexample, repeated rapists or paedophilescan be sentenced to prison andpreventative treatment after the sentenceis served. However, the prisonadministration decided the time to do thisprevention is while the prisoner is in theprison as they need to undergo treatmentto change behaviour while in prison.There is currently not as muchpreventative treatment as the prisonadministration would like but they aretrying to establish as many departmentsas possible for such treatment. In 2001,they want to open a preventative medicaldepartment for psychotics who are notresponsible for crimes and who cannot besentenced to prison and a department totreat people who are at risk of suicide.

The strategies for treatment in Polishprisons reflect those in the community onthe prevention of drug and alcoholaddiction. The law has made it necessaryto make available some of these drugsand alcohol programmes in prison. Forexample, there is co-operation withpsychologists trained by publicinstitutions in some prisons as theycannot afford full time specialists andhave employed part time people who arealso working in the community and whoare not prison military staff. Thetreatment that is offered to prisoners isdependant on their classification by thecourts. This includes prisoners who arementally disturbed, addicts to mind-altering substances and the physicallydisabled. If assigned to the therapeuticsystem the prisoner gets some educationand then goes onto a waiting list for


treatment. The prisoner will also haveaccess to, for example, AlcoholicsAnonymous meetings while waiting toget onto a programme. Young offendershave no choice they have to serve theirsentence via a programme. Drug addictsor mentally ill young offenders areautomatically assigned to the therapeuticsystem. The programme is organised byconsent and the prisoner takes someresponsibility regarding education workand their family. Every six monthssentenced young offenders on aprogramme are assessed by their casemanager and the penitentiarycommission.

There is specialist treatment for Polishprisoners with a mental illness and theyare treated well. Originally, alcoholicsand drug addicts were placed in thewings for mentally disturbed prisoners.Now they are introducing new wings.There are 22 wings for the mentallydisturbed (1400 prisoners), 11 wings foralcoholics (400 prisoners) and 10 wingsfor drug addicts (300 prisoners) in Polishprisons.

It is usually psychiatrists or psychologistswho are head of these specialist wings.The staff are organised into therapeuticteams consisting of a psychologist,doctor, activity therapist, psychiatrist andcase managers. Prisoners are admittedonto the wings based on regulations inthe Polish Criminal Executive Code andthe prison rules, as approved by thecourts. This treatment can be included inthe sentence — the court can decide that aperson should be placed on a specialistwing. The decision of the court is basedon the evidence from forensic experts.The treatment can be individual andgroup psychotherapy, work and culturalactivities as therapy and there are also

links and co-operation with the familiesof the prisoner. Each prisoner is assignedan individual treatment programmedesigned by the treatment team.Pharmacological treatment is only usedas an addition. There are alcohol anddrug-treatment programmes lastingthree-to-six months. Those within thesystem are of the view that there are notenough sections for alcoholics anddesigning and producing new wings foralcoholics is seen as a difficult task.

The treatment available has beendiversified over the years. The treatmentmethods used in prison have beendamaged as the chance for prisoners towork has declined. In the last fewmonths, the prison population has grownso that now each psychologist has anincreased caseload. If the prisonpopulation continues to grow there willbe less and less space in which to offertherapy.

There are 6 wings for psychiatricdisorders and 22 wings for therapeutictreatment. There is still a need for morehospital beds as it is difficult to sendprisoners outside for treatment asprisoners do not have health insuranceand there is then the problem of who isgoing to pay (although the PolishMinistry of Health do pay for sometreatment) There are 20 psychiatricproblems’ therapeutic wards with adifferent way of working with individualtherapy programmes. Each ward has apsychologist, nurse, educator and guard.It is important that these wards exist as itgives a chance to access professional help,the living conditions are better and thereis more freedom than on the other wings.It also teaches prisoners how to survive inthe community after being locked up in acell for years.


There were 44 suicides in Polish prisonsduring 2000. Cutting is also a frequentproblem in prison, mostly done by men,it is unusual for women to do this. Thetendency of swallowing objects isdecreasing in prison. There has been aslight change in regulations about self-mutilation. Until 1998, the law stipulatedthe period for medical assistance afterself-mutilation did not count as part ofthe sentence served, from now it willcount.

