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ABSTRACT: Background: The United Nations states that "prisoners should enjoy the same standards of health care that are available in the community." However, persons in custody continue to face barriers to care worldwide. The health of persons in federal custody in Canada is governed by the Corrections and Conditional Release Act (CCRA), which states that Correctional Services Canada is responsible for the provision of "essential health care" to all inmates. In the absence of concrete definition, these "essential" services provided in Canadian federal prisons often fall below standard. More research is needed into how "health care" is represented as a problem in Canada's federal prisons, and the impact on the incarcerated population. Methodology: Carol Bacchi's "What's the Problem Represented to Be?" (WPR) (Bacchi, 2009) framework was applied to the CCRA with a specific focus on health care. Questions one, three, and five of the WPR approach were applied, respectively, in order to analyze how the "problem" of "health care" is represented, how this particular representation came about, and the effects of this representation on the health of persons in custody. Findings: In applying the WPR approach to the CCRA, three main themes emerged. First, the notion of what services are constituted as "essential" in the context of federal prisons is more limited compared to the broader community. Second, the creation of the CCRA involved a great deal of discussion around the rights of persons in custody versus the protection of society, a dichotomy that has significant bearings on the treatment of those in prison. Third, this representation has negative effects on the health of those in custody. Conclusion: The representation of health care in the CCRA has negative effects on the health of persons in custody. Greater attention must be paid to these inequities in health care provision in order to meet UN standards. Keywords: Prison Health, Essential Health Care, Carol Bacchi, Inequity / Thesis / Master of Science (MSc) / LAY ABSTRACT The United Nations states that "prisoners should enjoy the same standards of health care that are available in the community." Despite this, persons in custody around the world continue to experience barriers to care and face unique health challenges. In Canada, the health of persons in federal custody is governed by the Corrections and Conditional Release Act. This legislation states that Correctional Services must provide "essential health care" and "reasonable access to non-essential mental health care" to inmates. Without clear definition, the interpretation of which services are "essential" is left to the discretion of correctional authorities, and as a result access and quality of care are significantly reduced in Canada's prisons when compared to the broader community. This thesis applied Carol Bacchi's "What's the Problem Represented to Be" analytical framework to examine how "health care" is uniquely represented as a "problem" for Canada's federal prison population, and the concerning inequities that are produced by this representation.

The United States has the highest incarceration rate in the world. The millions of people in prison across the country experience numerous health disparities and injustices despite having a constitutional right to health care. In chapter 1, the issues surrounding health inequity in prison are highlighted through two case studies on patient autonomy. From a bioethical standpoint, patient autonomy is integral to a person’s health, yet it is frequently violated in prison in multiple ways, including a lack of informed consent and the censorship of health literature. Greater awareness and advocacy efforts are needed to safeguard patient health within the carceral system.Chapter 2 highlights the importance of incorporating prison health into medical education, where currently few opportunities exist. In recent years, medical school curricula have placed increasing emphasis on the social determinants of health, which include prison health. Service-learning offers a potential means for incorporating prison health education into medical school curricula, as it represents an experiential learning modality that facilitates the formation of relationships between medical students and the surrounding community. The Lewis Katz School of Medicine’s prison health service-learning program was established in collaboration with Prison Health News and serves as one example for how students can learn about the social determinants of health and play a direct role in advocating for marginalized patient populations. / Urban Bioethics

