El personal de atención sanitaria

Analysis

Staffing levels

An adequate number of sufficiently trained health care staff must be allocated to each prison. They should be selected for their professional competencies and personal integrity. The pay and benefits should be equivalent to health staff working in the community so as to attract appropriate personnel. In general the health staff allocated to the prisons should include, as a minimum, General practitioners and Nursing staff. Health staff must be available at all times of the day or night in order to respond to medical emergencies as well as other health issues. Other staff such as psychiatrists and psychologists, dentists, physiotherapists etc. should either be based in, or regularly visit the prison, depending on the size of the prison population.

The actual numbers and specialisation of health staff will depend upon the total population and general profile of the detainees in the specific place of detention. For example, where there is a high turnover of detainees with drug or alcohol dependency a specialist in drug rehabilitation/drug substitution therapy may be warranted. A sufficient number of female health staff must be allocated to prisons, especially those in which women are detained.

Detainees should have access to medical investigations and care that is not available in the prison. This is usually through the referral of the detainee to the local clinic or hospital, although in some settings hospital Specialists may be able to visit the place of detention on a regular basis. This may assist the prison administration in terms of reducing the demand for transport and security to outside health facilities.

Detainees, even those with previous training in health care, should not carry out any duties in the prison health care service. This risks breaches in medical confidentiality and in trust of the independence of the health care service.

Staff training and supervision

After recruitment to the prison health service, health staff must receive initial training on working in the prison environment in general and on health and human rights, including provisions contained in national legislations, as well as international and regional standards.

Detailed training for health care delivery in places of detention must be provided and regularly updated, in particular on infectious diseases, mental health care, self-harm and suicide prevention, harm reduction in relation to drug use, the prevention treatment and care of HIV-AIDS, Hepatitis B and C and other blood-borne infections and the prevention and treatment of tuberculosis, especially multi-drug resistant tuberculosis. The ethical dilemmas and responsibilities of prison health staff are another key area for training.

women
foreigners
disabilities
minorities
children

Focus should also be given to the particular health care needs of female detainees, to minors, persons with disabilities and mental health-care needs, and LGBTI detainees. Prisons are also increasingly housing older detainees who require special attention and even adaptation of the facilities. Thus, the health staff must also become versed in health care for the elderly. 

In-depth training must be provided, especially for physicians, in the examination and documentation of cases of torture and other ill-treatment according to the United Nations Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (the “Istanbul Protocol”). Mechanisms must be put in place to allow such cases to be reported to independent and impartial bodies so as to ensure protection of the victim from reprisals and intimidation.

Monitoring and oversight of the level of health care provision and professional and ethical standards should be done by a body independent from the prisons. Ideally, by integrating the prison health service into the national health service, the Ministry of Health would take on the supervisory and monitoring role. The Ministry of Health should also ensure ongoing training and professional exchange with health colleagues in the community since working in prisons can lead to professional isolation.

Training in basic first aid should be provided to Prison guards since they will most often be the first responders to emergencies in the prison cells or sections. Prison health staff or external organisations such as national Red Cross or Red Crescent societies should provide regular refresher courses. Prison staff should also be trained in basic health promotion and prevention of disease so as to reinforce messages given by the prison health staff.

Dual loyalties of health care staff

Prison health staff are often employed by the Ministry responsible for prisons (usually the Ministry of Justice, but sometimes the Ministry of Interior) and therefore may feel subordinate to these authorities. However, the main duty of the health staff must be to the protection and promotion of the health of the detainees. Health care must be provided in full professional independence, without discrimination and with the autonomy and informed consent of the detainee-patient. Careful attention must be given to the ethical obligations to detainee-patients and awareness of, and approach to, situations of dual loyalties.

Common areas  where this arises may be the request for medical clearance for the infliction of punishments, monitoring of detainees in solitary confinement, and the role of health care staff in hunger strikes and force feeding. Health care staff must never be involved in assessing fitness for, approving or inflicting disciplinary punishments. Similarly the prison health staff should not be involved in intimate body searches (body cavity searches) of detainees, which is a security function and not a health care matter. Where intimate  body searches are authorized by law they should be performed by non-prison health staff so as not to interfere with the trust between the detainees and the prison health staff.

Health care staff and in particular physicians, have a particular obligation to document and report cases of ill-treatment that may have occurred before or after arrival in the place of detention.

One important measure to prevent and protect against such ethical dilemmas in prisons is the integration of the prison health service into the national health service. This will guard the professional and ethical independence of the health staff, as well as providing recourse to an independent body in case of conflicts.