There has been no formal evaluation ofhow well the treatment programmeswork. However, there is some feedbackfrom research done in one prison inWarsaw where prisoners who haveaddiction problems were interviewed.The head of treatment in the PolishPrison Service is satisfied that theprogrammes work, based on discussionsshe has had with colleagues who tell herthat many of the prisoners are veryhappy with their therapy. Colleaguesfrom other prisons also get feedback fromex-prisoners who have continued not touse addictive substances for six monthsor more after release from prison.

Health promotion

Health promotion is just starting inPoland but they have the most developedstrategy amongst the three countriesvisited. There have been many health-care reforms and they need some time tosettle now. The prison health-promotionstrategy is set centrally but the headsfrom the medical centres in the regionsalso add to the strategy. There are fifteenregional offices each with a head doctor.

The doctors are working towards healthpromotion and they go to the prisons.There is an annual meeting about thehealth promotion strategy for members of

the prison health service. It is a two wayprocess of staff training and changes topolicy. The health promotion strategywill introduce a methadone programmefor prisoners later this year (2001).Prisoners currently receive a lot of healthpromotion information from the medicalcentres and they can also get informationfrom the doctors during the medicalexamination at entry to prison.

The Polish head of prison health careaims to inform the Ministry of Health thatprison provides a good opportunity tofocus on health promotion and educationabout health (for example, TB, Hepatitis,HIV, drugs) and encourage the Ministryof Health to take responsibility forprisoners. In the area of transmittablediseases there is a TB preventionprogramme. Information about riskbehaviour is provided at the time of entryto the prison, especially focusing onsexually-transmitted diseases. There arealso some interviews with prisonersconsidered to be in ‘at risk groups’. Theprison radio is also used to provideinformation on risk behaviours anddrugs. There is continual education usingbooks, posters, and information. Theprisoners are involved with the prisonradio and it is possible for them to choosethe subjects for the programmes. Videosare also used and given to prisoners towatch.

It was mentioned that it is not easy towork with health promotion strategies inprison because people think that theproblem stops when prisoners are putinto prison. The climate in Polish societyis slowly changing.

In the Polish Prison Health CareDepartment, health promotion is alsoconsidered to be important for prison


staff. This year (2001) a Hepatitisvaccination programme for staff willbegin. It is hoped that the Ministry ofHealth will pay for this for security staff,as this is a requirement for their job. It isthought that the staff will be willing totake the vaccination and they will have topay a small part towards the cost in orderfor them to take responsibility for theirown health care.

The second project for staff health will bean anti-smoking campaign and this willalso be introduced for prisoners at a laterdate. They want to try to change thesmoking culture of the prison: 90% ofprisoners are smokers. Nationally therehas been a high profile anti-smokingcampaign but it is mostly educatedpeople who are giving up. The workingclass are still smoking.

Previously, the health of Polish prisonstaff has been ignored. The prisonenvironment is stressful and aggressive.There will be a questionnaire sent to staffto rate their stress levels and views ontheir health. A psychologist has beendesignated to work with the prison staffin each prison. The harm reductionproject is designed to make their jobseasier. Alcohol reduction will be the nextproject.

In Hungary, there is a sexually-transmitted disease policy that requiresall health care staff in prisons to educateboth staff and prisoners. The PrisonHealth Care Department also provideseveral booklets that are simplified fromthose supplied by the Ministry of Health.There are some non-governmentalorganisations who provide films andvideos. All prisoners have sessions ingroups (some large and some small)about personal hygiene, fungus, drugs,

HIV, influenza, TB and mental healthtreatment. The department has a half-year work plan and the dates for thegroups are made available in advance.Prevention information is included and iscompulsory for both staff and prisoners.Health materials are not translated intoother languages due to a lack of money.What money there is has gone to translatethe prison rules.

In the Czech Republic there is a harm-reduction policy. It is one of the duties ofthe health care staff to provideinformation. Posters and discussions arealso used.