Background: Two-year nationwide prison recidivism rates stand at over 60%, and minorities and the poor are at greatest risk both of first-time incarceration and of offending repeatedly over time. Initiatives that may address prison inmates’ lack of resources and increase their success in their communities after release are now an important topic in the study of criminal justice policy. Over the course of the past two decades, the public health concern of HIV/AIDS has increasingly become a part of this discourse on re-entry, as the disease disproportionately affects minority communities both in and outside of prisons. Affected reentrants face not only the challenges associated with employment, education, housing, and other social infrastructure that impede their long-term re-entry into mainstream society, but must also navigate issues surrounding continuity of medical care and behavioral risk reduction. In 2009, Georgia State University received funding to conduct an evaluation of Georgia’s Pre-Release Planning Program (PRPP) for HIV-positive inmates, and conducted semi-structured interviews with 25 former inmates who had received services from PRPP. This thesis work attempts to assess the content of the interviews and the potential impact of such an evaluation on corrections policy, especially in light of other similar programs that have been funded nationwide. Methods: A literature review was conducted to provide information on state and Federal pre-release programs for HIV+ prisoners that have been funded since the 1990s. A qualitative analysis of the GSU interview transcripts, consisting of coding for major themes, was completed. The goal of the analysis was to determine what program components had been most beneficial to participants, and also what needs had gone unfulfilled. Results: Most participants (23/25) in receipt of pre-release planning services in Georgia felt that they had benefitted from the program. A majority (19/25) attended the appointments set up for them by the program coordinator. Respondents were generally satisfied with their medical care, though cases existed where respondents had been unable to access a stable provider or medication supply as planned. The greatest aid to participants from PRPP was in the area of medical care. Limitations were perceived in the areas of employment after release and the Department of Labor program to which PRPP referred participants, as well as housing to a lesser degree. Study participants acknowledged and appreciated the program coordinator’s hard work with the resources that she had, and recommended transitional housing and work programs as ideal resources to improve their situations. Almost all (22/23) expressed interest in a community mentoring program to aid their progress post-release. Conclusions: Literature showed a variety of education and prevention program models targeting HIV in prisons since the 1990s. The best program outcomes were associated with the longest period of intervention and the most intensive case management (Rhode Island), but further evaluation is needed, and funding for such programs is a real and consistent concern. When combined with the literature on previous and existing programs nationwide, the voices of these participants provide a good idea of what may be next for a successful pre-release program in Georgia. 1) Planning services should begin sooner before release—possibly at the time of admission to prison—and should provide a longer period of follow-up, in order to capitalize on the time available for intervention with this vulnerable population and to more effectively prevent recidivism. The addition of support staff for the Georgia PRPP may allow this to occur. 2) Provision or expansion of the community mentoring program proposed in Spaulding’s 2009 study and supported by participants in these interviews, providing for matching of mentors with mentees by family and ethnic background, may be an important way to improve health outcomes among this population while facing a dearth of funding. 3) Securing and advocating for additional funding for vocational, counseling, and medical support services available to the general prison population is crucial, in order to support opportunities for skills advancement and true corrections in life path among a historically deprived incarcerated population. A cost-effectiveness analysis by state officials is recommended in order to measure the true economic value of such programs—especially in contrast to the public burden of unchecked recidivism. 4) A change in the Georgia laws that severely restrict the civil rights of ex-felons—including the right to vote, to be considered for many job opportunities, to be admitted to certain professional schools, and to receive state or federal financial aid for secondary education—is essential if former inmates are to be realistically expected to succeed outside of prison.

Inmates with gender identity disorders (GID) pose special challenges to policy makers in U.S. prison systems. Transgender persons are likely overrepresented in prisons; a reasonable estimate is that at least 750 transgender prisoners were in custody in 2007. Using the Freedom of Information Act, requests were mailed to each state, the District of Columbia, and the Federal Bureau of Prisons in 2007. The requests were for copies of policies, directives, memos, or other documents concerning placement and health care access of transgender inmates. By April 2008, 46 responses were received; 6 states did not reply. Information was qualitatively analyzed and summarized. There was substantial disparity in transgender health care for inmates with GID or related conditions. Most systems allowed for diagnostic evaluations. There was wide variability in access to cross-sex hormones, with some allowing for continuation of treatment and others allowing for both continuation and de novo initiation of treatment. There was uniformity in denial of surgical treatments for GID.

