WHO perspective on addressing women's health in prison

Honourable ministers, distinguished colleagues, ladies and gentlemen, I am here today to share the WHO perspective on why and how we should address the complex problem of women’s health in the prison context.

I hope that our collaborative work through the Health in Prisons Project and the Kyiv Declaration will help to bring the solutions within our grasp.

Usually WHO tackles issues that have a large scale or a vast impact on health across nations. Today we are here to focus on a different kind of problem due to the depth of the tragedy.

The negative consequences of poor health services for women in prison can ruin not just one life, but generations.

When a woman goes into prison and takes drugs for the first time, or contracts AIDs, her criminal punishment will have a lasting impact on her and her entire family. If a woman does not receive appropriate treatment for HIV or her other illnesses, she could be sentenced to a life of poor health.

Our collaborating partners in the United Kingdom have shared with us research that is ongoing about the health status of women in prison. This research has helped to paint a picture of what life is like. The media have also presented news stories which reveal the unique challenges that women face before, during, and after their time in custody.

A woman’s time in prison could either be the first time that she is introduced to dangerous drugs or exposed to diseases such as tuberculosis. On the other hand, the prison system could provide her with her first opportunity for drug treatment, employment training, and comprehensive health treatment.

As policy-makers we have a choice. Do we run the risk that the time spent in prison will result in a lifetime of poor health, or do we commit the resources to provide the opportunities for improvements in health?

There are many factors that are unique to women in prisons: for example, the central role of women within the family. When women are imprisoned, the family often falls apart. Their children are often placed in institutions becoming a greater burden on the state.

The loss of family contact and worry about their well-being will cause greater strain on women’s mental health. In Europe hundreds of thousands of children are affected by their mothers’ imprisonment, including over 10 000 babies.

Recently, we conducted a survey comparing 500 male and 500 female prisoners here in Ukraine. The results show that the average number of children per prisoner is 0.7 for male prisoners and 1.4 for female prisoners: 70% of women in prison have children, compared to 40% of men in prison.

Women in prison have specific and different health problems from men. Prison policies and procedures may not address these additional demands. For instance, women’s reproductive health issues are often neglected. Additional needs stemming from menstruation and pregnancies are often not properly considered or addressed.

This summer we performed a survey among Member States in the European Region.
We received 27 responses, 24 from our collaborating Member States and 3 outside our Health in Prisons Project network. The work was completed in collaboration with the United Kingdom Women Offender Health Research Interest Group. Our aim is to review the health situation of female prisoners and the provision of health care initiatives for women in prison.

The first question asked for the five most frequently reported health complaints by women in prison. Mental health problems are by far the most common health complaint with women prisoners: 81% of the countries involved in the survey reported this health complaint in their top five. Drug addiction was second and high blood pressure third.

Let us now consider women’s unique health issues in more detail.

• We see that 80% of all women in prison have an identifiable mental health problem. Women in prison suffer from mental health problems to a much higher degree than both the general population and the male prison population. Reported problems include depression, anxiety, neuroses, posttraumatic stress disorder, self-mutilation and suicide.
• 75% of women prisoners suffer from a substance-related disorder, most frequently a drug dependency. Drugs are often the key to the women’s crimes. The European Monitoring Centre for Drugs and Drug Addiction states that problematic drug use rates are higher among women than men. Female prisoners are more likely to inject drugs than male prisoners, putting them at a higher risk of transmission of HIV and hepatitis.
• Women entering prison more often suffer from sexually transmitted diseases than men. This is a result of high-risk behaviour, including injecting drug use and participation in prostitution.
• Women prisoners are three times more likely than male prisoners to report having experienced physical or sexual abuse prior to their imprisonment. Women who have experienced violence and abuse are often suffering from low self-esteem, poor coping skills and a lack of confidence. Victimization also contributes significantly to poor health outcomes in terms of mental health problems and physical health complaints. This trauma is often linked to the women’s criminal pathway.
• Women prisoners are more likely to engage in self-harm or to commit suicide than male prisoners. For instance in England and Wales, women were found to be 14 times more likely than men to harm themselves.

Women tend to place a greater demand on medical services than male prisoners and they need a gender-specific framework for health care which pays particular attention to mental illness, substance use problems and histories of physical and sexual abuse.

Prisons are an integral part of the community and prison health is an integral part of public health. Unfortunately though, there is still a gap between public health and prison health. Prison health is a unique part of the health system because it is usually run by a ministry separate from that responsible for health care: often the ministry of justice. Prison health and public health services should work closely together so that equivalent standards of care can be provided.