All new prisoners to Czech prisons go toa special admissions wing where theystay up to two months. While there, theyare informed about their rights andobligations, interviewed by apsychologist, educator and social worker.During this time, they will get harm-reduction information but there is nospecial policy about what informationshould be given. Some materials aregiven to prisoners. An interpreter will beprovided where necessary, according tothe legislation, but the availability of atranslator depends on the languagerequired.

The harm-reduction policy guidelines areset by the Czech Republic Department ofPrison Health Care and a booklet isprovided for the prison medical staff.Every six months there are meetings ofthe head doctors from all prisons and thekey issues are discussed. It is thought thatthere is good co-operation between thedifferent health centres in the prisons andthe Department of Health Care. InPankrac Prison, for example, there are anincreasing number of foreign prisonersand some information on the prison rules


has been translated into Russian, Englishand Arabic. This has also happened forHIV, TB and sexual diseases. If they needa translator, they use someone fromwithin the ministry or possibly someonefrom the embassy.

Prison practices affecting thehealth of prisoners

Cleanliness and hygiene

In Poland, it is possible for somesentenced prisoners to wear their ownclothes. Women prisoners are able tohave a shower every day if they want toand this is set down in the law.

In Hungary, women and juveniles canshower every day. Prisoners who workcan shower every day, if they are notworking they can shower once per week.Sentenced prisoners are provided with auniform. Remand prisoners can washtheir underwear where this is possible.There is a central laundry in prisons,which prisoners do not have to pay for..In the Czech Republic, it is possible formale prisoners to have a shower at leastonce per week or more frequently, basedon the recommendation of a doctor.Women can shower at any time. Theshowers in some of the prisons are notgood and prisoners often demolish them,so it is a continual process of repairingthem.

Prisoners can have their own clothes butthey often have no money and the clothesthey have are often very poor. The Czechprison administration are trying toimprove the prison uniforms but theyhave no money for this. Prisoners can

wear their own clothes if they wash themregularly, that is, if someone brings infresh clothes for the prisoner.

Food in prison

In the Czech Republic, there should be anurse present (at least part time) whocontrols the nutrition in each prison. Thenurse also controls the menu and thequality of the food. The doctor, once perweek, signs the weekly menu. The doctorhas to control the quality of the meals.

The food in prison is considered to be asgood as on the outside. The prison servicenorm is to spend approximately 2 eurosfor raw materials per day for mostprisoners and additional money for othercases, for example, pregnant women. Thesystems for providing special diets is thesame as on the outside. There are twelvepossible diets available; Czech law insistson this. It is also possible for specialmeals for religious requirements to beprovided under special internalregulations of prisons. Attempts aremade to offer a balanced diet but fruitand vegetables are expensive and notavailable in large quantities.Approximately one and a half euros perday are allowed for drinks.

In the Czech Republic, from 2001, kitchenhygiene will be checked by externalhygienists. This used to be theresponsibility of an internal hygienist.The role of the medical doctor in thequality of the food is changing now thathygienists are based in the community.Dieticians report to the Chief MedicalOfficer and he reports to the governorand external hygienist. The prisongovernor has the duty to remedy anydefects reported.


About half the prison kitchens are not ingood repair. This is reported tomanagement but the lack of moneymeans that nothing is done to solve theproblem. However, the state of prisonkitchens is seen as an essential issue thatneeds to be dealt with. The new system ofinspection will mean that there will besubstantial fines for sub-standardkitchens and this may help the prisonservice to be able to deal with thisproblem. In Pankrac Prison the food isconsidered to be good and there havebeen no complaints for the last one or twoyears. The kitchens are not new but therehas been some reconstruction and somenew equipment and they are cleaner nowthan they were before.

Food standards in Hungarian prisons arebased on the norms set by the Ministry ofHealth, which specify the energyrequired for work. Prison administrationofficials consider that the norms are settoo low and that the diet is lacking invitamins. The variety and amount of foodis, though, often more than the prisonersget outside. There are special dietsavailable for health reasons, religion andfor vegetarians.

