Prison and Harm Reduction, What's the hold up?
By Anne Marie DiCenso
It has been over 12 years since a group of concerned AIDS activists, ex-prisoners, and members of community-based groups first gathered in a Toronto kitchen to discuss the need for harm reduction in Canadian prisons. In those early days, they came up with a comprehensive strategy on AIDS in prison that looked at issues that had never before been addressed in the Canadian prison system. It was the birth of PASAN (Prisoners with HIV/AIDS Support Action Network), the first ever prison and AIDS organization.
In the early 1990s when PASAN was created, the rates of HIV infection in the prison system was known to be 10 times that of the general public. Today, the situation has worsened, with prisoners not only at risk of contracting HIV from the lack of clean needles, unsafe tattooing and consensual unprotected sex or rape inside federal prisons; they also risk contracting HCV, the virus that causes Hepatitis C - a disease with equally debilitating consequences.
Current statistics show that approximately 77% of prisoners use drugs, with between one to two per cent testing positive for HIV and an alarming 29-40 per cent contracting HCV. With the increase of police repression in Canada and the impact of the American government’s “War on Drugs” the numbers of people being incarcerated will continue to grow, along with HIV and HCV rates. It is a needless epidemic - virtually ignored by the general public and politicians - yet so easily curbed by a concept that (drug) users have understood for years - harm reduction.
Harm reduction is a practical approach to drug use and one that recognizes that quitting drugs may not be realistic for everyone. It is user-driven, non-judgmental, community-based and broad-based in terms of its attempts to take into consideration and address whole systems which alienate, isolate and marginalize people and contribute to increased drug use.
Harm reduction responds to the health risks of users and works with them to identify potential risks and decrease drug-related harm. It recognizes drug users as part of a larger community, protecting and improving community health as a whole.
Harm reduction recognizes that two different types of problems result from illegal drugs. One set of problems results from the negative effects of drugs on an individual and the other from society’s efforts to criminalize drug users and eliminate drugs. Harm reduction is not solely about changing individuals’ behaviour. It is also about societal change. It challenges society to rethink how drug use is seen and recognizes that many of the harms associated with drug use are caused by prejudice and a “war on drugs” approach to drug policy that criminalizes - rather than helps - drug users.
Harm reduction has been around as a concept for a number of decades but it is only since the late 1980s that it has been recognized by public health professionals and community groups as a key strategy in reducing the transmission of HIV and HCV. As a result of this wider public acceptance, users outside prisons today have much better access to free needles, safer crack kits (for smoke-able drugs), methadone and condoms.
But inside Canada’s prisons, the story is quite different. The federal correctional system is made up of 52 prisons across Canada with each institution housing men and women who are serving sentences of two years or more. There are five regions mandated to operate these federal correctional facilities: the Atlantic, Quebec, Ontario, the Prairies and the Pacific. Each region is accountable to Correctional Services Canada’s (CSC) National Headquarters in Ottawa.
Although there are many ways to reduce the transmission of HIV and HCV, there are only a few measures that can be implemented inside federal prisons to bring about those changes. Since 1992, PASAN activists have been fighting for federal prisons in Canada to implement four main harm reduction measures. These include: bleach distribution, safer tattooing, syringe exchange and methadone maintenance. All were supported by The Expert Committee on AIDS and Prison, a Correctional Services Canada funded study on prisons and HIV/AIDS, published in 1994.
Bleach Distribution: Although not widely used in the community any more, bleach continues to be an important harm reduction strategy in federal prisons. As there are no needle exchange sites in Canadian prisons, bleach is used by users to clean their works (drug paraphernalia). It is not clear, however, if bleach is 100% effective for cleaning homemade rigs, such as those used in prison, as no studies have been conducted to date. It is known, though, that bleach is not always effective in eradicating the HCV virus which lives outside the body much longer than HIV.
Bleach was not formally available in federal prisons until 1995 when a policy was issued by Correction Services Canada (CSC) requiring that “bleach be freely available, readily accessible and distributed in a way that ensures anonymity and minimizes risk of injury.” At that time, it was also recommended by prison activists that full-strength bleach, together with instructions on how to sterilize needles and syringes, be made available to prisoners in all institutions.
Unfortunately, as time has shown, CSC policy has not always become CSC practice. Bleach distribution is still erratic for most federal prisoners. Bleach was originally intended to be made available to all prisoners so that no one would know whether prisoners were using it for cleaning their floors or doing laundry or to clean their works. However, since each institution can interpret policy as they see fit, many institutions put bleach out for prisoners only once a week, sometimes not at full strength and often given out in ways that correctional staff can see who is taking it and take note of perceived drug users. Many institutions also run out of bleach and it can take several weeks before it’s available again. This situation leaves drug users with no choice but to clean their works with whatever they can find on their living units. Often this means some form of detergent which has no bleach in it. As prisoners often have to share their works with as many as 50 other prisoners, bleach is imperative in reducing the spread of HIV/AIDS and HCV.
