Putting patients first!

SPOTLIGHT: PRISON HEALTH CARE – A BOTTOM LINE

“The security features inherent to federal correctional facilities are designed to keep people in as much as they are to keep people out. As a result, the management of the federally-sentenced population is largely conducted away from public scrutiny. Invisible to the general population, federally-sentenced persons are often forgotten.”
The Senate of Canada, Human Rights Committee, Interim Report, February 2019

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These often forgotten inmates in our federal prisons are wholly dependent upon Correctional Service of Canada for the necessities of life, including health care. The Corrections and Conditional Release Act (CCRA) says that CSC is responsible for providing “every inmate with essential health care and reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration in the community.”

Despite the millions of dollars budgeted annually for health care and the aggressive treatment targeting some conditions, like HIV and HEP-C, access and timely attention to care is a major source of inmate complaints and grievances. That is a slow and cumbersome process, but inmates can elect to file a complaint through the professional associations of doctors, dentists, and nurses. However, doing that means the incriminated doctor, dentist or nurse cannot treat the complainant during the review process.

Yes, while the voices of inmates are devalued by CSC, there are others who make studied and authoritative assessments that can’t be ignored. Or can they?

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“Healthcare in CSC penitentiaries is not provided independently of corrections. Instead, healthcare providers are employees of CSC, though recently CSC has been making changes purportedly to encourage their independence. This is nevertheless a violation of the Mandela Rules, which requires that prison health services be organized in close relationship to the general public health administration and that medical providers act in full clinical independence.”
West Coast Prison Justice Society, Damage Control, June 2019

“Bill C-83 includes several positive health care obligations, and recognizes the professional and clinical independence of health care professionals, but the legislative requirements are again vague and don’t include enforceable standards. Health care providers should partner with federal and provincial Ministries of Health, without the influence or interference of prison administrators, and without any CSC staff supervision or oversight. And, add legislation to ensure confidentiality between health care providers and prisoner patients.”
Canadian Bar Association, letter to Ottawa on Bill C-83, November 19, 2018

“There are many areas of correctional health care practice that give rise to clinical role conflicts of ethical dilemmas, where clinical independence and professional autonomy may be impaired or impeded or where health care providers may feel compelled to follow correctional authority rather than health care rules.”
Office of the Correctional Investigator, Annual Report, 2017-2018

“The crux of the matter boils down to the fact that role conflicts and misunderstandings between health care and custodial staff are common and everyday occurrences. Examples abound: population movement schedules determine health care clinic hours; when or if an inmate’s medical escort takes place is dependent on staffing levels; who provides care or how it is provided in a prison setting is not a matter of patient choice.”
Ibid.

“….United Nations Standard Minimum Rules for the Treatment of Prisoners (now known as the Mandela Rules)….state that clinical decisions may only be taken by the responsible health care professionals and may not be overruled or ignored by non-medical prison staff. Though a review of the Mandela Rules was purportedly conducted and completed, in response to an Office request for an update, CSC provided no documentation, report or findings to corroborate its claim that CSC health care services are compliant with the Mandela Rules. Saying or believing that the Service is compliant with domestic or international rules and standards is different from demonstrating it. As with many other activities within CSC, transparency would go a long way towards ensuring that health care standards behind bars are demonstrably met.”
Ibid.

“Federally-sentenced persons also provided the committee with disturbing personal accounts of health and dental care services, most often involving doctors or dentists hired by the CSC on contract. On the other hand, some federally-sentenced persons had a more positive view of certain mental health nurses and clinical social workers with whom they were in contact but felt that they had inadequate access to these professionals, especially outside of normal business hours. In other words, a mental health crisis should occur between 9:00 a.m. to 5:00 p.m., Monday to Friday in order for the affected individual to receive help. Overall, the committee has heard many examples of how security concerns of staff routinely trump health – especially mental health – needs of prisoners.”
The Senate of Canada, Human Rights Committee, Interim Report, February 2019

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This is a sampling of what is in front of the federal government and Correctional Service of Canada. They’re from the latest of a long list of opinions, research, studies and examinations over many years that have called for change.