In Poland, food is considered by theprison administration to be much betterin prison than in the community.However, it is not a healthy diet. There isconsidered to be too much fat in thecurrent diet in the prisons and the head ofhealth care wishes to reduce the amountof fat. There are 2600 calories per day forthose not working, if working the diet is3200 calories plus another 1000 if doingheavy work. Nonetheless, the diet isvaried and there are dieticians whoprepare the menus. Medical staff checkthe food prior to it being served toprisoners and the menus have to be

signed by the doctor. There are also ninespecial types of diets prepared.

Activities and work

The opportunity to be engaged inmeaningful activity is an important factorin prisoners’ overall sense of well beingand health, especially in situations wherethey have very limited time out of cells andwhere the cells are overcrowded. Theopportunity for such activities varied inthe three countries and was effected by therate of overcrowding in the prisons.

In Hungary, in some remand houses,education programmes are available,usually short vocational or basiceducation. More than 2000 prisoners haveparticipated in this vocational training.There are religious services in the prisonand a full time priest in the remandhouses. Prisoners have had access topriests since 1990. Between 5 – 10% ofprisoners have asked to talk to the priests.There are 11,300 sentenced prisoners ofwhom 4,700 have no work (especially inwinter as it is too cold to be in the fields);2,500 prisoners are involved in educationprogrammes. If a prisoner works, they getone third of the minimum national salary.If they take education they get one ninthof the minimum salary.

In the Czech Republic, young prisonershave access to the vocational departmentof the Ministry of Education and in sixprisons they have a school. It is hoped toincrease the number of these apprenticeschools. It is mandatory for juveniles (15–18 years) to attend these schools. Thoseaged 18–26 years, if they need it, alsohave to attend these schools. There arealso other courses available in eachprison, basic education for adults andjuveniles and other courses like Czech


language for foreign prisoners. The aim isto keep prisoners active and to make upthe gaps in their education and socialskills.

The overriding philosophy is that, withsome prisoners, it is important to employthem in order to rehabilitate them. Forother groups, for example, youngoffenders, it is important to provideeducation, which is more important fortheir future employment than regularemployment whilst in prison. Since 1965,work and education are on the same levelof importance. Prior to this education wasprimarily provided by evening classesafter work but now it is available duringthe day.

It is mandatory, under Czech legislation,for sentenced prisoners in the CzechRepublic to work. In reality, about 40% ofprisoners are employed and there was aslight increase last year with about 1000more prisoners being employed than in1999. The remainder work occasionally.There should be no difference betweenCzech prisoners and foreign prisoners inthe availability to work. Pre-trialprisoners have no obligation to work. Thepay received depends on the number ofhours worked, based on the minimumwage of 149 euros per month. If there isno work available, prisoners are given 2euros per month. If they are doingeducation, they are not paid.

In Pankrac prison, sentenced prisonersare mainly employed on the maintenanceof the prison but the numbers employedhave had to be cut since the introductionof the minimum wage, the prison can nolonger afford to employ them, resultingin a drop of employment from 85% toabout 60%.

In 1999 in Poland, 25% of sentencedprisoners or 11,410 prisoners wereworking. There is an unemployment rateof prisoners of 42% of those who could beemployed. The majority of the work ispaid domestic work (74%). In all, 5% ofprisoners are working outside the prisonand 1% are involved in craftwork(activities that can be done in the cell, forexample, sewing or light assembly). Theactivities available for prisoners in closedprisons are very limited. Prisoners whowork get almost the same amount ofmoney as they would in the community,that is, the minimum wage. The lack ofwork is one reason why TV is allowed inthe cells and 90% of prisoners have a TVset in their cell. Small animals like birdsor cats are also allowed in prison.Prisoners are not paid for doingeducation but they do get a small amountof pocket money.

Key issues in health provision

HIV

Currently, in the Polish prison system,there are 981 HIV-positive prisoners(2001). There is no mandatory testing forHIV on entry to the prison as prisons arepart of the national project for HIV andthe testing is voluntary in the same wayas outside. There has to be signed consentfrom the prisoner for an HIV test. Not allprisoners are screened as this isconsidered by the prison administrationto be a waste of money as all prisonersshould be treated as if they are HIVpositive. If a prisoner has the HIV testthey get pre- and post-test counselling.Prisoners who are HIV-positive are notseparated from the rest of the prisonpopulation and their status is confidential


so that even the prison governor does notknow who is HIV-positive.

