Medical Records Provided by Imprisonment—Medical Care for Inmates

 

Introduction

I think this society is not yet prepared to face inmates—perhaps out of fear, out of disgust, or simply out of misunderstanding. When someone commits a crime, we are eager to expel them, to isolate them from ordinary life, as if beyond those walls lies a world of our own that might, more or less, become a little more beautiful as a result. But in reality, this is not always the case. We know far too little about inmates, yet we judge them far too soon. A person enters prison only after committing a crime and being sentenced in society, and Article 1 of the Prison Act explicitly states that prisons, serving as correctional institutions, aim for nothing less than helping inmates reflect, reform, and eventually return to social life. Since we expect prisons to properly fulfill their correctional functions, we must confront the systemic issues within the entire prison administration. Among these, prison environment and prison healthcare stand out as key priorities for prison reform. We were fortunate to invite Lin-Yuan, a nurse formerly employed at Peite Hospital attached to Taichung Prison, to discuss the "prison" as seen through the eyes of a nurse.

Improving Basic Living Conditions in Prisons is Fundamental to Safeguarding Health

The current public health prevention framework primarily consists of "three stages and five levels":

1. Primary prevention comprises two stages: the first level involves basic protection and health promotion, conducting public health awareness campaigns, basic health check-ups, blood draws, and similar operations; the second level is specific protection, aimed at preventive healthcare measures targeting specific diseases.
2. Secondary prevention is the third level: early diagnosis and early treatment.
3. Tertiary prevention aims to avoid or reduce the threat and impact of diseases on life, limiting the occurrence of disabilities through appropriate treatment and engaging in later-stage rehabilitation work.

Lin-Yuan is a nurse at Peite Hospital. The inmates she encounters through her work are patients sent from prisons to Peite Hospital for medical treatment, falling under the actual diagnosis and treatment of the third level. Her observation is that the root of the problem lies in the basic hygiene and health promotion work of the first level, where there is still vast room for improvement. Prisons fail to provide a sound public health environment, and awareness campaigns regarding health concepts are severely lacking. Under this premise, discussing the second, third, and subsequent stages is pointless if we expect any substantial help toward prison medical reform.

"For instance, in the summer, the space is very small and the number of people is very high. Sweat and high temperatures cause many infectious diseases. Even if someone gets bitten by a mosquito and scratches the skin until it breaks and bleeds, they might report to the clinic the very next day due to cellulitis. It is hard to imagine getting cellulitis from a mosquito bite in daily life, but the conditions are just that dire."

Lin-Yuan shared that when she first arrived at Peite Prison, she was surprised by why the illnesses patients contracted were "such basic conditions." In other words, the ailments suffered by inmates would hardly ever be seen in a normal living environment; they are sicknesses caused by compromised basic living conditions. The aforementioned case of an inmate developing cellulitis from a mosquito bite is related to the poor water quality, as the daily water supply in the prison consists merely of simply filtered groundwater. Coupled with the fact that inside the cells, wiping oneself with a towel is only permitted outside of bathing hours, and water supply times are restricted, towels cannot be properly washed. Throughout the day, the time spent wiping with semi-dry towels exceeds that of wet wiping, causing skin abrasions and injuries. Furthermore, bedding such as quilts must be stacked and stored centrally, which is not only damp but also causes cross-infection. Another example is scabies (a skin disease caused by the itch mite). Due to limited prison space, rather than isolating inmates individually, patients are "isolated together" to avoid infecting healthy people, but the problem is that those already infected end up cross-infecting each other. Moreover, because basic hygiene conditions are poor, creating an environment favorable for itch mites to thrive, scabies recurs repeatedly.

Aside from ailments caused by harsh, cramped, and crowded living spaces, many chronic diseases stem from high-fat, high-sodium, and high-sugar diets. An inmate's daily meal allowance is 60 NT dollars, limiting the ingredients available, and they eat bulk-prepared communal meals. To make the food more palatable, prison meals are often very salty, which is detrimental to health. Meanwhile, the prison commissary sells only a few snacks; when inmates find the food unpalatable, they resort to buying instant noodles, which is equally harmful to their health. Lin-Yuan mentioned that sometimes she reminds inmates to pay attention to how diet affects health, but the inmates would reply that since they are currently locked up, there is nothing they can do about it.

