Prison health is Public Health

Get ready for some controversy. I'm here today to talk about an injustice in the Canadian healthcare system that is grossly overlooked.

I have a 2 year college diploma in rehabilitation science, a 4 year undergraduate degree in health science, and a 2 year master of science in physiotherapy. In my eight years of formal healthcare education, we learned about Indigenous care, women's health, child and prenatal health, geriatric and bariatric consideration, rural and remote communities, physical and cognitive disabilities, mental illness, and more.

Not once were inmates discussed as a marginalized population. Inmates in Ontario make up a larger population than most small cities north of Orillia.

Why? The obvious answer that most people would give is that inmates are criminals and therefore should not be entitled to healthcare.

I wholeheartedly disagree.

Inmates commit crimes and therefore lose their social freedom. Under no constitution or human rights code does it state that they lose basic rights or accessibility to necessary health services. Many may disagree, but as regulated healthcare professionals, should we not be putting our personal, religious, and ideologies aside to serve individuals in need?

The Nelson Mandela Rules state that "the relationship between health-care professionals and prisoners is governed by the same ethical and professional standards as those applicable to patients in the community"

The World Health Organization States that "Prisoners will return to society once they have served their sentences, and their good health is in the interest of the wider community". Good prison health lowers the costs of imprisonment by:

• improving the health of the whole community

• reducing public health expenditure

• improving reintegration into society and reducing reoffending

• reducing health inequalities

• reducing the size of prison populations

When I was a physio student, a few colleagues and I were tasked with making a business plan. As we watched our entire cohort develop every type of private practice imaginable, we sought for something different.

• What hasn't been done?

• What doesn't exist in the physiotherapy world?

• What market is truly, unjustly unserved?

We chose to advocate for inmates through a non-profit, public sector role. Shoutout to A.D, S.Q., and J.R for fueling my fire with The Penitentiary Physiotherapy Project. This was an opportunity for us to dig deep into the intricacies of Canadian health policy, discriminatory and unethical practices in correctional facilities, and advocate for the rights of individuals who will in time be reintegrated into society.

Inmates are the only group of people in Canada without access to necessary healthcare services including physiotherapy. Other marginalized groups have very poor access, however inmates are the only population that is actively barred from receiving physiotherapy services.

They experience higher rates of chronic illnesses and consequently contribute to higher healthcare costs during and after release compared to the general public.

There is a critical need for physiotherapy services in penitentiaries, which is justified based on an abundance of literature that displays the discrepancies between chronic illness prevalence.

Despite the fact that there is legislation in place that advocates for the health needs of inmates, necessary health services continue to be underfunded and in the case of physiotherapy, not funded at all.

"Where will the money come to fund physios for criminals?" you might ask.

Well, as most successful businesspeople would state, "you have to spend money to make money", and spending money to care for inmates will actually save the government a lot of money.

Look at this table below that compares rates of chronic illnesses in inmates compared to the general population in Ontario

Health Condition	Ontario Prevalence	Inmate Prevalence
Obesity	26%	68%
Chronic pain	17%	27%
COPD	4%	15%
Blood Diseases	0.8%	28%
Diabetes	7%	8%

Now let's look at the statistics below that illustrate how much more inmates (current and released) use the healthcare system compared to the general population:

Service	Baseline Cost	Inmate Use Rate	Surplus Cost
ER Visit	$304	4.3x	$1304
Knee Revision Surgery	$17,200	4.0x	$68,800
Overnight Hospital Stay	$6656	3.1x	$20,633

In a simplified way, this table means that for every single service used by a member of the general population, current and released inmates are using it 4.3, 4.0, and 3.1 times more, which makes healthcare more costly overall.

"Why physiotherapists?", you ask?

Well, doctors and nurses already exist in penitentiaries for basic healthcare needs. But think about the patients who leave prison for a knee surgery and go right back to prison without any rehab. This patient will get released from prison unable to function properly, unable to manage in a home, unable to work, and will likely end up back in prison. Think about the patient who has chronic back pain who will likely get released from prison and need to dull their pain with opioids, likely resulting in a return to prison.

What if there was an alternative? What if they didn't need opioids? What if we gave them a chance?

Prison is a place where your freedom is revoked, not your basic human rights.

Physios have the capacity to not only contribute to health equity be treating inmates, but reduce the ever-growing burden on our crumbling healthcare system. If you'd like more numbers or statistics, feel free to reach out!

If healthcare is a right, then it should be provided as such to all.

Prison health is public health.