Prisoners in the Polish prison system whoare HIV-positive are given anti-viraldrugs in co-operation with the NationalCentre for Communicable Diseases in thecommunity. The Ministry of Healthsupplies and pays for the drugs.Previously in Poland, therapy stoppedwhen a prisoner came into prison.

In the Czech Republic, when HIV wasfirst seen in the 1980s, risk groups ofprisoners (homosexuals, prostitutes anddrug users) were mandatory tested until1994. In 1994, legislation guaranteeinganonymity and the voluntary agreementto HIV testing was adopted by the PrisonService. The only groups who are testedwithout consent are pregnant women,unconscious people, those accused of asexual offence and those ordered to betreated for sexual diseases — testing forall other prisoners is voluntary. WhenHIV is diagnosed, the prisoner is treatedthe same as all other prisoners (notisolated). Prisoner confidentiality isguaranteed as usually no one knowsunless a prisoner asks to be placedseparately when the prison governor isthen informed. The prisoner’s HIV statusis put in his medical file but HIV is notwritten rather the international code isused so good confidentiality is achieved.

Previously, prisoners’ files had been seenby some unauthorised person so this useof the international code for HIV is asafeguard. There is only one personauthorised to know who is HIV in theprison service and this is the doctor at thePrison Service Headquarters.

In the Czech republic HIV appears to bestable at the moment with only seven

people known to be HIV-positive out ofthe 21,000 prison population8. Between1986–2000 in the Czech prisons 68,355people were tested and 17 cases of HIVpositive prisoners were identified.

In Czech prisons there are two steps todiagnosis of being HIV positive, first thereactive test followed by a confirmationtest. When the second test is positive thenthe prisoner is considered to be HIV-positive. There is only one laboratory fortesting. For post-test counselling theprisoner goes to special public regionalcentres that are mostly in Prague. Thedoctor arranges for post test-counsellingand a treatment schedule according to theprisoner’s health condition. Prisonerswho are non-symptomatic stay in theprison. When the level of T cells reaches acertain level, a proposal is made by thedoctor to obtain release from the prisonfor the prisoner. This release is notpossible for prisoners with life sentences.

HIV testing is compulsory in Hungarianprisons and is part of the Ministry ofHealth regulations, which says thatprostitutes, homosexuals and prisonershave to be tested. The testing isanonymous and forms part of the medicalprocess at admission to the prison.Prisoners are told why the doctor istaking blood. There have only been fivecases of prisoners refusing to take the testin 15 years. In the opinion of the head ofPrison Health Care, they have goodresults. Of 14,862 tested, there have been3 cases (2 of whom were foreigners) whowere HIV-positive and there are only atotal of 8 prisoners who are HIV-positivein Hungarian prisons. The system oftesting and management of HIV isconsidered to work well in Hungary and

8 It was not known how many of the 21,000 prisoners

had taken the HIV test.


is the reason for the low numbers of HIV-positive prisoners. However, there isprejudice, both in prison and in thecommunity, towards people who areHIV-positive. In addition, it was felt thatmost prison staff did not want to workwith those who were HIV-positivewhereas the new unit for HIV-positiveprisoners employs staff who are trainedand who understand the problems ofHIV.

The World Health Organisation has beenpressing the Ministry of Health to changethe policy of mandatory HIV testing andthe European Committee for thePrevention of Torture and Inhuman orDegrading Treatment or Punishment(CPT) is also not happy because ofprisoner’s human rights — however, inHungary the human rights organisationwant this system to continue. The PrisonService’s response to the CPT is that theywant this system to continue. If the PrisonService went against the policy of theMinistry of Health the Prison Servicewould not receive the money to continuetreatment for HIV-positive prisoners.When prisoners are found to be positivethey are taken to a special unit inBudapest.