Lin-Yuan stated that as part of the public health prevention system, tertiary nursing work can actually do very little. Treating patients and providing medication once an illness has already occurred cannot fundamentally reverse this vicious cycle. Therefore, the aspect we should value most in prison medical reform is primary prevention: first improving the basic living conditions of prisons, paired with the nurses deployed in prisons to carry out primary health advocacy and basic protection work, strengthening public health awareness, building inmates' capacity for self-health awareness, and reducing the incidence of disease. Only then can limited medical resources be utilized more efficiently. This benefits not only the inmates themselves but also perfects the entire prison medical system.

Strengthening the Function of Nurses in Prisons is Crucial

In general hospitals, there is a so-called "medical model." Within this model, nurses must observe who might be sick, continuously monitor sick individuals, and report information to doctors so that doctors can make accurate judgments. Currently in prisons, although one or two nurses may be deployed (varying by prison), they are primarily responsible for administrative tasks and trauma care, akin to school nurses in a school infirmary. If the prison has a sick bay, they also assist in patient care, as well as aid in judgment and emergency response for external medical transfers. However, given current staffing levels, it is actually difficult for nurses to thoroughly observe and understand each inmate's health status, nor can they reliably monitor the medical conditions of all inmates. A more fundamental problem is that in smaller-scale prisons, nurses only work day shifts with no night-shift nurses on duty. Consequently, judgments regarding emergency medical transfers at night may have to rely on custodial staff rather than individuals with professional medical knowledge. Although the Agency of Corrections under the Ministry of Justice has established a series of criteria for emergency external medical transfers, from a professional medical perspective, their reference value is limited. This is because so-called "emergency situations" sometimes involve sudden conditions in patients, making it reasonable to compare them against prior monitoring records. Additionally, medical practice requires a comprehensive assessment of the patient's condition. None of these are judgments that custodial staff are capable of making.

Currently, some inmates in prisons suffer from mental health issues. Because custodial staff have not received adequate medical training, they treat abnormal behavior as "making trouble." This also highlights the importance of nurses observing and understanding inmates' psychological conditions from a health perspective and assisting with monitoring.

• Poor Practice: The Death Case of Lin Wei-Hsiao, an Inmate at Taipei Prison

  In 2014, an incident occurred at Taipei Prison where an inmate, Lin Wei-Hsiao, was subjected to restraints such as handcuffs and leg irons, with the leg irons linked and wrapped around his back, supplemented by the wearing of a helmet, a tongue depressor, and blankets, and was fixed to a corridor railing, resulting in his death from respiratory and metabolic failure. Lin Wei-Hsiao suffered from mental illness and struggled to adapt to living conditions after being transferred to Taipei Prison. Custodial staff, not knowing how to handle the situation properly, treated his disorderly conduct as general disciplinary violations, and ultimately even placed Lin in restraints and physical fixation, leading to his death. Judging from the Control Yuan's investigative report, corrective measures, and impeachment cases, the entire matter was handled by custodial staff. Throughout the process—including the early stages of various adaptation difficulties, up to the final improper use of restraints and physical fixation—there was no indication of any nurse assisting in understanding or monitoring Lin's condition.

  In prisons, certain measures pose potential risks to the physical and mental health of inmates, particularly physical fixation or solitary confinement. It is best to have nurses assist in monitoring these situations. Under current regulations and staffing allocations, leaving custodial staff solely responsible for such tasks not only harms the rights and interests of inmates but also places custodial staff in an untenable position.

• Good Practice: The Story of a Dedicated Nurse at the Taoyuan Branch Prison

  The Taoyuan Branch Prison currently functions as a specialized prison ward for female psychiatric patients and is staffed by one nurse. Having served there for a long time, this nurse is deeply familiar with the conditions inside the Taoyuan Branch Prison and is willing to answer phone calls outside of working hours. When trouble arises inside the prison at night, she answers calls to understand the situation and offer advice. This nurse cares about and understands the physical and mental condition of every inmate inside, building good relationships with them. Believing that ailments of the mind are connected to ailments of the body, she also pays attention to the inmates' dietary habits.

  This nurse not only cares for the inmates but also provides necessary health education to fellow custodial staff. At the Taoyuan Branch Prison, to prevent inmates from self-harming or harming others, physical fixation may sometimes be applied. The application of physical fixation is assisted by the nurse's judgment.

  However, it must be pointed out that the situation at the Taoyuan Branch Prison involves one nurse caring for over thirty inmates (the statutory capacity for female psychiatric detainees is 38), which naturally results in a much higher quality of care than ordinary prisons (where the ratio of nurses to inmates may be one to several hundred, or even a thousand).