I'd love to hear your questions and thoughts,

The Public Health (resident) Physio

References:

1. Goyert PR. Physiotherapy behind bars: a challenge in rehabilitation. Physiotherapy Canada. Physiotherapie Canada. 1991 Jan 1;43(3):40-3.

2. John Howard Society of Ontario. Fractured Care: Public Health Opportunities In Ontario’s Correctional Institutions [Internet]. [place unknown: publisher unknown]; 2016 [cited 2022 Aug 6] Available from: https://johnhoward.on.ca/wp-content/uploads/2016/04/Fractured-Care-Final.pdf

3. Kouyoumdjian F, Schuler A, Matheson FI, Hwang SW. Health status of prisoners in Canada: Narrative review. Can Fam Physician. 2016 Mar;62(3):215-22. PMID: 27427562; PMCID: PMC4984599.

4. Murphy Y, Sapers H. Prison Health as Public Health in Ontario Corrections. Journal of Community Safety and Well-Being. 2020 Apr 23;5(1):19-25. 5. Stewart LA, Nolan A, Sapers J, Power J, Panaro L, Smith J. Chronic health conditions reported by male inmates newly admitted to Canadian federal penitentiaries. CMAJ Open. 2015;3(1):E97-E102. Published 2015 Jan 13. doi:10.9778/cmajo.20140025

6. Tuinema J, Orkin AM, Cheng SY, Fung K, Kouyomdjian FG. Emergency department use in people who experience imprisonment in Ontario, Canada. CJEM. 2020; 22(2): 232-240

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8. New Choice Health. Ontario, OR Knee Replacement Surgery Cost Comparison [Internet]. [place unknown: publisher unknown]; 2022 [cited 2022 Aug 6]. Available from: https://www.newchoicehealth.com/places/oregon/ontario/knee-replacement-surgery

9. Wood G, Lalonde S, Walsh K, Harper K. Outcomes of hip and knee total joint arthroplasty in a Canadian inmate population over a 10-year period. Canadian Journal of Surgery. 2018 Oct;61(5):350.

10. Canadian Physiotherapy Association. Role of physiotherapy in primary healthcare. [PDF].

11. United Nations. Universal Declaration of Human Rights. [PDF]. 1948. Available from: https://www.un.org/sites/un2.un.org/files/udhr.pdf

12. CanLII. Canada Health Act, RSC 1985, c C-6. [Internet]. [place unknown: publisher unknown]; 2022 Jul 13 [cited 2022 Jan 31] Available from https://canlii.ca/t/532qv

13. Statista. Percentage of Canadians who reported being diagnosed with chronic obstructive pulmonary disease (COPD) from 2003 to 2020. [Internet]. [place unknown: publisher unknown]; 2022 [cited 2022 Aug 6]. Available from: https://www.statista.com/statistics/434316/share-of-canadians-reporting-being-diagnosed-with-copd/

14. Statista. Percentage of Canadian adults that are overweight or obese based on BMI from 2015 to 2020. [Internet]. [place unknown: publisher unknown]; 2022 [cited 2022 Aug 6]. Available from: https://www.statista.com/statistics/748339/share-of-canadians-overweight-or-obese-based-on-bmi/#:~:text=In%202020%2C%20around%2028%20percent,by%20about%20two%20percentage%20points.

15. Statista. Percentage of Canadians who reported being diagnosed with diabetes from 2003 to 2020. [Internet]. [place unknown: publisher unknown]; 2022 [cited 2022 Aug 6]. Available from: https://www.statista.com/statistics/434091/share-of-canadians-reporting-being-diagnosed-with-diabetes/

16. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain in Canada. Pain research and management. 2011 Nov 1;16(6):445-50.

17. Ministers. Government of Ontario; 2022 [cited 2022 Aug 6]. Available from: https://www.ola.org/en/members/current/ministers

18. Canadian Institute for Health Information. Cost of Standard Hospital Stay [Internet]. Ottawa (CAN): CIHI; 2022 [cited 2022 Aug 6]. Available from: https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/015/cost-of-a-standard-hospital-stay/;mapC1;mapLevel2;/

19. Kouyoumdjian FG, Cheng SY, Fung K, Orkin AM, McIsaac KE, Kendall C, Kiefer L, Matheson FI, Green SE, Hwang SW. The health care utilization of people in prison and after prison release: A population-based cohort study in Ontario, Canada. PloS one. 2018 Aug 3;13(8):e0201592.

20. https://www.icrc.org/en/document/prison-health-public-health