Safer Tattooing: With the wide availability of clean needles, sterilized equipment and the fact that tattoo shops must comply with numerous public health regulations, getting a tattoo in Canada brings little risk. Not so in federal prisons. Tattooing has been a rite of passage for prisoners for decades and is an important part of prison life. But in federal prisons tattooing and tattooing equipment are still considered contraband (practices or material that are not allowed in federal prisons) and are confiscated if found and the owner punished. The result? Tattoos in prison are often done with used needles or other unsterilized equipment - despite the fact that tattooing without sterilized equipment is one of the major means of transmission of HCV.
Very little has been done on tattooing in prison to date and no studies are available on the issue. However, prisoners and activists have pushed for safer tattooing strategies for many years now. In 1996 the Lifers Group, a groups of prisoners serving life sentences at Joyceville institution in Ontario, requested that a pilot tattooing project be implemented in their institution. This was following a study released earlier that year by Dr. Peter Ford, a prison and HIV/HCV specialist, showing approximately 40% of prisoners in that institution had HCV. The Lifers Group asked to have tattooing available to prisoners without it being considered contraband or the prisoners involved being charged. However, despite the support of Dr. Peter Ford and other activists, the pilot project was never implemented.
PASAN also published an article with the knowledge and assistance of many federal prisoners outlining what the best form of prison tattooing should be. This article was called “Driving the Point Home” and was released to the public in 2003. Finally, in 2004, CSC stated that they will implement one pilot tattooing project in each of the five federal regions in the next few months. Specifics on what these pilot sites will look like has not been clearly identified.
Sterile Needles: Needle and syringe exchanges have been one of the most important harm reduction issues for prisoners to date. Many prisoners start using injection drugs for the first time after becoming incarcerated and have found that not having access to clean needles is a serious problem. Although prisoners use whatever drugs are available inside, drugs that can be injected are the most sought after as they go through your system faster, reducing the risk of being detected through urinalysis. Urinalysis is routinely used on prisoners to detect drug use, leading to reprimands for the prisoners who are caught and the possibility of serving more of their sentence inside. Using drugs that are less likely to be detected through urinalysis and that cannot be detected through smell (like smoke-able drugs) makes more sense when you are trying not to get caught. As prison life is difficult and corrections tends to incarcerate a large number of drug users, sharing rigs and other injecting equipment becomes a necessity for prisoners.
Although activists have been calling for needle exchange programs in prisons since 1992, no Canadian prison system had started a program as of 2004. The federal prison system has been studying the issue for many years and created a committee in 1999 to develop recommendations for the federal government. This committee was made up of activists, correctional front line staff, health care professionals and correctional policy analysts. Although the group agreed that needle exchange was a viable option, and that a pilot project should be implemented, government officials did not act on the recommendation.
Correctional staff who oppose the distribution of needles in prison say it condones drug use. In reality, it is not an endorsement of drug use, but a concern for the health and safety of prisoners - and the broader health of the community given that most prisoners will eventually be released. Not providing clean needles to prisoners when it is known that injecting drugs is occurring, is paramount to condoning the spread of HIV and HCV. It is paramount that needle exchanges be implemented as soon as possible in all prisons in Canada.
Methadone Maintenance: Methadone has been widely used to treat opiate users since the early 1960s. Although methadone for prisoners has been one of activists’ main recommendations since 1992, methadone did not become available inside federal prisons until 1996. At that time, federal corrections introduced methadone maintenance phase 1, a treatment option only available to opiate users who had been on methadone while out on the street. Those who had taken up opiates like heroin while inside were not eligible. CSC admitted that this was not enough and planned to extend the distribution of methadone to all opiate users who qualified, whether or not they had previously been on methadone. The expansion of the program was delayed for three years, however, because of inadequate funding.
To date, methadone is available in federal prisons; however, there is a long and arduous process involved in qualifying for the program. As well, many prisoners cannot access the program as there are not enough doctors in corrections who are able to prescribe methadone to them.
Harm reduction continues to be an important and elusive issue for prisoners in federal prisons. Although some progress has been made in identifying harm reduction strategies and, in some cases, moving these strategies forward, major problems still exist. Prisoners face huge barriers to safer drug use which continues to affect their ability to live healthy lives. Without further action on this issue, more prisoners will become infected with HIV and/or HCV. This is a human rights issue. And it is an issue for people of colour, Aboriginal people, street involved people and poor people in general. In Canada, while 3% of the general population is Aboriginal, federal prisons admit that at least 20% of their population is made up of Aboriginal people. Statistics are not kept on the number of poor people and people of colour, but anecdotal information shows us that these populations are highly over represented in federal prisons. As activists and socialists, we need to renew our commitment to prisoners’ rights. Without those of us on the outside working for change, we leave those on the inside to disease and perhaps death. The responsibility is ours, the time is now.