Dossier n. 263/2018 [Abstract] Taking care of chronic-diseases-affected patients in penitentiaries: epidemiological profiles and environmental context

The Italian prison context is characterized, as far as healthcare is concerned, by a population that at least in 60-70% cases is affected by chronic diseases, often already at a young age. Moreover, a significant disadvantage related to health determinants can be registered, characterized by an even more evident socio-health fragility increasing with age.

On January 8^th, 2013, the European Court of Human Rights in Strasbourg found the Italian State guilty for violating art. 3 of the European Convention on Human Rights due to the conditions in which prisoners are forced to live. Although the sentence concerns structural situations, these are made even more evident by overcrowding. Moreover, the discomfort caused by climatic and atmospheric events can be added, particularly heavy in summer and winter.

It is safe to assume that the high prevalence of chronic diseases and the conditions caused by structural problems and overcrowding may pose an additional risk to detainees’ health.

The project referred to in this document was financed by the National Center for Disease Control and Prevention (CCM) of the Italian Ministry of Health and involved Emilia-Romagna, Tuscany, Lombardy and Calabria Regions for a total of 19 penitentiaries. The project aimed to:

• detect chronic pathologies affecting the detained population;
• develop and promote the implementation of software for managing medical records in penitentiary institutions;
• develop care profiles for chronic diseases as it is available to free citizens;
• highlight operating methods to be adopted for dealing with emergencies and environmental problems (heat, cold, microclimate, indoor pollution) that characterize the prison context and the territory on which the prison reality is based.

Data collection concerned:

• lifestyles and health status of a population of detained people with chronic diseases, monitored for one year with tools similar to those used by primary care physicians;
• microclimatic conditions in the prison, to highlight prisoners’ locations that are potentially harmful to health and to improve residential aspects in penitentiaries.

Clinical data detection allowed to “draw” the features of the typical prisoner: 52 years old, Italian (81%), with an elementary or lower secondary education level (over 70%), smoker (58%), sedentary; obese or overweight (71%). Fifty-seven % do not do physical activity or dedicate to it a very short time during the week: only 27% practice it at least twice a week. Only one third works, of which 50% for less than 20 hours a week. The prisoner is often in a situation of personal distress (52%), particularly for family reasons, with a considerable share of insomnia (36%), and often uses psychiatric drugs to sleep. Only 25% report a prescribed diet, followed in 2/3 of cases; almost half of diabetics (45%) are not on a diet. A history of drug addiction affects one in four prisoners, mostly from cocaine abuse (the previous abuse of cocaine is found in 40% of hypertensive subjects and in 19% of the carriers of cardiovascular diseases). The detainee is in therapy with specific drugs.

Monitoring subjects for the project length led to a first, strong, evidence: in prisoners with chronic diseases it is not always easy to carry out an outpatient treatment in the same terms proposed by the Local Health Service for free citizens. Situations vary according to the local health organization, health personnel’s participation, operators’ will, the collaboration of penitentiaries’ directorates.

Thus, almost a decade after the reform of prison medicine, which transferred healthcare skills towards detainees from the Ministry of Justice to the National Health Service, the objectives of prevention and health promotion in prison still have wide margins of improvement.

With regard to indoor data measured in summer 2016, conditions of strong discomfort were reached within 15 prisons out of 19 (only establishments where conditions of extreme discomfort are reached in at least two thermohygrometers were considered in this count); the four institutions in which these extreme situations have not been reached are Volterra, Pavia, Reggio Calabria and Catanzaro.

The daily concentrations of indoor PM_2.5 were substantially higher than those detected outdoors in the 3 stations for which it was possible to make a comparison. It is also noted that the WHO limit value of 25 μg/m³ for daily exposure was frequently exceeded during the monitoring period, due to both high background levels and contribution of indoor sources, in particular cigarette smoke. In conclusion, PM_2.5 concentrations may represent the greatest criticality in prison areas.