Africa: health beyond epidemics

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Frédéric Le Marcis is an anthropologist. He focuses on epidemic responses in prison environment in different African countries. He currently lives and works in Guinea, where he leads a research programme on the COVID-19 pandemic. Here are his insights.

Prisoner health remains neglected in the incarceration system. In the absence of a comprehensive approach, prisoners rely on their families, NGOs and international programmes to access the care they need.

Prison infirmaries, where they exist at all, are rarely integrated into the overall healthcare system. Prison administrations do little to meet the vital needs of prisoners. Nutritional deficiencies are common, skin diseases are recurrent, and prisoners often depend on the financial means of their families or NGOs when it comes to healthcare access. These difficulties, highlighted by COVID-19, are not new. They  compound the social marginalisation of the prison population, as does the reluctance of States to offer convicted persons what they cannot even guarantee to the general population.

"The house of the infamous"

In Africa, imprisonment echoes banishment, a common form of punishment during the pre-colonial era, as evidenced by certain local names used to refer to prisons: Diéboudou or “the house of the infamous” in Bété (west-central Ivory Coast) and Bi soua or “the garbage house” in Agni (east-central, southeastern, northeastern and eastern Ivory Coast). This marginalisation of prisoners in society translates in the political sphere into difficulty putting programmes on the agenda aiming to improve prison conditions (healthcare, food, overcrowding, water and sanitation).

There is a lack of interest in health, in favour of security. This is reflected in the status of healthcare actors in prisons, which varies by country and prison location (urban or rural area). Some fall under the Ministry of Justice (meaning security takes precedence over health) and others under the Ministry of Health (but with no direct involvement in supervision and training of prison healthcare staff).

A perfect storm

The life course of prisoners and the risks of infection in prison contribute to a high seroprevalence of HIV and HCV. The link between prison and epidemics (HIV, hepatitis C and tuberculosis) has been described as a “perfect storm”[1] in the making, as was confirmed by the SARS-CoV-2 pandemic. Once established, its spread was facilitated by three key factors:

• Difficulty in organising mass rapid testing of the entire prison population and identifying comorbidities
• The physical inability to protect people because of overcrowding and a lack of equipment
• The inability to isolate positive cases due to a limited number of dedicated cells

Difficulties in managing COVID-19 in prison are associated with characteristics highlighted for prison health in general. Not surprisingly, the response is focused more on curbing the emerging epidemic in prison than on addressing inmate healthcare and rights in a sustainable way.

Health beyond epidemics

Structural, geographical, and cultural power dynamics in prison determine the way in which individuals cope with illness, whether male or female, young or old, rich or poor. They create inequality in terms of how both illness and access to healthcare are experienced.

Recognising these determining factors implies considering hygiene and health at the core of a complex and unequal system of resources and power. For prisoners, healthcare access means dealing with hierarchies and a multiplicity of normative frameworks within which the value of health is relative. In prison, ‘health’ can mean many things at once:  a common good, a universal right, a resource for prison managers taking note of the sick, a way of obtaining favours from prison officers who authorise exits from the facility, and a way to get some fresh air or make a transaction in the main prison yard.[2]

Achieving universal healthcare in prison is crucial to protect the general population.[3] Prisoners return to communities on their release and officers come and go, making prison a place of movement. 

However, seen from the actor's point of view, prisoners’ health problems reveal a facet that is notably overlooked by prison healthcare programmes: inmates show recurring signs of beriberi due to the low-quality food rations provided by the prison administration. In Burkina Faso, "the average daily amount for purchasing food and condiments, as well as cooking them, is approximately 165 CFA francs [about 0.30 US dollars] per prisoner";[4] so inmates depend largely on food parcels sent by their families. Other pathologies linked to the insalubrity of the facilities and the lack of hygiene, as well as pathologies  linked to mental illness, have been observed. They pose no risk of an epidemic and most often remain unaddressed by international health programmes.

Security and health: two parallel logics in the prison system

Funding aimed at improving the functioning of the justice system and strengthening the rule of law is provided by international organisations, especially in the Sahelian strip, where the intensification of the fight against terrorism has resulted in prison population inflation.[5] The general populations' trust in the State and its elites is low. Nevertheless, health and security interventions, as well as those pertaining to the rule of law, are implemented separately. It is necessary to decompartmentalise them.

Failure to take into account the basic needs of inmates and limit the duration of pre-trial detention is a reflection of the poor quality of the social contract binding the State and its citizens by rights and duties. Refusing to consider health needs in prison means missing the opportunity to strengthen this social contract and playing into the hands of individuals promising a better future in a new social contract.

For persons deprived of their liberty, prison constitutes a denial of rights, while it should instead re-establish the contract between citizens who offend, and society. Advocacy with the general population has proven necessary to make health and prisoners’ rights  legitimate topics in the public sphere. The important questions provoked by epidemics illustrate why we must treat health as a truly global medical –  and legal –  issue.