In Hungary, specialised treatment forHIV is only available in one hospital inBudapest. The rationale for the separationof HIV-positive prisoners is because thetreatment is only available in this onehospital. All the HIV-positive prisonersreceive the treatment available in thecommunity and the NHS pays for this.These prisoners have showers in theircells, all of which are single cells. There isa community room with games andtelevision and one social worker isavailable for them. There is a specialistservice in the community for sexually-

transmitted diseases and the prisoninforms them about HIV-positiveprisoners. If it is a new case, the specialistservice will go to the unit with theprisoner and they will tell the prisonerthe consequences of the HIV test. So thereis post-test counselling provided.

Tuberculosis (TB)

In Poland TB screening has stopped inthe community and TB is not spreadingwithin the prison. On entry to the prison,there is an x-ray for TB. The incidence ofTB is approximately 7 times more inprison than in the community. However,the number of TB cases in prison is goingdown. At the moment there is not aproblem with the strain of TB that isresistant to drugs. Every prisoner isscreened for TB each year. There are fourTB wards in the prison health system andthere are currently 274 cases of TB.

In the Czech Republic in 1999, there were2060 cases of TB amongst prisoners and85 cases in the TB hospital. Most (75%) ofthese prisoners had been tested before onprevious admissions to prison.Exceptionally, a prisoner may contract TBwhile in prison but so far only onewoman prisoner has. There are no deathsin prison due to TB as a prisoner in thiscondition would normally be pardonedbefore death.

The incidence of TB in prison in Hungaryis about 4–6 times more than in thecommunity. In 1999, there were 39 casesper 100,000 of TB in the communitycompared to 145 per 100,000 in prisonand this has risen to 212 per 100,000 inprison in 2000. There is specialisttreatment provided in the central prisonhospital for TB in Budapest.


Hepatitis

The head of Health Care said that inPoland the incidence of various diseasesis not always accurate as individualprisons record the number of casesmanually and this can be subject to error.In general hepatitis is not considered tobe a problem in the prison system. Thedifferent types of hepatitis are notseparated but from next year they will berecorded separately. Overall, theincidence of hepatitis is growing. Mostlyof hepatitis B and not so much ofhepatitis C. This is why they are focusingon vaccinations for prisoners and staff forhepatitis B. Prisoners will be able to askfor the hepatitis vaccination in the future,especially for prisoners with a drugaddiction and the vaccination hopefullywill be paid for by the Ministry of Health.The co-operation with the nationalMinistry of Health is good and slowly theprison administration is getting them totake responsibility for prisoners’ health aswell.

In the Czech Republic there is a relativelyhigh number of cases of hepatitis C in theprison system with there being 53 cases in2000 compared to 42 cases of Hepatitis B.Hepatitis is considered to be a growingproblem but not dramatic compared withthe number ten years ago. The number ofcases has been static for the last fiveyears.

In the Hungarian prison system during2000 there was 1 case of acute hepatitis A,1 case of acute hepatitis B and 1 case ofacute hepatitis C. There were 113 chroniccases of Hepatitis with 60% beingHepatitis B and 40% being Hepatitis C. Itwas not known if this incidence ofHepatitis was connected to drugs as theprison service do not test for hepatitis ona regular basis. If a prisoner donates

blood while in prison the blood is testedby the blood service and the prisoner willbe informed if they have hepatitis.

Syphilis

In Poland there were not many cases ofsyphilis reported in the prison system in2000. There were 114 cases reportedwhich is less than 100 per 100,000. It waspointed out that this figure may be due tothe way records are kept in the individualprisons.

In the Czech Republic syphilis is trackedas mandated by law and it is controlled inprisons. Each prisoner has a blood testand there has been a dramatic increase inthe number of cases. Each prisoner whohas a positive test result goes to Brno fortreatment.

In the Hungarian prison system therewere 14 cases of syphilis during 2000.

Terminally ill prisoners

Prisoners in Polish prisons who areterminally ill can ask the courts to begiven sick leave to go home or to receivetreatment outside in the community (ifthey require long term treatment) or theycan ask for a break in their sentence of upto six months.

