Adopted: October 2000

PREAMBLE

1. Prisoners have the right to humane treatment and appropriate medical care. Standards for the treatment of prisoners have been set down in a number of Declarations and Guidelines adopted by various bodies of the United Nations (See annex).
   
   
2. The relationship between physician and prisoner is governed by the same ethical principles as that between the physician and any other patient.
   
   
3. There are strong public health reasons for reinforcing the importance of these rules. The recently reported increase in incidence of tuberculosis amongst prisoners in a number of countries reinforces the need for considering public health issues when designing new prison regimens, and for pressing for reforms of existing penal and prison systems.
   
   
4. Prisons can be breeding grounds for infection. Overcrowding, lengthy confinement within closed, poorly lit, badly heated and consequently poorly ventilated and often humid spaces are all conditions frequently associated with imprisonment and which contribute to the spread of disease and ill-health. Where these factors are combined with poor hygiene, inadequate nutrition and limited access to adequate health care, prisons can represent a major public health challenge. Keeping prisoners in conditions which expose them to substantial medical risk constitutes a humanitarian challenge. An infectious prisoner poses a risk not only to other prisoners but also to prison personnel, the prisoner's relatives, other prison visitors and the wider community when the prisoner is released. The most effective and efficient way of reducing disease transmission is to improve the prison environment, targeting overcrowding for the most urgent action.
   
   
5. The increase in active Tuberculosis (TB) in prison populations and the development within some of these populations of resistant and especially "multi-drug" resistant forms of tuberculosis, as recognised by the World Medical Association in its Statement on Drug Treatment of Tuberculosis, is reaching very high prevalence and incidence rates in prisons in some parts of the world.
   
   
6. Other conditions, such as Hepatitis C and HIV Disease, do not have as high a risk of person-to- person communicability as tuberculosis but pose transmission risks from blood to blood spread, or sharing and exchange of body fluids. Overcrowded prison conditions also promote the spread of sexually transmitted diseases. Intravenous drug use will also contribute to the spread of HIV as well as Hepatitis B and C. These need specific solutions that are not dealt with in this statement. However the principles set out below will also be helpful in reducing the risk from such infective agents.
   

Actions Required

7. The World Medical Association considers it crucial both for public health and humanitarian reasons that careful attention is paid to:
   
   
   1. protecting the rights of prisoners, regardless of their infected status, and according to the various UN instruments relating to conditions of imprisonment. Prisoners should enjoy the same rights as other patients, as outlined in the WMA Declaration of Lisbon;
      
      
   2. ensuring that the conditions in which detainees and prisoners are kept, whether they are held during the investigation of a crime, whilst waiting for trial, or for punishment once sentenced, do not contribute to the development, worsening or transmission of disease. This also refers to the conditions in which persons are held while going through immigration procedures, although prisons should not normally be used to house such persons;
      
      
   3. ensuring that prisoners are not isolated, or placed in solitary confinement, without adequate access to health care and all appropriate responses to their infected status;
      
      
   4. upon transfer to a different prison, inmates' health status should be reviewed within 12 hours of arrival to ensure continuity of care;
      
      
   5. ensuring the provision of follow-up treatment for prisoners who, on their release, are still ill, particularly with an infectious disease. Because interruptions of treatment may be particularly hazardous both epidemiologically and to the individual, planning for and providing continuing care are essential elements of prison health care provision;
      
      
   6. the efficacy, necessity and justification for public health mechanisms, which may in the rarest and most exceptional cases involve the compulsory detention of individuals who pose a serious risk of infection to the wider community. Such steps should be exceptional and must follow careful and critical questioning of the need for such constraints and the absence of any effective alternative. In such circumstances detention should be for as short a time as possible and be as limited in restrictions as feasible. There must also be a system of independent appraisal and periodic review of any such measures, including a mechanism for appeal by the patients themselves. Wherever possible alternatives to such detention should be used;
      
      
   7. This model should be used in considering all steps to prevent cross infection and to treat existing infected persons within the prison environment.
      
      
8. Physicians working in prisons have the duty to report to the health authorities and professional organisations of their country any deficiency in health care provided to the inmates and any situation involving high epidemiological risk for them. NMAs are obliged to protect those physicians against any possible reprisals.
   
   
9. The WMA calls upon member associations to persuade national and local governments and prison authorities to address urgently these aspects of health promotion and health care in their institutions, and to adopt programmes that ensure a safe and healthy prison environment.
   

10.300 Annex

International texts relating to medical care in prisons

(Bibliographical information indicated with an asterisk * to be found at the end of this document)

Universal Declaration of Human Rights (Articles 4, 9, 10 and 11). Adopted by the United Nations General Assembly on 16 December 1948. *Sources A,B,D,E.

Standard Minimum Rules for the Treatment of Prisoners (Rules 22-26). Approved by the United Nations Economic and Social Council on 31 July 1957.* Sources B,C,D,E.

International Covenant on Economic, Social and Cultural Rights (Article 12). Adopted by the United Nations General Assembly on 16 December 1966. Entry into force: 3 January 1976. *Sources A;B,D,E.

International Covenant on Civil and Political Rights (Articles 6, 7 and 10). Adopted by the United Nations General Assembly on 16 December 1966. Entry into force: 23 March 1976. *Sources A,B,D,E.

Principles of Medical Ethics Relevant to the Protection of Prisoners Against Torture (Principle 1). Adopted by the United Nations General Assembly on 18 December 1982. *Sources B,C,E.

Body of Principles for the Protection of All Persons Under Any Forms of Detention or Imprisonment (Principle 24). Adopted by the United Nations General Assembly on 9 December 1988. *Sources B,C,E.

Basic Principles for the Treatment of Prisoners (Article 9). Adopted by the United Nations General Assembly on 14 December 1990. *Sources B,D,E.

United Nations Rules for the Protection of Juveniles Deprived of Their Liberty (Principles 50-54). Adopted by the United Nations General Assembly on 14 December 1990. *Sources B,D,E.

WHO Guidelines on HIV Infection and AIDS in Prison. Issued in March 1993, Geneva (Document WHO/GPA/DIR/93.3).* Source E.

Bibliographical details of sources

(Indicated with an asterisk * in preceding section)

A. Brownlie, I., Ed. Basic Documents on Human Rights. 3rd edition. Oxford University Press, Oxford, 1992.

B. Human Rights: A Compilation of International Instruments. United Nations, New York and Geneva, 1994 (Vol. I: Universal Instruments). It is understood that this compilation is available in the five official languages of the United Nations.

C. Ethical Codes and Declarations Relevant to the Health Professions: An Amnesty International Compilation of Selected Ethical Texts. 3rd edition. International Secretariat, Amnesty International, London, 1994.

D. Melander, G. & Alfredsson, G., Eds. The Raoul Wallenberg Compilation of Human Rights Instruments. Martinus Nijhoff Publishers, The Hague, London and Boston, 1997.

E. Alfredsson, G. & Tomaševski, K., Eds. A Thematic Guide to Documents on Health and Human Rights. Martinus Nijhoff Publishers, The Hague, London and Boston, 1998.

1.2.2001