Prison health care in Nova Scotia
By Robert Strang 
Nova Scotia has a population of 940 000; less than 25% of BC’s 4.5 million population. In 2001 the Central Nova correctional facility opened in Nova Scotia in the same location as the East Coast Forensic Hospital, bringing the number of provincial correctional facilities to six (five adult and one youth). 

At that time, the dep­uty ministers for health and justice agreed that the Ministry of Justice would provide the security for the forensic hospital and the provincial correctional facilities, and that the Ministry of Health, through the Capital District Health Authority (CDHA), would provide health care for prisoners in adult provincial correctional facilities, and for young offenders in the Nova Scotia Youth Facility through the IWK Health Centre. An independent review of health services in corrections by the Department of Health identified the need for additional equipment and physicians, and funding was provided to meet this need.

Today the CDHA provides health services for Nova Scotia and operates the QEII, the largest teaching hospital and adult academic sciences centre in the Maritimes. In affiliation with Dalhousie University, QEII provides training for physicians, nurses, and social workers. The CDHA also hires and guides the conduct of all corrections health care staff for each of Nova Scotia’s adult correctional centres, where on any given night a total of 550 adults are in custody. The Central Nova facility alone has the capacity for 224 male and 48 female offenders.

The results of an unpublished  2003 survey undertaken by the Provincial Offender Health Services in Nova Scotia to explore the health needs of the corrections population are consistent with published data from other jurisdictions. The mean age of the survey participants was 32 years; 80% were between 20 and 49 years; 60% reported that they used illicit drugs; over 50% were daily users, and 61% wanted to stop using drugs. Almost 50% of participants reported that they had emotional problems; 32% had made suicide attempts; and 94% report­ed feelings of hopelessness.[1] 

When health services for corrections were taken over by the CDHA in 2003, the existing health policies were found to be appropriate; however, there were limited resources for implementation. After 2003, health care staffing was increased and community partners in the CDHA collaborated to provide additional programs. 

One example of these new programs is a mental health clinic developed by a community outreach mental health service and delivered by two community mental health nurses hired for the corrections program. This men­tal health team runs a weekly clinic, with 45 to 50 inmates attending each clinic. 

The mental health team also uses the same software used by community mental health programs, al­lowing patient records to be accessed from the community. In addition, there is regular communication with commu­nity clinicians, who are welcome to visit their incarcerated pa­tients. This enables incarcerated women to receive treatment that was requested or initiated in the community while they were in prison, and allows for follow-up after they are released from prison. 

Other health initiatives include: 
•    Clinics for female inmates focusing on women’s health, including prenatal and postnatal care, conducted by a nurse practitioner employed by the IWK Health Centre.
•    An expanded methadone maintenance program that promotes continuity of care for women returning to the community after incarceration.
•    An infectious diseases clinic, which is held at the correctional centre once a month.

The provision of health care services in provincial correctional facilities by the CDHA in Nova Scotia has been found to improve the continuity of care for men and women as they move from prison into the community. Although an initial investment in re­sources was necessary, the im­prov­ed health and well-being of the corrections population reduce health care costs and rates of recidivism in future.

International research findings
By Brenda van den Bergh and Alex Gatherer
The imprisonment of women raises important and difficult issues for all societies. The results of 3 years of research on women in prison, undertaken by the Quaker Council for Eu­ropean Affairs and Quaker United Nations Office, makes it clear that the struggle for gender equality has far to go, that human rights needs are not always met, and that social injustices are part of  the problem in several countries.[1] 

A study completed jointly by the WHO Health in Prisons Programme[2] and the United Nations Office on Drugs and Crime resulted in the 2009 publication of a background paper containing the Kyiv Declaration on Women’s Health in Prison.[3] This was followed in 2011 by the publication of practical checklists and guidance notes for policymakers and prison management and health staff.[4] 

Characteristics of women in prison
Many of the difficulties faced by prisoners are the same for men and women. However, women in prison share characteristics that greatly influence their needs and underpin some of their specific challenges. Of these, three predominate:

Women prisoners are a minority. In virtually every society, women constitute a small proportion of the total prison population; in about 80% of prison systems worldwide, the proportion of women varies between 2% and 9%, with a median of 4.3% in 2006.[5] Prisons have usually been built and are run to cope with the needs of the majority, namely men. Furthermore, the small numbers of imprisoned wo­men mean that there are usually fewer prisons available for them. This results in women frequently be­ing imprisoned far away from their homes, leading to difficulties for wo­men wishing to maintain their family ties. The ma­jority of women in prison are convicted for nonviolent property or drug-related crimes, for which they serve relatively short sentences.[1] There is seldom a need for the high levels of prison security that women too often face.