In Hungary if a patient is terminally illthe doctor may apply for an interruptionof the sentence (this is a quick process) orfor a pardon from the President of theRepublic (but this is a slow process). Insome cases prisoners do not haverelatives to take care of them and this istaken into account when the decision toallow release is made. In 1999 there were75 cases applied for and in 2000 therewere 63 cases applied for. Not all of thesewere released. In the case of interruption


of sentence for long-term treatment, at theconclusion of the treatment the prisonerhas to come back to finish the sentence. In2000, five people were allowedinterruption of their sentences.

In the Czech Republic in the case ofterminal illness, a proposal is made to thecourt to cancel the sentence and toarrange to move the prisoner to thepublic hospital nearest to their home.This is not always acceptable to the courtsand the courts move very slowly, but inthese cases, they try to move morequickly.

Dentist and opticians

In Poland there is a dentist facility inevery prison. If a prisoner needs falseteeth, these can be supplied. Glasses canalso be supplied by the prison medicalservice.

In the Czech Republic there are enoughdentists in the bigger prisons and there isnormally a full time dentist in sentencedprisons and a part time dentist in remandprisons.

There are enough dentists in the biggerHungarian prisons with a full timedentist in sentenced prisons and a parttime dentist in remand prisons.

The role of the prison doctor inpunishments

The physician’s oath is seen as being veryimportant in Hungary. There are notconsidered to be problems or conflictsbetween health care and custodial dutiesDoctors do advise on fitness forpunishment when a prisoner is sent to an

isolation cell and the doctor will visit theprisoner daily while in isolation.

In Poland the doctor visits the prisonerbefore he or she is put into isolation andif requested a psychologist will also visit.There is not perceived to be a conflictbetween the doctor’s health care andcustodial duties. The case manager alsohas a duty to go twice per day to check onthe prisoner. In reality isolationpunishment is very rarely used now inPolish prisons.

In the Czech Republic a prisoner can bepunished with up to 28 days in isolationor up to 20 days in a closed situation (23hours locked up). Before either of these,the doctor has to sign that the prisoner isfit enough. The prisoner has a medicalcheck up to ascertain this. The doctorthen visits at least once per week and theprisoner can ask to see the doctor onother occasions. The European PrisonRules say that a doctor should visit suchprisoners once per day but the above isthe Czech legislation and practice.

Conclusions

The report has highlighted some keydescriptive data about the health careprovision in the prison systems of theCzech Republic, Hungary and Poland.Overall, there was enthusiasm for changeand a continual striving to improve thequality of prisoner health care in all threesystems. Staff were keen to implementthe European and WHO guidelines forprisoner health but all felt that they wereconstrained to some extent by the prisonbudget. The exception was in regards toHIV and mandatory testing wheredespite the WHO and EuropeanGuidelines, the Hungarian prison service


was convinced that mandatory testingwas necessary and that it worked.

There was awareness of changes in thewider societies, which would eventuallyhave an impact on the prison populationparticularly regarding increasing drugabuse and alcoholism. The areas of drugabuse and alcoholism require constantvigilance especially when we look at theexperience in prisons in Western Europewhere there is a large problem with drugaddiction, HIV and hepatitis C. TheHungarian Prison Service’s response todrugs includes staff education, theintroduction of drug free units andminimising the amount of drugs gettinginto prison. Dealing with drug andalcohol addiction requires theimplementation of multi-disciplinaryways of working (Council of Europe,2000). The extent and effectiveness ofmulti disciplinary work to combat drugand alcohol addiction in the threecountries varies. For example, in Czechprisons, treatment teams work in a multi-disciplinary way in theory but thismethod of working is still beingdeveloped. In Poland, there is sometraining for staff in the first two weeks oftraining school. After this, once thedifferent professional groups are workingin the prison, they develop ways ofworking by themselves. Workingeffectively in a multi-disciplinary way isnot always straightforward and there is aneed for training to address the differentprofessional backgrounds in order toachieve a co-ordinated approach withprisoners (MacDonald, 1999).

As yet health promotion and harmreduction is in the developmental stagesin the three countries. Poland has themost developed strategy both forprisoners and for prison staff.