One bottom line sees the appointment of a Minister who chooses to manage rather than be managed.

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Hey, I’m the patient!

SPOTLIGHT: WHOSE HEALTH CARE IS IT, ANYWAY?

“The sole task of health care providers in correctional settings is to provide health care with undivided loyalty to the patients, with unrestricted clinical independence, acting as the patient’s personal caregiver without becoming involved in any medical actions that are not in the interest of the patient health and well-being.”
Pont, Engglist, et al, American Journal of Public Health, April 2018

Health care in the prison systems was previously framed in “Scene One” on March 3rd of this year, and “Scene Two” on April 14 where a note pointed to a future third entry about dental care in federal institutions. Those first two postings were necessarily harsh as inmates can run into problems accessing reliable care due to “dual loyalties” among some health care workers.

Nurses, psychologists, pharmacists and social workers are employees of Correctional Service of Canada, whereas doctors and dentists are contracted. The focus here is dentistry.

A toothache is distracting, uncomfortable, and left untreated, can result in excruciating pain and a serious infection. As previously noted, inmates submit a written request for health care and then wait for attention. It’s unlikely an inmate will ask for a dentist unless there is some urgency, but a nurse is just as unlikely to consult promptly with an inmate when a request is received by the health care unit.

Sit and wait. It’s not unusual to wait weeks or even months to see the institution’s dentist, and aside from knowing there is a waiting list for treatment, an inmate doesn’t know when help will come. For the most part, a dentist’s time is managed at the discretion of the institution’s on-site health care workers who generally don’t recognize the word “emergency.”

Dental services are contracted and so too are the number of service hours, often expressed as a maximum number of hours per year. For example, the dentist who services Millhaven Institution in Bath with roughly 500 potential patients is available a maximum of 364 hours a year, and may run one to three clinics a month, depending on need which is established by institutional nurses. Joyceville Institution in Kingston has up to 637 hours a year for about 750, Collins Bay in Kingston a maximum of 644 hours per year for 760, and Warkworth Institution in Campbellford lists dental services one day a week for just over 500. And, all managed by institutional employees.

Given the ratio of hours to population, dental therapies are more curative than preventive. There are examples of people waiting so long for help they’re admitted to institutional hospitals on IVs to fight infections. There are examples of inmates taken to outside dentists for help when advocates press CSC national headquarters and regional offices for action. Too, outside referrals can be critical of the damage delays can cause.

To be fair, negative experiences with institutional dental services are not entirely universal. An inmate can feel ignored at one point but get help in reasonably short order another time. Consistency is illusive. The culprit? Refer to the first paragraph.

Part II of the spotlight on health care follows.

Solitary confinement & the prison industry.

SPOTLIGHT: WHY THIS JUST WON’T GO AWAY

The controversy and legal actions over the use of solitary confinement in provincial jails and federal prisons has been a media staple for the last many years. This site has reported at least twice on the practice of separating inmates from population (“The Canadian Bar Association comments” – March 17/19 & “Solitary Confinement” – February 3/19).

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The previous Ontario government hired former federal correctional investigator Howard Sapers to recommend reforms to provincial jail policies, including a rethink of the segregation of inmates, sometimes up to 24 hours a day which contradicted even the existing guidelines. Ontario employed Sapers in response to court rulings against established policies, but the ministry’s later revisions limiting segregation practices didn’t necessarily make for major changes.

Jail guards in Ontario adapted. One method that created quasi-segregation conditions when an inmate could not be placed in old solitary cells was to substitute the most remote cell on a range. Since new rules required a certain number of hours out of a cell, those hours were timed to when other inmates were locked up.

The effectiveness of the reforms in Ontario jails depends upon the willingness of management to do just that….manage. Meanwhile, some provinces continue to use solitary confinement as a recourse for inmates who are aggressive, suicidal, mentally unstable, or as reprisal for anything not meeting staff approval. Whether it’s a provincial or the federal government, the one option to force change is the courts, and the stamina to withstand appeals.