This thesis presents an ethnographic study of the experiences of men living with and dying from serious illness in prison, with a particular focus on the kinds of care they receive and the ways in which they experience that care. The dissertation draws on extensive ethnographic fieldwork conducted over two years in U.S. state prisons in Maine, presented in three standalone papers. The first paper outlines how the prison and its health care system shape the illness experiences of older and ageing prisoners and asks, what does it mean when the lives of prisoners collide with contracted for-profit medical care and how might their lives be constituted as unworthy of care? The stakes lie in applied policy and practical solutions for custodial services. The second paper explores the experience of caring and being cared for in the context of a prison hospice program, in which incarcerated men provide care to peers who are ill or dying. Through tracing one man’s end of life journey, this chapter considers how hospice caring makes and remakes death and life in prison, and the ways in which this “nefarious” form of escape from disciplinary power translates in the repressive penal regime. The final paper has its roots in sensory ethnography and the emerging field of sensory penality. This is a reflexive piece in which I probe my sensorial subjectivity and particularly touch as a medium of inquiry to explore the sensations of life, death, and dis/connection experienced in a prison infirmary. The observed feel of life and death illuminates new ways of understanding care in custody as a space of simultaneous brutality, beauty, indignity and intimacy. Taken together, the papers shed light on constellations of care in prison, the contingency of relations and personhood, and points of friction between care and custody. / Dissertation / Doctor of Philosophy (PhD) / At a time when the prison population is rapidly ageing and more people than ever are dying in custody, this thesis explores what it is like to experience serious or terminal illness in prison, the kinds of care prisoners receive and how they experience that care. Based on ethnographic fieldwork in U.S. state prisons, three themes are examined: 1) how the prison and its privatized health care system shape the illness experiences of older prisoners; 2) how prisoners mediate the experience of dying in prison through a peer- based prison hospice program; and 3) how the senses and especially touch elicit new ways of knowing and understanding end of life in prison. Taken together, the three papers shed light on forms of care in prison, the mutability of relations and life, and points of friction between care and custody.

A presente dissertação tem por objetivo a proposição de mecanismos de compensação, pela via judicial, das iniquidades provocadas à saúde dos presos em regime fechado de reclusão, tendo em vista que os presídios brasileiros são, hoje, ambientes potencialmente endêmicos à saúde humana. Considerando-se que o acesso aos serviços de saúde nas prisões é modulado por julgamentos morais entre agentes penitenciários e os detentos, e que o sistema mantém e produz excessos e desvios durante a execução penal, serão objeto primordial desse estudo os incidentes processuais do art. 185 da Lei de Execução Penal, aos quais se delineará hipóteses de aplicação com vistas a individualizar a pena nos casos de adoecimento do recluso. Para tanto, a argumentação se construirá no sentido de que a manutenção de presos em situação de agravo ou enfermos, por negligência do Estado, é uma conduta que mantém pontos de aproximação com a tortura institucional, inadmissível no contexto do Estado Democrático de Direito. O trabalho será eminentemente teórico e propositivo, e articulará temas de saúde pública, direito da execução penal e política criminal. / The purpose of this dissertation is to propose mechanisms of compensation, through the judicial way, of the iniquities provoked to the health of prisoners in closed regime of incarceration, bearing in mind that Brazilian prisons are now potentially endemic ambience for human health. Whereas access to health services in prisons is modulated by moral judgments between prison staff and prisoners, and that the system maintains and produces excesses and deviations during the criminal execution, the primary object of this study will be the procedural incidents of article 185 of the Criminal Execution Law which will outline hypotheses of application with a view to individualizing the sentence in cases of illness of the prisoner. Therefore, an argument will be built in the sense of maintaining prisoners in situations of injury or illness, by negligence of the State, it is a conduct that maintains points of approximation with the institutional torture, inadmissible in the context of the Democratic State of Law. The work will be eminently theoretical and propositive, and articulate issues of public health, criminal enforcement law and criminal politics.

