The lack of health care within prisons is an issue that plagues prisons across the country, despite the constitutional requirement that every prisoner is entitled to the exact same health care as what is available at public hospitals. According to a Sunday Independent report, this constitutional requirement is poles apart from reality. Serious over-crowding, staff shortages and medical neglect seem to exacerbate, sometimes even cause, health problems. In addition, medical parole processes are so cumbersome that inmates become increasingly ill, with the threat of death hanging over them, before parole is granted.
The report says several inmates have died waiting to be released on medical parole, others die shortly after being released. Some of these deaths could have been avoided had these prisoners been released into family-care, or received better health care behind bars. Official statistics, from the Judicial Inspectorate for Correctional Services (JCIS), show 10 inmates died a “natural” death at Medium B last year, from illnesses varying from tuberculosis to meningitis. Between 2013 and 2014, nine prisoners died from diseases such as epilepsy and renal failure.
According to the Department of Correctional Services (DCS), there are 1,469 full-time health care professionals comprising of nurses, medical practitioners, psychologists, pharmacists and social workers to treat 154,648 sentenced and awaiting-trial inmates. At Medium B, there are 15 nurses, including one on standby at all times, and two sessional doctors and a departmental doctor. However, this translates into a prisoner only being able to see a nurse about once every two-and-a-half weeks.
The JCIS’s latest report notes overcrowding is a common issue as “it is accepted that the over-population of inmates per available infrastructure is a problem in certain centres and then, within such centres, largely in the communal cells and, in some instances, single cells where inmates are ‘doubled-up’ or even ‘tripled-up'”. Although this is not the case with all correctional centres, it notes that “these conditions are unacceptable and have been found to be so during our inspections around the country”.
The report also dealt with seven complaints around “medical release”, and 20 of the 109 assaults on prisoners by officials that it investigated were because of “no medical treatment”. Lukas Muntingh, co-founder and project co-ordinator of the Civil Society Prison Reform Initiative (CSPRI), notes the number of health care complaints is “definitely an indication that – system wide – this is a problem”.
“During our inspections, we found that medical staff were in many cases unaware of the amended provisions. The department has indicated that the total medical releases for 2013/2014 were 20. The figure is low and our view is that much effort is required by the department and ourselves to ensure the administrative processes are fluid and efficient.”
The report says South Africa’s medical parole regime was overhauled a few years ago, leading to a new administration that came into effect at the end of March. Under the amendments to the Correctional Matters Amendment Act, a Medical Parole Advisory Board was introduced on February 23, 2012 “to assist in making the medical parole application processes trouble-free, fair and transparent”, the DCS explains.
The board has 10 doctors who accept applications from both doctors and family members, while previously only the medical practitioner treating the offender could apply for medical parole. Previously, decisions were made by 52 parole boards, one for each management area, which means decisions may not have been consistent, but this was before the amendments to the act, Muntingh says.
Under the new dispensation, in the normal course of events, a medical practitioner will identify offenders who might qualify for possible medical parole. An offender or family may also apply for medical parole but any such application must be recommended by a medical practitioner before it will be submitted.
Before the new system came into effect, the early release of inmates on medical grounds was a “highly contentious issue” because the law was not specific enough, and the DCS allegedly failed to initiate applications in worthy cases. The old dispensation also only allowed the release of inmates who were in the “final phase of a terminal illness”, while those who were suffering from life-threatening illnesses, but who were not bedridden or noticeably terminally ill, were considered ineligible for early release on medical grounds. The CSPRI notes, before the amendment, “it was also of concern that the proportion of inmates who had been released on medical grounds over the years had been extremely low compared to the number of inmates who had died of natural causes in prison”.
Yet, the report quotes Muntingh as saying that very little seems to have changed because the requirements for medical parole are so onerous as to render them unworkable. He adds: “The process is just so Kafkaesque in its nature; it is impossible or difficult. Look at the number of applications versus those granted. It’s about one out of 10, and that’s just people who managed to get through the application stage. I’ve heard what the DCS considers heavily is whether there is adequate care on the outside. I’ve heard of cases where people have been transferred from prison to hospices, which I think is a wholly workable solution. It is a ‘Catch 22’, if you don’t have a family to go to, but if you stay, you hasten your demise.”
Muntingh says doctors often wait until it is almost too late to get the paperwork started, then the prisoner dies. “The Medical Parole Board (MPB) makes the decision very quickly if the information is there, but DCS must collate all the information, and I don’t think they are bothered a lot of the time. You can’t fault them for establishing a thorough process. But if a person is really sick, they may not survive a month.”
Attorney Marius Coetzer concurs DCS officials take too long to deal with paperwork, while the prison staff and medical parole board could interpret the medical parole conditions in several different ways. For those who are terminally ill, the medical parole process should be streamlined, he adds. Coetzer notes the medical parole board gets too many applications and there are too few staff and supporting medical staff in prisons. “Also, the decision-making process is too drawn-out and takes too long. The medical prison board should sit every day, not just once a month.” In addition, written reasons – paving the way for an appeal – are only provided when a prisoner pressurises officials.”
Another issue, says Coetzer, is that prison staff tell inmates that they could organise medical parole for them at a price. “They obtain the contact details of family members and then contact those family members, demanding that they pay an amount in cash to the prison staff member(s) if they want to have the inmate paroled. The amount asked for varies from R5,000 – R15,000. I have had two such instances during the last six months. Not only is it corruption, but the family gets defrauded and relieved of their money.”
John Stephens, a legal researcher at Section 27, says the non-profit organisation had a client with TB and who was also HIV positive, but the department failed to treat him and he got so sick he was finally released. He says healthcare in prisons is a major issue, and Section 27 has dealt with several cases, but the department is seldom responsive. Stephens says prisoners clearly have a right to healthcare at the same level that is provided by public hospitals, and at no cost to themselves, as this is stipulated in law. In some instances, there are logistical issues, such as a lack of nurses, or escorts to take prisoners to hospital. Sometimes, although there is no proof of this, there is a wilful denial by DCS officials to provide healthcare, he adds. “We have had our clients intimidated for speaking out.” Prisons are also “desperately” short of medical staff, in direct violation of the law,” says Stephens.
Muntingh notes the ratio of staff, according to official DCS figures, is better than for the general outside populace. “It’s not as if there are not enough of them.” But, on a case-by case basis, there may be a shortage of doctors in some prisons. Depending on the prison, it may be sufficient for a doctor to visit for a few hours a day for a few days a week, but in overcrowded prisons there are more than enough prisoners to justify a full-time doctor, he adds. It would be easier if prison healthcare was run by the health department, as there would be a different contractual process. “(But) I think it must create problems for them.”
DCS spokesperson Manelisi Wolela says, however, “that in those certain instances, when offenders are not taken to the different health institutions for their follow-up appointments, because of staff shortages, these appointments will then be rescheduled”. Wolela says protecting inmates from infectious diseases such as TB is important because it is important for the health of the prisoners. He notes the department has spent R150m on improving health services provided in correctional centres. “Health worker capacity has been bolstered and equipment has been improved to provide better quality HIV and TB services. The systems have been redesigned to routinely screen, counsel, and test inmates for TB and HIV.
“Correctional Services facilities are being assessed from an environmental perspective so that disease infection control and prevention can be improved.2
As of February this year, Wolela says, 167 462 inmates were routinely screened for TB, a process that was not routinely done before 2013. As a result of the interventions, he says the rate of new infection will decline. “In fact, over the last three years, the numbers of deaths from TB have decreased by more than 25%, from 55 102 in 2011 to 40 542 in 2013.”Full report in The Sunday Independent