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The government of Canada has been in the courts for years, first arguing its support for Correctional Service of Canada’s existing prison policies, particularly with the use of solitary confinement, and then appealing decisions that have gone against it. Actions challenging the prison agency have been centered in British Columbia and Ontario where rulings have either been upheld on appeal or are pending.

Knowing the jig is up, the government tabled Bill C-83 last year which it claimed did away with solitary confinement, passed it to committee, sent it on to the Senate which returned a package of amendments that the Commons rejected, shepherd it through third reading, and received Royal Assent this summer.

Bill C-83 is now law. Rather than segregating federal prisoners who are a risk to security or themselves, inmates would be moved to “structured intervention units” (SIUs) where they are intended to get “better programming,” more mental health care and more contact with others.

Firstly, not all institutions have a range of programming even for inmates in population. What does “better programming” for SIU inmates mean in those prisons? Notably, a group of over 100 lawyers and academics sent a letter to the Senate while that body was considering the legislation to say that SIUs “continue to be solitary confinement under another name.” It claimed that without the Senate amendments the bill “specifically allows for prolonged solitary confinement without independent oversight. This is a clear violation of international human rights.”

Ralph Goodale, the minister responsible for CSC, argued Bill C-83 includes independent oversight through “independent external decision makers” without specifying the process for selecting candidates, the qualifications expected, or how appointments would be made. Senator Kim Pate, a member of the Senate Human Rights Committee and a lifelong advocate for prisoners’ rights, questioned how independent the new external reviewers will be if chosen by the minister. Senator Pate claims that without judicial oversight the law will be unconstitutional. Expect to see more lawsuits, no matter which party forms the next government.

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Here’s a thought. Nobody has to tell government prison agencies how harmful and damaging solitary confinement is under most conditions. They’re on the front lines. They know the downsides. So, for one, why should it be left to civilian bodies and the courts to force governments to do the right thing? Why aren’t our elected bodies and the public servants working under them leading the way to long overdue reforms?

What’s more, once the system failures have come to light, why isn’t CSC and its provincial counterparts openly interacting with the courts and the public to find solutions to effectively manage difficult institutional inmate crises?

Why are they so afraid of the light?

Hope is not a carrot.

…….one last ‘switch’.…..

Jason Godin, former national president of the Union of Canadian Correctional Officers, and a founding member of the organization representing 7,300 federal correctional officers in Canada, left the top post on May 9 after three years in office, and 18 years on the union executive after its 2001 inception.

He is a man of long and broad experience. And yet, in a brief interview last year when commenting on changes Correctional Service of Canada was making to the inmate grievance mechanism, he welcomed the revisions as a foil to what he considered nuisances. Disparaging inmate protests is self-serving when Mr. Godin knows offenders often have legitimate cause, and he’s only too familiar with the use prison guards themselves make of a grievance system when they claim management is not acting in their best interests.

As it was, filing a grievance was cumbersome and potentially risky for an inmate, responses often slow in coming….sometimes up to a year or more…, and upwards of 95% were summarily dismissed without community standard due process. The modifications are unwieldy and discouraging, and while they may not be intentionally inhibiting, there’s no question that they are. It all comes across as only a sop for appeasing the prison population.

Inmates have two redress tools. They can hire a lawyer and take CSC to court, or they can file a grievance. One is out of reach for most, and the other is out of touch. How does this square with the rehabilitative ideals of ‘corrections’?

Prison reform activists have been challenged for decades by questions around accountability and transparency issues within our penal systems. Correctional Service of Canada protocols for candid dialog, for ‘opening the books’, for welcoming scrutiny is like the pendulum of a great clock. It swings freely and with abandon, but the scope of the arc is strictly confined.

