Dying Early Behind Bars: Nothing “Natural” About Deaths in Canadian Prisons
IMAGE: “Maximum security cell block in Kingston Penitentiary” by Boardhead. CC 2.0
As an institution near-explicitly dedicated to disempowerment and deprivation, the prison system is as pure an antithesis to a healthy setting as possible. Yet – and it should go without saying – the institution responsible for incarceration and rehabilitation also has a responsibility to provide care to, and respect the human rights of inmates. While the state should always aim to uphold the human right to life and health, it is especially responsible when the persons in question are directly and explicitly in the state’s care. Whether the Correctional Service of Canada (CSC) has properly upheld these responsibilities is up for debate. Practices liberally used in federal prisons – double-bunking, solitary confinement, overcrowding, disproportionate incarceration of and use of force against Aboriginal persons – have earned Canada significant criticism from international bodies and human rights committees. However, the disregard for prisoner well-being and rights may manifest in more insidious ways. For example, in the deaths of inmates from natural causes.
Natural cause deaths are ones attributed to terminal diagnoses, medical complications, or cardiac arrest by the CSC – and they account for about 70% of all inmate deaths, more than deaths by suicide, overdose, murder, and unknown causes combined. The average age of these deaths is about 60 – more than 20 years shorter than the national life expectancy. Controlling for terminal diagnoses, this trend still holds true. Even at face value, these statistics bring up a number of questions – are these deaths comparable to “normal” mortality ranges or rates? Are they somehow preventable or premature? Can we truly call these deaths “natural”?
In 2013, the independent prison watchdog office of the Correctional Investigator assembled a report on 50 of these inmate deaths labelled “natural”.The report found that 35 of the 50 deaths were flagged as “expected” – individuals with a terminal diagnosis. Yet of these 35, only 31 received palliative care. Additionally, a concerning discrepancy in terminal diagnoses exists between inmates and the general population. While the first two leading causes of deaths -cancer and cardiovascular disease- match the national mortality rates, the third leading cause of death was from infection with influenza or pneumonia. In the general population, less than 3% of deaths are attributed to infection. In correctional facilities that number is more than 10%. The deaths attributed to diagnoses of AIDS, hepatitis, sepsis, influenza, and pneumonia are causes for concern.
A diagnosis with any one of these conditions alone is by no means a sufficient condition for an “expected” death – it seems as if these deaths are at least in some part preventable, premature. Even if these deaths are entirely inevitable, the infections most likely are not. Public health measures and legislature to minimize infections in prisons are poor, and have been criticized as a missed opportunity at best, and grossly inadequate at worst. Considering the disproportionate prevalence of infectious diseases in prison populations, and the inherent infection risk of incarceration, measures to control and prevent the spread of infectious disease in prisons should be a public health priority. Part of this is attributed to the entering inmate population, which have disproportionately higher rates of infectious disease, and part of this is attributed to the high rate of acquiring infections within prisons. The high-risk environment within prisons promotes the spread and exacerbation of infections, and within a compromised population, this continued structural negligence can be actively harmful. Better policies do not have to be adopted solely for the benefit of inmates – improved measures against the spread of preventable, infectious disease would not only lower the prevalence of these infections in inmates, but in correctional employees, visitors, and the general public as well.
Furthermore, the conditions of Canadian federal prisons – crowding, solitary confinement, double-bunking, cells as small as five meters squared- significantly contribute and exacerbate the spread of infectious disease in a compromised population. The failure to properly address this issue is a symptom of continued neglect – there is little “natural” about the rate and prevalence of deaths attributed to preventable infections.
In addition to the nature of the deaths themselves, the Correctional Investigator also raised concerns on the accountability, transparency, and justice of the investigations into these deaths. The CSC is legally bound – as it is legally bound to provide a sufficient standard of health care to inmates – to investigate any instance of inmate death or serious injury. This includes suicides, murders, assaults, overdoses, and deaths deemed to be from natural causes. However, since 2005, “natural” deaths have been investigated through a different process than for other deaths or injuries – a streamlined Mortality Review Process (MRP). None of the MRPs had been independently or expertly reviewed until the Office of the Correctional Investigator prepared a report in 2013.
The 2013 report involved the review of fifteen natural death cases by a physician consultant. Of these, all but one were flagged as “expected” by the CSC. Investigating the same charts and patient information available to the CSC, the independent medical practitioner raised concerns over “questionable diagnostic practices, incomplete documentation, quality and content of information, delays and lack of follow-ups on treatment recommendations”, with some combination of concerns present in all fifteen cases. Additionally, an investigation of the compliance of the MRP itself found that it was “not carried out in a timely or rigorous manner, and it [failed] to meet basic investigative standards [of] independence, thoroughness, and credibility.”
