Disclosures: Dr. Ruth Elwood Martin is the Director of the Collaborating Centre for Prison Health and Education (CCPHE) at the School of Population and Public Health within the Faculty of Medicine at the University of British Columbia. The CCPHE is a research group with academic faculty and community partners across Canada who are driven by the lived experience of people with incarceration history to study the distinct needs of the incarcerated and formerly incarcerated populations, using elements of community-based and participatory action research. CCPHE aims to bridge gaps between the prison system, judiciary, health care system, community, and post-secondary institutions to reduce disparities that impact people with incarceration history. Mitigating potential bias: Recommendations are consistent with current practice patterns.
What care gaps we have noticed
Many people leave prison with nothing more than the clothes they were wearing when they were admitted, a small stipend and a bus ticket. It is common for formerly incarcerated people to feel isolated, ostracized, and excluded from their communities during reintegration, which is reinforced by both formal and informal discrimination in employment, housing, and education as well as by family, friends, and the general public.
Family physicians are often uncertain about taking on new patients with criminal records and may perceive that this population is malingering, deceitful, and drug-seeking. Moreover, physicians may be concerned for their safety and the safety of their other patients and staff. Family physicians may also feel that formerly incarcerated people do not take good care of their health.
While family physicians may feel cautious about taking on formerly incarcerated patients, formerly incarcerated patients themselves are often guarded when meeting family physicians, worried that they will be dismissed or receive sub-standard care, and may feel unsafe sharing their incarceration history. Formerly incarcerated people may have had negative experiences with doctors inside prison, and/or may feel that prison doctors or psychiatrists were complicit in traumatic experiences, such as prolonged solitary confinement.
Further, there are few if any existing supports for physicians interested in caring for the population within their practice and supporting reintegration into the community.
Data that answers these questions or gaps
Existing evidence indicates discrimination is common-place against incarcerated and formerly incarcerated people. In one study of men recently released from prison, more than 40% indicated a history of health care discrimination due to their incarceration history (Frank et al, 2014). In this study, healthcare discrimination was also correlated with an increased number of visits to the emergency department, illustrating a possible link between healthcare discrimination and negative effects on help-seeking behaviors. A BC study demonstrated that discrimination on the basis of recent imprisonment by family physicians can present a barrier to accessing primary care for formerly incarcerated individuals (Fahmy et al, 2017).
Incarcerated populations experience considerable health inequities compared with the general population (Fazel & Baillargeon, 2010; Bouchard, 2004). Individuals are often negatively affected by the social determinants of health, including unstable family and social relationships, precarious housing, reduced educational achievement, interrupted employment histories, and high prevalence of mental health and substance use disorders (Enggist et al, 2014; Kouyoumdjian et al, 2015). When released from prison, individuals face barriers to successful reintegration, including a lack of continuity of health care, delays in connection to social services, lack of adequate income, formal and informal discrimination, and social exclusion (Binswanger et al, 2015; Europe WHO, 2008; Kouyoumdjian et al, 2015). In addition, formerly incarcerated individuals are particularly vulnerable to overdose death immediately after release from prison due to opioid naivety (Winters et al, 2015; Groot et al, 2016).
The Nelson Mandela Rules, formerly called the United Nations Standard Minimum Rules for the Treatment of Prisoners, outline that “Health-care services should be organized in close relationship to the general public health administration and in a way that ensures continuity of treatment and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence.”
What we recommend (practice tip)
To address the issue of health care discrimination and coordination of care people with incarceration history, the CCPHE has collaboratively developed Guidelines for Family Physicians working with Formerly Incarcerated People. The guidelines were co-developed through engagement with family physicians working closely with formerly incarcerated people in community health clinics, and through consultation with other health and social service providers and external partners, including the community non-profit sector.
From the Guidelines, the role of the family physician when meeting with a formerly incarcerated patient is to facilitate connection to compassionate care. In practice, strive to:
- Obtain consent for the transfer of patient medical records from the most recent prison at which they stayed.
- Support the patient to achieve immediate reintegration needs (e.g. obtaining personal documentation, refilling a prescription medication dispensed in prison, accessing dental care, procuring an eye exam, etc.).
- As needed, offer harm reduction supports (including naloxone) while being cognisant that many people may have parole or probation rules that mandate abstinence from substance use and violation of these rules can result in re-incarceration. Stressing patient confidentiality and the communicating the differences between the judicial system and the medical system are essential for this conversation.
- Take a medical and social events history as you would with any other patient.
- Screen for mental health and substance use disorders.
- Take a comprehensive sexual health history, being cognisant of the possibility of past sexual trauma.
In addition, the Prison Health Program Committee of the College of Family Physicians of Canada is another resource for better supporting this patient population. You can indicate an interest in the Prison Health Program Committee through your online profile with the College of Family Physicians of Canada. Further, the CCPHE website hosts many resources for health professionals.
Lastly, in the College of Physicians and Surgeons of BC’s standards and guidelines, there is a section on access to medical care, which states that in the case of people with involvement in the criminal justice system, “refusing to treat anyone in such circumstances violates the medical profession’s ethical principles”. This imperative through the college encourages family physicians to be inclusive of this patient population within their practice.
Through supporting family physicians in the community in their treatment of formerly incarcerated people, we hope that primary healthcare provided to this population will be improved.
- Fazel S, Baillargeon J. The health of prisoners. The Lancet. 2011;377:956-965. (View with CPSBC or UBC)
- Laishes J, Moloughney B, Kyle V, et al. A Health Care Needs Assessment of Federal Inmates in Canada. Can J Public Health, 2004;95:s1-s64. (View)
- Enggist S, Møller L, Galea G, Udesen C, eds. Prisons and Health. 1st edition. Copenhagen Ø, Denmark: World Health Organization; 2014. (View)
- Fahmy N, Kouyoumdjian F, Berkowitz J, et al. Access to primary care for persons recently released from prison: an audit study. In peer review, Annals of Internal Medicine. Submitted October 2017.
- Kouyoumdjian FG, McIsaac KE, Liauw J, et al. A Systematic Review of Randomized Controlled Trials of Interventions to Improve the Health of Persons During Imprisonment and in the Year After Release. Am J Public Health. 2015;105(4): e13-33. (View)
- Binswanger I, Whitley E, Haffey PR, Mueller S, Min SJ. A Patient Navigation Intervention for Drug-Involved Former Prison Inmates. Subst Abuse Treat Prev Policy. 2015;36:34-41. (View)
- World Health Organization Europe. Trencin statement on prisons and mental health. Copenhagen Ø, World Health Organization; 2008. (View)
- Winter RJ, Stoové M, Degenhardt L, et al. Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia. Drug Alcohol Depend. 2015;153:43-49. (View with CPSBC or UBC)
- Groot E, Kouyoumdjian F, Kiefer L, et al. Drug Toxicity Deaths after Release from Incarceration in Ontario, 2006-2013: Review of Coroner’s Cases. PLoS One, 2016:1-11. (View)
- Frank JW, Wang EA, Nunez-Smith M, Lee H, Comfort M. Discrimination based on criminal record and healthcare utilization among men recently released from prison: a descriptive study. Health Justice. 2014;2:1-8. (Request with CPSBC or view with UBC)