All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community. Unfortunately, we often see that there is still a gap between public health and prison health services provided.

Of course, the women themselves are painfully aware of the failure of the health system. They know that they have human rights and that those rights are not protected when they do not receive adequate health care. We must consider how we can improve health provision within prisons generally and women’s health services in particular.

At WHO we regard prison health services as part of health systems that contribute to the social well-being of all of society. I think it is worth stressing that people marginalized due to incarceration must not be forgotten by the health system. And the special needs of women within this population must no longer be neglected by health policy-makers.

In view of this unmet need, WHO/Europe started the Health in Prisons Project in 1995. The purpose of the Project is to support Member States in improving public health by addressing health and health care in prisons, and to facilitate the links between prison health and public health systems both at national and international levels.

We provide expert advice to Member States on prison health system development and on a number of technical issues relating to communicable diseases, especially tuberculosis, HIV/AIDS and hepatitis, illicit drug use including substitution therapy/harm reduction and mental health.

Our current activities include:

• an annual conference and network meeting with an annual publication on prison health system development;
• country work such as the evaluation of prison health systems in Andorra and Kyrgyzstan (we have also made recommendations on the linkage of community services with the prison health service in Croatia);
• a number of publications on specific health issues.

Our most important recent publication is the health in prisons guide. The WHO guide addresses many topics about prisoners’ health, including a chapter on the special health requirements of female prisoners. The guide was produced in both English and Russian. Since then, it has also been translated locally into Albanian, Chinese, Croatian, Farsi, Italian and Polish.

Our project has reached several conclusions on how best to develop a better prison health system.

 First, it is very important to break down the isolation of the prison health services from public health services. In 2003, the Health in Prisons Project published the Moscow declaration on prison health as part of public health. We stressed that prison health and public health services should work closely together. Equivalent standards of care should be provided to people regardless of whether they are outside or inside the prison system.

Unfortunately, there is still a gap between public health and prison health. Prison health is a unique part of the health system because it is often managed by a different ministry, not the ministry of health. It is important to realize that prisons are a major source for the spread of communicable diseases into the community, owing to prison overcrowding, turnover of the prison population, and the interaction between the prison population and society, through prison staff and family visits.

Second, a comprehensive approach is essential, so that all prison staff – and not just health care staff – understand what is necessary for successful treatment and prevention of diseases.

Third, the leadership role of the governor and chief executives of prisons must be recognized and promoted, so that senior management can help produce the best possible therapeutic environment within the prison.

Finally, politicians and policy-makers must also take a lead, recognizing that prisons perform a vital public service and that inadequate prison health will considerably affect the public health in the community.

This year we focus on the unique issues of women’s health, and we have compiled our reports and recommendations in the draft conference declaration.

We wish to thank our partner organizations, United Nations Office on Drugs and Crime, the Quakers and many other organizations for their work in the field of women in prison in recent years.

I would like to highlight the key principles in our declaration.

• The imprisonment of women should be considered only as a last resort, when all other alternatives are found to be unavailable or unsuitable.
• Prison health service provision and programming should specifically address mental illness, in particular substance use disorders and post-traumatic stress disorder.
• If children are involved, the needs of the children must be the main and determining factor in decisions regarding women’s imprisonment, including putting the needs of the child first when considering whether and for how long the child should stay with its mother in prison.
• All policies affecting women in the criminal justice system must recognize the significant variations in need which can exist between different groups of women.
• Health service provision for women’s needs in prison must be individualized, framed and delivered in a holistic and humane manner.

We hope that this declaration will have a great impact on the policies and procedures for women in prison, leading to improved health conditions of and better health care provided for this very vulnerable group of society.

We look forward to continued collaboration with our Member States to monitor the progress towards better, fairer and more gender-sensitive services, made available for women in all parts of the criminal justice system.

Later today you will have the opportunity to review and discuss the recommendations of the declaration.

Improved health of women prisoners is likely to succeed only if the role of governments, policy- makers and senior management is understood, accepted and applied. In broad terms, this requires that:

1. the criminal justice system is seen to be serving the interests of women in their care, so that gender-specific health and other needs are readily met and easily accessed;
2. every prison which is required to house women prisoners have a written policy showing that the practices in that prison are sensitive to the special needs of women and that the staff have undergone gender sensitivity training; and
3. where and whenever children are involved, their needs and best interests are clearly seen as the first and main consideration in what is provided for them.

We hope that this conference will provide you with the evidence, tools, and inspiration that you need to adopt the Kyiv Declaration.

Good luck and thank you for your commitment to this important work.