The shortfall in the standard of care, accountability, transparency, and justice in the treatment, investigation, and prevention of “normal” and especially “expected” deaths would be considered ethically reprehensible in a public health system,. But this is a corrections system – a system where the reprehensible reduced standard of care is perhaps too enmeshed into the workings of the prison itself. In addition to ethical obligations, the Corrections and Conditional Release Act legally binds the CSC to ensure “reasonable access to health care with professionally accepted standards of practice”.
Yet health issues are the most-reported concerns from inmates. Since the existing protocol cannot keep up with modifications to provide adequate care on a case-by-case basis, a change in the fundamental protocol is crucial. Such a systemic change should be determined by the demographics and characteristics of the inmate population to best serve all inmates.
This population is characterized by a few noteworthy trends – it is increasing, compromised, increasingly diverse, and aging. From 2003 to 2013, the rate of incarceration grew by 17% while the general population only grew by 6% while the crime rate dropped year-to-year.
Looking deeper into the demographic breakdown, the increasing diversity also becomes apparent. In 2013, a quarter of the incarcerated population was of aboriginal ancestry. In women’s prisons, more than one in three inmates is of Aboriginal descent. The rate of incarceration for black Canadians was 9%; nearly three times their representation in general society. For Aboriginal, racialized, and Black populations, this rate of incarceration in the past decade has increased by about 46%, 75%, and 90% respectively whereas a 3% decline in the incarceration of white inmates was seen over this same period. This growth in the inmate population mirrors larger patterns of demographic change in Canadian society – increasingly complex, ethnically diverse, and culturally pluralistic. But this growth cannot solely be attributed to overall population diversity. It also warrants a look at the social capital, equity, and opportunity afforded to these populations.
Poverty and income are powerful predictors of crime, addiction, and incarceration. The conditions that produce and reproduce poverty, income disparity, and unmet health needs are partially mediated through a lack of social capital. Studies have shown a powerful link between social and economic inequality and violent crime – crime is a manifestation of unmet social needs. From a social determinants of crime perspective, the statistics of inmate demographics seem unsurprising. A majority of incoming inmates have a history of underemployment, addiction, and substance abuse. The average level of education received before admission is Grade 8. In women’s prisons, nearly 70% report a history of sexual abuse and 86% report a history of physical abuse. Poverty, lack of social capital, underemployment, poor education, trauma are powerful determinants of unmet health and social needs, illness and incarceration.
The population entering prisons is already compromised, vulnerable, marginalized – they are predisposed to poorer health even before exposure to the unhealthy environment inside prisons.
Moreover, the inmate population is aging – one in five inmates is 50 or older, another one in five is between 40-49, and 23% of the inmate population is incarcerated for life or with an indeterminate sentence. Not surprisingly, prison populations have a disproportionately high prevalence of non-communicable diseases as well. More and more inmates are living with age-associated illnesses that may require very specialized and/or expensive care – including palliation – before their sentence is over. The cumulative effect is that an increasing number of this complex, growing, and aging prison population will contract and die from chronic and acute diseases in federal custody – deaths that may have been prevented if they were not imprisoned.
The demographics linked to poor health access and outcomes, unmet social needs, incarceration, and elevated stress, are one and the same. The conditions of incarceration are undoubtedly intensely stressful. Unsurprisingly, inmates report high rates of stress-related illness. The entering inmate population already has disproportionately high rates of trauma, mental illness, and sexual abuse. All three of these have been linked with accelerated psychological and biological aging. The cumulative effects of these stresses manifest in a population that presents as much as ten years biologically older than their chronological age. While Stats Canada defines an elderly person as anyone over 65, many jurisdictions define an elderly inmate as anyone over 50.
A number of changes in federal policy in sentencing and parole will also undoubtedly contribute to the current prison health crisis. The “tough on crime” era of the Canadian federal conservatives – which is still very much in place – will likely generate a prison crisis for the Canada of tomorrow. Moreover, sentencing and parole policies have been modified such that inmates are staying longer before first release, federal security levels are higher, and the practice of solitary confinement is up. This translates into a larger inmate population, longer sentences, and more inmates contracting and dying from chronic and acute diseases behind bars.
Balancing justice and humanitarian concerns for inmates is difficult, but must be actively considered given the high-health-risk nature of the prison environment, the vulnerability and complexity of entering inmate demographics, and the system’s capacity for negligence. Suffice it to say, the cumulative effects of demographics, conditions, and policies are becoming evident in an aging population with increasing complaints, diagnoses, and deaths attributed to “natural” chronic conditions. Though the challenge of creating healthy prisons for an increasingly complex population is not a small one, it is ethically necessary – a criminal sentence should not mean a shortened life expectancy. It has been 40 years since Canada abolished the death penalty, a development celebrated as a great human rights achievement for the nation. Yet a prison sentence today could result in a “natural” death behind bars with little natural about it.