There are places out of reach. Or is there? As an example, it’s here that one difference prison guards have with firefighters and police officers is apparent. No matter what perspective one has of police conduct in our communities, the shield sheltering the integrity of cops against charges of impropriety is not as insulating as the firewall that protects and ensures the security of guards. (see “The Firewall” posted November 4 of 2018) Why is this necessary? With the constant interaction between guards and inmates, the efficacy of the prison landscape benefits from the viewpoints of all parties.

And what does hope have to do with carrots? Inmates know. CSC assessments maximize the negative and minimize the positive, battering the hope offenders may clutch for a better tomorrow. While the correction plan assigned to all prisoners offers pathways to that new day, too often the lures are the proverbial carrots on a stick that lead down a road of hope-bashing obstacles.

Lastly, here’s a question. Who will finally take the lead and rectify the joke our last Conservative government made of inmate pay scales?

……two spotlights on the way.

Prison light switch #4……

……taking it easy on the system – for a change.

The prison environment is punitive by necessity. That’s why Correctional Investigator Ivan Zinger says offenders are sent to prison as punishment and not for punishment. Even in those European models where dynamic security measures in some institutions means inmates are not locked in their cells, and where programs permit some to spend weekends with their families in the community, a prison is still a prison.

Almost all offenders in Canadian federal institutions will return to the community, and Correctional Service of Canada has a mandate to assist with that often difficult transition by maximizing opportunities for success. Putting health care aside for a later date, there are aspects of prison life today that support an affinity with life in the community, there are elements that can be massaged to do the same, and there are progressive proposals to be considered.

In June of last year, it was announced two prison farms in Ontario would reopen this summer. The program officially relaunched two days ago at Collins Bay and the farms there and at Joyceville are now ramping up operations. The Pen Farm Herd Co-op was among a diverse group of farmers and social justice advocates working to re-establish these training opportunities since the previous federal government closed the last farm in 2010. Great move!

Book Clubs for Inmates is a registered charity that organizes volunteer-led reading groups to improve inmate literacy. Since retired Anglican priest Carol Finlay initiated the program in Collins Bay in 2008, clubs are now operating in 36 institutions across the country.

James Fox, a California-based instructor founded the Prison Yoga Project in 2010 which has spread to 300 U.S. prisons in 28 States. He began a training course in Vancouver in June of this year to prepare teachers for Canadian prisons and is in the process now of dealing with the delays and difficulties navigating through our government bureaucracy.

A prison needle exchange program is rolling out across Canada. There are pluses and minuses. It’s controversial. Guards here demonstrate in opposition to what they see as a threat. Various models in countries which have prison needle exchanges include two where needles are stored in plastic safety cases. One commonality throughout however is that inmates in every country have complaints about how these programs are structured.

Death, dying and MAID in prison is a challenge looking for a speedy resolution. CSC has been developing a protocol around medical assistance in dying but the bottom line in every instance is the same. No terminally ill man or women should die in prison when a preferable alternative is readily available, either for palliative care or an assisted death. The present cumbersome compassionate release process begs for prompt action to expedite quick transfers when time is short.

Stepping onto rocky, difficult terrain, consider appropriate and case-specific programming at all security levels for inmates who spend as much time out of their cells as is possible to schedule. Then, to push the envelope further, reimagine the previously tested safe tattooing program by auditing earlier outcomes to determine the benefits of a revised blueprint. And to put a period on this segment, a revision of the tobacco ban along with ongoing anti-smoking initiates would impact the pervasive prison black market for a saner environment.

One thing that won’t change. Prison is still prison.

……another switch? ……on the way.

Prison light switch #3……

…..now to continue.

SECURITY: ……in the dictionary as protection and safeguards, as well as care, custody and sanctuary, and then further as assurance, certainty and reliance, we live increasingly in a risk-averse environment, a symptom of our changing world.

The conspicuous presence of security measures conditions us to see potential threats as ever-present, a boon to a growing industry. But, the best training programs encompass a range of assessment techniques in applying appropriate responses to whatever situations arise. A street is not shut down because a shoplifter was at work in the corner store.