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2015-04-22T17:39:20Z No. of bitstreams: 1 ELIANA OLIVEIRA PEDREIRA LIMA.pdf: 820097 bytes, checksum: fc27bd7fdbcf9e6a0cad1aed0f04add4 (MD5) / Made available in DSpace on 2015-04-22T17:39:20Z (GMT). No. of bitstreams: 1 ELIANA OLIVEIRA PEDREIRA LIMA.pdf: 820097 bytes, checksum: fc27bd7fdbcf9e6a0cad1aed0f04add4 (MD5) Previous issue date: 2013-06-05 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Understand how to process the relations in everyday life of prison and evaluate the situation of health care in the detainee CDP São Vicente/SP was the main objective of this study aimed to ascertain the specific living conditions of detainees in the town of São Vicente/SP; see how they detect diseases before and during incarceration in the town of São Vicente/SP; know the actions taken by health professionals and ways to treat diseases of the detainees; identify which inmates' complaints of CDP São Vicente/SP in relation to health care of the detainee. This is qualitative research conducted in Provisional Detention Center Dr. Luis Cesar Lacerda de São Vicente, São Paulo, and ten prisoners as subjects and a health care professional who works in the prison unit. With detainees, the instrument used was a semi-structured interview and the professional, open interview with script. Data collection occurred during the months from July to December 2011. The results revealed that the profile of inmates does not differ from that found in other studies. Of the ten inmates, four are in the range of 20 to 30 and the remaining six between 31 and 40 years. The low education level was confirmed, as two did not complete primary school and eight complete elementary school. Regarding marital status, three singles and seven are married. Regarding the number of children, three prisoners have no son, four even has two sons, two of three to four children and only one inmate have five or more children. The color self-declared also confirmed, with browns and blacks add nine prisoners and one white. Seven inmates are from Baixada Santista and three from other cities in the state of São Paulo. Seven primary and three are repeat offenders, and still, eight and two regularly receive visits any visit. A professional is female, 50 years old and worked for nine years and six months in SAP, throughout this period in the town of São Vicente. The analysis of data was based on two main themes: life in prison and the inmate health care. The everyday prison is marked by idleness, power relationships and coping strategies. In health care the inmate was found that prisoners are assisted minimally, because there is a shortage of health professionals, such as doctors and nurses, and the distribution of drugs is only regulate when it comes to TB, HIV and mental illness. In other cases, there is delay in treatment and medication from the prison unit and are usually family members who bring drugs. With regard to food, this is general dissatisfaction, although it is an important component to maintaining health. The research sought to show a clip from the reality experienced by prisoners regarding health care in the town of São Vicente. / Compreender como se processam as relações na vida cotidiana do cárcere e avaliar a situação da atenção à saúde do detento no CDP de São Vicente/SP foi o principal objetivo desse estudo que teve como objetivos específicos conhecer as condições de vida dos detentos no CDP de São Vicente/SP; verificar como se detectam as doenças antes e durante o processo do encarceramento no CDP de São Vicente/SP; conhecer as ações desenvolvidas pelos profissionais de saúde e formas de tratamento das doenças dos detentos; Identificar quais as queixas dos detentos do CDP de São Vicente/SP em relação à atenção à saúde do detento. Trata-se de pesquisa qualitativa realizada no Centro de Detenção Provisória Dr. Luiz Cesar Lacerda de São Vicente, São Paulo, tendo como sujeitos dez presos e uma profissional da área da saúde que atua na unidade prisional. Com os detentos e com a profissional de saúde, o instrumento utilizado foi a entrevista semiestruturada. A coleta de dados ocorreu durante os meses de julho a dezembro de 2011. Os resultados revelaram que o perfil dos detentos não difere do encontrado em outros estudos. Dos dez detentos, quatro estão na faixa dos 20 aos 30 e os seis restantes entre 31 e 40 anos. A baixa escolaridade foi confirmada, pois dois não concluíram o ensino fundamental e oito completaram o ensino fundamental. Quanto ao estado civil, três são solteiros e sete casados. No que diz respeito ao número de filhos, três presos não tem filho, quatro tem até dois filhos, dois de três a quatro filhos e apenas um detento têm cinco ou mais filhos. A cor auto-declarada também se confirmou, sendo que pardos e negros somam nove presos e apenas um branco. Sete detentos são da Baixada Santista e três oriundos de outras cidades do Estado de São Paulo. Sete são reincidentes e três primários, e ainda, oito recebem visitas regularmente e dois nenhum tipo de visita. A profissional é do gênero feminino, 50 anos de idade e, trabalha há nove anos e seis meses na SAP, todo esse período no CDP de São Vicente. A análise dos dados se deu a partir de dois eixos temáticos: a vida no cárcere e atenção à saúde do detento. O cotidiano prisional é marcado pela ociosidade, relações de poder e estratégias de sobrevivência. Na atenção à saúde do detento foi constatado que os presos são minimamente assistidos, pois há falta de profissionais de saúde, como, médico e enfermeiro e, a distribuição de medicamentos só é regular quando se refere à Tuberculose, doenças mentais e HIV. Nos demais casos, há demora no atendimento e medicação por parte da unidade prisional e geralmente são os familiares que trazem os medicamentos. No tocante à alimentação, essa constitui insatisfação geral, embora seja um componente importante para a manutenção da saúde. A pesquisa buscou evidenciar um recorte da realidade vivida pelos presos quanto à atenção à saúde no CDP de São Vicente.