Incarcerated health: Effective healthcare does not top the priority list in prisons


Yes, they've been caught doing something illegal, but as they serve their prison sentence, does that mean that their right to healthcare is adversely affected?

Prisons have existed since ancient times. There is almost no country in the world today that has no prison. Most prison inmates are there because of the criminal justice system. However, there are some who are there because of political or security reasons.

The primary concern of all prisons is security, as its function is to confine its inmates, with limitation of a variety of freedoms. Although successful prisons are rehabilitative, repeat offenders are stubbornly high.

Effective healthcare does not top the priority list in prisons. However, if effective healthcare isn't available, the prisoners have no other alternative, unlike the general population. Prisons are difficult sites to provide healthcare services. Global concerns about the health of prisoners and the quality of healthcare available to them have existed for a long time.

Marginal Group

Generally, prisoners are poor, disadvantaged and vulnerable. Most studies report that when compared to the general population, prisoners are much more likely to be unemployed, homeless and socially deprived, with generally very low levels of educational attainment.

The turnover of prisoners is high. According to the Statistics Department’s 2013 Statistics Bulletin, there were 68,443 prisoners in 2012, of which 37,762 (55.17%) were Malaysians and 30,681 (44.83%) non-Malaysians. Of that number, 6,992 (10.22%) were females, of which 5,137 (7.51%) were non-Malaysians and 1,855 (2.71%) Malaysians.

A significant proportion of the prisoners are illicit drug users. According to data attributed to the Home Affairs Ministry, the number of prisoners in October 2013 was 39,740. Of the prisoners, 29.4% were foreigners, 6.5% were females and 2.2% were minors.

The capacity of the 35 prisons is 32,000, giving an occupancy rate of 122.3%. (Source: accessed 10 July 2014.)

A prisoner’s journey through the prison system depends on the sentence and his or her conduct in prison. Even if the sentence is of a short duration, the journey is fraught with multiple environmental obstacles which impact on health, directly and indirectly.

Prisons are ominous, with high walls and barbed wires externally. The internal physical environment is not much better, with confined places, locks, overcrowding, etc. Exposure to violence, illicit drugs, infectious diseases including HIV/AIDS and victimisation are common in prisons throughout the world.

Prisoners are dependent on the prison staff for almost every aspect of their existence. They usually have limited opportunities to influence the determinants of their health. Accommodation, diet and exercise are all beyond their control.

The effective management and treatment of prisoners’ health is challenging. Their health and social needs are extensive and diverse, and many have poor physical and mental health. There isn't much information about the physical health of the inmates and staff in Malaysian prisons, let alone their mental health.

TB Case Study

However, recent studies on tuberculosis (TB) by a team led by Prof Adeeba Kamarulzaman of the University Of Malaya and Dr Haider Al-Darraji in collaboration with Prof Frederick Altice from Yale University provide a glimpse of their physical health. The studies involved surveys of the prevalence of latent TB using tuberculin (Mantoux) tests in representative samples of prisoners and prison officers in Kajang and Pengkalen prisons in Selangor and Kelantan respectively.

The prevalence of tuberculin positivity among prisoners and prison officers was very high, with 88.8%, 87.6% and 80.95% in Kajang prisoners, Pengkalan Chepa prisoners and Kajang prison officers, respectively. These numbers are the highest ever reported tuberculin positivity in prisons and reflect the high likelihood of ongoing transmission of TB in Malaysian prisons.

A rapid test which permitted the rapid diagnosis of TB within two hours and the gold-standard TB culture was carried out in equal numbers of HIV-infected and HIV-uninfected in Kajang prison. There was a very high prevalence of active TB among both the HIV-infected and HIV-uninfected prisoners (12% and 6% respectively).

The overall prevalence of previously undiagnosed active TB was 7.7%, which is 77 times higher than that of the general population. Preliminary data from an intensified TB screening unit established in July 2013 also revealed high levels of previously undiagnosed active TB, especially amongst HIV infected prisoners.

Data on the mental health of inmates in Malaysian prisons is unavailable.

Australian data may provide an insight into the extent of such problems, with reports in 2012 that 26% of prison entrants there were referred to mental health services, and 46% of discharges had mental health issues, including alcohol abuse and illicit drug use. (Source: The health of Australia’s prisoners 2012.)

With the significant drug addict population in Malaysian prisons, the extent of their mental health problems cannot be insignificant.

Providing Healthcare

It is not feasible for all sick prisoners to be treated in Health Ministry facilities. As such, the healthcare facilities in prisons and the healthcare providers in the prison service play an important role in determining prisoners’ health.

There are few Malaysian doctors in the prison service because its terms and conditions are not comparable with that of the Health Ministry. This has resulted in a reliance on non-Malaysian doctors to provide healthcare in prisons. This situation raises several issues, including that of patient safety, quality of care and security.

Prisons are also politically sensitive. Custodial deaths, celebrity prisoners and stories of prisoners receiving undue privileges and sentences deemed disproportionate have contributed to public views.

While some may portray prisoners as undeserving, it must be remembered that their health have serious implications for the health of the prison staff, their families and the general population. This is especially so with the large numbers of illicit drug users whose stays in prison are often transitory.

There is an urgent need for a comprehensive programme that addresses the root causes of ill health in prisoners, especially communicable diseases and mental health. This includes active screening, treatment and prevention of TB, HIV, illicit drug use and mental health in the whole prison population. The particular needs of female prisoners have to be addressed too.

Having Malaysian doctors in the prison service would contribute towards ensuring that the standards of healthcare in prisons are no less than that available to the general population. In short, it is necessary to remember that an individual’s right to health does not cease upon becoming a prisoner.

> Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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