Prison security touches all areas of institutional operations and exercises a top to bottom priority over every detail of procedure and practice. This degree of authority and autonomy is condoned and expected under the circumstances, and the perception that control is absolute is as important as is the fact of it.

In a democracy, great power comes with great responsibility. We assume without a second thought that the men and women responsible for security in our institutions execute their obligations keeping the base purpose of a correctional system in mind. It’s one thing to take necessary measures to manage pressing concerns but disrupting programs and routines beyond the resolution is counterproductive. Tempering safeguards with an eye to the certainty of long-term expectations is a protocol worth pursuing.

GUARDS: Police officers, firefighters, and correctional officers have a commonality. All who work in these jobs do so by choice, knowing assignments can be volatile, dangerous, and potentially lethal. Depending on postings, there is also considerable down time where staff are still expected to be vigilant, watchful, and ever ready on stand-by, and this despite a lack of stimulation. The differences between prison guards and police/firefighters will be addressed elsewhere and later.

Guards have a list of duties, and through either a dynamic or static security process they also present an opportunity to be a positive part of the correctional program, a resource that seems to be overlooked. The uniform guards wear identifies them as officers with Correctional Service of Canada, an agency of the federal government, whose purpose is to serve the people. Because prison inmates have more contacts with guards than other CSC employees, they are front-line representatives of the society to which almost all inmates will one day return.

Understandably, guards do not bring their mobile technology into the workplace. They are a potential risk, and a distraction too which is why televisions are also prohibited in the towers and bubbles. Despite that long duty list, there are periods where overseeing their charges can tax alertness and is it here that part of the job description, “supervise and interact with offenders,” takes on a greater significance. It is here that guards can play a positive role in helping inmates complete their correctional plans.

Something to be considered.

…….still more soon.

Toronto South Detention Centre……

……to be fair, we got an answer.

“About 200 Toronto South Detention Centre guards refused non-essential work at the jail on Monday, March 4, after an alleged assault by inmates injured eight staff members on the previous weekend.”

So began the April 21st posting reprinting our letter to the provincial minister, critical of the bias with the department’s reporting of operational issues at this Toronto jail. Despite so much evidence to the contrary, government, guards and their union cite inmate hostility as a central cause of the problems at the institution….along with ongoing complaints by guards of staffing shortages.

As the media reported later, that weekend attack on guards was precipitated by an earlier assault by guards on an inmate. Unjustified use of force by either side isn’t sanctioned in principle, but it’s notable that officially, guards don’t attack inmates.

The March 15 letter to Minister Sylvia Jones pointed out that “no inmate who is not deranged awakes of a morning and decides to assault a guard….. Are you aware of the consequences?” A second letter followed on May 6 asking for a comment when there was no response. “I Hate Inmates!” posted on May 19 implied an answer was doubtful.

Unexpectedly, a lengthy June 19 letter over the minister’s signature addressed the issues raised, and with an unusually candid and liberal bent for a Conservative cabinet minister. “We are creating better housing options, redefining segregation…..better mental health screening and assessment tools.” “We have implemented measure to provide better oversight and support…..” “At Toronto South Detention Centre, steps are being taken to improve staff and inmate safety…..” At TSDC, “a new initiative…..will address key challenges…for improvement through a formal culture audit.” “Overcrowding is a key issue….hiring remains a top priority….to meet existing shortages, reduce lockdowns, ease workloads…..”

There was more in the same vein, not anticipated from a minister of a political party more attuned to a let-them-rot-in-hell scenario for imprisoned offenders. But, Minister Jones’ letter ended with, “Your feedback is important and will help our government inform its policies.”

“Policies.” Therein lies the hidden juggernaut waiting in the shadows. No minister of any party, no head office bureaucracy, no amount of input from outside the system has ever been able to successfully address the difference between policy, and practice in the trenches.

MORE LIGHT SWITCHES IN OUR FEDERAL PRISON INDUSTRY WILL CONTINUE NEXT WEEK………