It is important that imprisonment shouldbe seen as a good opportunity toencourage health promotion with hard toreach and vulnerable people. There is atendency for prison administrations tosee the health care staff as havingresponsibility for providing harmreduction and health promotion but thisshould also be the responsibility for themanagement and the whole prison staff.In order to provide effective harmreduction and prevention, prisonadministrations and individual prisonsneed to formulate written prevention andharm reduction strategies that addressthe incidences of risk behavioursoccurring in the prisons. Harm reductioninformation should also be provided in arange of languages that reflect the prisonpopulation. In response to the increasingnumbers of foreign prisoners in Czechprisons health information about HIV, TBand sexual diseases have been translatedinto Russian, English and Arabic for usein Pankrac prison hospital.

In all three countries sex in prison and therisks that accompany unprotected sex,particularly in male prisons, are eitherdenied or underplayed for a variety ofreasons. The first step to providingeffective harm reduction and preventionis the official recognition that riskbehaviour is occurring in prison. Thefailure to acknowledge that sexualbehaviour occurs in prison prevents theeffective introduction of harm reductionmeasures, such as making condomsavailable to prisoners.

Health care departments in the threeprison systems are all at risk due toshortages of staff and problems aboutfuture recruitment in a situation whereprison medical staff are better paid in thecommunity than in the prison service. It


was heartening to see the variety ofstrategies being adopted to try to bothrecruit staff and to retain those alreadyworking in the system. In Poland, forexample, one strategy is to train prisondoctors as GPs as it is not easy to get thisspecialist training in the community.

The Hungarian Prison Service hasdeveloped their computer system whichhas greatly aided the recording ofmedical data especially of incidence ofcommunicable diseases. In Poland, bycontrast, such data are recorded by handand are not totally reliable. A uniformsystem of collecting and analysing datashould be a priority to enable prisonadministrations to plan effectively tomeet the health needs of their prisonpopulations.

Health care that is equivalent to thatprovided in the community is part of thefundamental rights of every prisoner. Inall three of the countries there wasconsidered to be equivalence of healthcare in prison and the community. Insome cases health care in prison wasconsidered to be better than that availablein the community.

All three prison systems wereexperiencing overcrowding. This placedstrains on staff and reduced the amountof constructive activity available toprisoners; it also impacted on the overallhealth of the prison population. AsTomasevski (1992:xiii) argued:

Prison health services operateunder many constraints. Thenature, severity and scope ofprison health problems is to alarge extent determined bythe sentencing policies andpractices. For this reason, the

prison health personnel havethe unenviable task of copingwith the consequences, whilethe causes remain beyondtheir reach.

It is important that thegovernments of the threecountries visited take theresponsibility to support theirprison service by providingsufficient finances to enable thecontinuing development in theprovision of a healthyenvironment for prisoners inaccordance with internationalstandards.


References

Council of Europe, 2000, Health Care inPrison, Multilateral conferenceorganised by the Council of Europe,Strasbourg 1-3 December, 1999.

Council of Europe, Committee ofMinisters Recommendation No. R (98)7 footnote 1 of the Committee ofMinisters to Member StatesConcerning The ethical andOrganisational Aspects of health Carein Prison (Adopted by the Committee ofMinisters on 8 April 1998, at the 627thmeeting of the Ministers' Deputies).

MacDonald, M., 1999, A ComparativeReport of the Prison Audits in 10 Italianand 10 English Prisons. Research Report.Birmingham. University of CentralEngland.

Tomasevski, K., 1992, Prison Health:International Standards and NationalPractices in Europe. Helsinki Institutefor Crime Prevention and Control,affiliated with the United Nations,Publication Series 21. Helsinki.

Walmsley, R., 1996, Prison Systems inCentral and Eastern Europe: Progress,Problems and International Standards.European Institute for CrimePrevention and Control affiliated withthe United Nations, Publication SeriesNo. 29.Helsinki.

Prison Health Care in the Czech Republic, Hungary and Poland

Documents

Transcript of Prison Health Care in the Czech Republic, Hungary and Poland