Women prisoners have different health needs. Female prisoners have more and different health needs than their male counterparts. These range from issues of normal female functions, such as menstruation, to re­productive health issues (including pregnancy), to complex mental health needs (including posttraumatic stress disorder, depression, and self-harming be­havior).[3] Women in prison are very likely to have experienced violence and abuse prior to their imprisonment, yet they seldom find themselves in a facility with staff able to understand them and give them the support necessary after such traumatic experiences.

Women prisoners have different home and family responsibilities. Many women in prison have dependent children. It is not clear how many children are affected by their mother’s imprisonment, as data are poorly collected. One of the most challenging decisions that authorities have to make concerns what to do with the children involved. 

Suitable facilities, such as special mother-and-baby units allowing infants to stay with their mothers at least for a period, are becoming more and more available. However, both options—admitting children to prison or separating them from their mothers (and often accommodating them in state institutions or foster care)—are likely to damage the children. Decisions have to be made in the best interests of the child, something that is often very difficult to assess. 

Lack of equivalent services for women
National governments are responsible for providing health services to prisoners, and international human rights recommendations state that the care provided in prisons should be equivalent to the care available in the community. There are, however, considerable variations worldwide regarding the health care services available for women in prison.

In most countries, the responsibility for providing prison health care lies with the Ministry of Justice or the Interior instead of the Ministry of Health. This may have a major influence on what is or can be provided to prisoners. The difficulty of recruiting professional health staff for work in prisons and ensuring the quality of health services in isolation from community health services are just two of the challenges. The Moscow Declaration on Prison Health as Part of Public Health stresses the importance of strong links and collaboration between prison health and public health services.[6] If these vital links are lacking or too weak, problems of equivalence and continuity of care are unavoidable. 

Need for action
Availability of a wide range of ser­vices is essential for dealing with prisoners’ health needs. (Figure [11]) For women in pri­son some services are of particular im­­portance, including drug-dependence treatment and psychological support to help cope with posttraumatic stress disorders, self-harming behavior, and profound feelings of inadequacy. The impact of imprisonment, of separation from children and family, and of confinement in a male-dominated environment with few facilities dedicated to women’s requirements results in needs that only a minority of prisons can actually meet.

Social justice requires that everyone be treated fairly, without prejudice. The minority status of women in prison has been accepted for too long as justification for not correcting the gender bias that still exists in many prisons. If prisons can address gender inequalities and support health protection and promotion for women, much can be achieved while women are imprisoned and after their release.

Conclusions
The high cost of imprisoning women in financial, social, and health terms strongly suggests that women should only be sentenced to prison when all other alternatives are unsuitable or unavailable.[3] Until fewer women are incarcerated, there are some steps that can be taken immediately to improve the current situation. 

First, policymakers and senior managers in the prison service should understand the basic differences be­tween the needs of women and men, and ensure that prisons are able to provide for women’s fundamental health needs, and make education, employment, and recreation programs suitable for women available. Second, all staff working with incarcerated wo­men should receive training in gender sensitivity and learn about the different pathways men and women follow to crime. Third, staff should be encour­aged to keep up to date on internation­al recommendations, human rights requirements, and standards of care.

The changes needed will require po­litical awareness and a serious commitment to gender equity and social justice.

Competing interests
None declared.

Phsycian handout
This handout [11] can be copied by physicians and given to female patients who were formerly incarcerated. The organizations listed--Women in2 Healing, Collaborating Centre for Prison Health and Education (CCPHE), and Elizabeth Fry Society--all work to enhance the social well-being and reintegration of women into their families and communities after incarceration. The CCPHE provides an up-to-date database of listings for various health, education, and social resources available to women during the first 72 hours after their release from correctional institutions in British Columbia. 

The database can be accessed through Women in2 Healing (www.womenin2healing.org [12]), a participatory research group that seeks to empower women emotionally, spiritually, mentally, and physically. Similar support is available from the Elizabeth Fry Society, which provides women with information about counseling, transitional housing, and other social resources. 

Physicians can also help women who have been incarcerated by using the Ten Tips for Physicians available at http://ccphe.familymed.ubc.ca/resources/health [13].

Dr Strang is the chief public health officer, Department of Health and Wellness, Nova Scotia. Ms van den Bergh is a technical officer at the WHO Regional Office for Europe, Health in Prisons Programme, Division of Non-communicable Diseases and Health Promotion, Copenhagen, Denmark. Dr Gatherer was director of public health for Oxford, an honorary visiting fellow of Green College, University of Oxford, and an advisor to the WHO European Health in Prisons Project since its inception in 2006.