Nevertheless, Lin-Yuan reminds us that nurses entering prisons or working in prison hospitals should first receive some human rights education. She mentioned that before entering the prison medical system, although she had never been exposed to the justice system and knew little about these crimes or inmates, continuous exposure to various social issues led her to believe that "being imprisoned" and "being sick" are two separate matters that cannot be lumped together. "Doing something wrong does not mean one does not deserve decent medical treatment." There are many reasons for being imprisoned, among which quite a few individuals are imprisoned due to long-term low social standing, neglect, or due to systemic and unavoidable reasons. Therefore, when entering a prison to provide medical services, one must understand that the population they serve is not the general public. The difference does not lie in how patients are cared for, but rather in adjusting one's own mindset and possessing basic human rights awareness. The same holds true from a therapeutic and correctional standpoint: the purpose of offenders entering prisons is to enable them to repent, improve, and become suited for social life, and it is a matter of course that having committed a crime, they enter prison to take responsibility for their actions. However, based on the founding purpose of prisons, treating inmates as less than human for extended periods and adopting an exceptionally poor attitude toward them simply because they have erred creates a discriminatory environment where changing anything becomes extremely difficult, making "repenting, improving, and adapting to life" an empty slogan.

Better Medical Care: Hospitalization for the Sick, Establishing More Prison Hospitals, and Cooperation Between Medical and Custodial Teams

During the interview, Lin-Yuan mentioned, "There was once an inmate in Taichung Prison who, while sleeping, choked the neighboring inmate to death in the middle of the night. When asked for the reason at the time, he simply said: 'Anyway, that person has to serve a long sentence anyway, so I might as well choke him to death.' That inmate actually frequently visited the Peite clinic, but the custodial side simply did not take his mental issues seriously."

Lin-Yuan believes that prisons are not actually good therapeutic environments. The handling method for inmates with mental disorders is sometimes simply solitary confinement in isolation cells. Perhaps the original intention is for the convenience of custodial treatment or to prevent them from becoming vulnerable in communal prison life, but solitary confinement is neither the best method for correction nor treatment. Inmates in solitary confinement often experience depression, abandonment, and self-negation due to their daily lives being restricted to a confined space and prolonged isolation. Consequently, their mental health deteriorates further, and they even develop additional physical illnesses. This is detrimental not only to physical and mental treatment but also misses the original intent of correction. Under such circumstances, from the perspective of providing appropriate medical care, inmates should not actually be kept in prisons; instead, psychiatric medical services should take over. Lin-Yuan also believes that current prison hospitals are insufficient. Ideally, prisons of a certain scale should be equipped with prison hospitals to look after the health of inmates close to home.

For prison healthcare to improve, mutual cooperation between custodial staff and medical professionals is indispensable.

The movement of personnel in and out of prisons naturally involves considerations of custody and management. When we asked Lin-Yuan about the attitude of the custodial and management side when a medical judgment indicates an inmate's need for external medical care, she smiled wryly and said, "Sometimes they just delay it. Custodial external transfers are more troublesome, so they might drag it out until the next shift of administrators comes on duty. They often don't send them to the hospital immediately. Sometimes when the condition is very critical, the doctor will directly say it cannot wait and report it to the prison supervisor, but the prison supervisor will often say manpower is insufficient." "Yet manpower really is severely insufficient, and there are situations where custodial staff work overtime. We try our best to cooperate as well, but when things are truly critical, for the sake of the patients' rights, our attitude still has to be firm." These two statements sum up the conflict and helplessness between medical care and custody. It is easy to understand that each has its own considerations, which is why we must ponder how to enhance medical quality under custodial requirements.

We also asked Lin-Yuan to offer some thoughts. She believes that the current status of insufficient custodial manpower must be improved. Additionally, teamwork is a viable approach, with members jointly comprising both the custodial and medical sides. Borrowing the morning meeting model from psychiatry—where psychiatric wards hold morning meetings so everyone is aware of patients' conditions, allowing information to flow freely and enabling joint discussion on how to handle matters to best safeguard inmates' basic rights—treatments can be administered consistently after communication and coordination. Special attention must be paid to the fact that the custodial system and the medical system must stand on equal footing. Under the current system, custodial managers often hold a top-down command relationship over medical personnel. Although not truly subordinate to the custody system, the mindset of "we are the landlords" frequently exists, leading to stagnant communication and preventing sound cooperation between the two sides, which is beneficial to neither inmates nor patients.

Conclusion

"Can prisons truly provide a therapeutic environment?"

I think under the current circumstances, the answer is no. If we hope for this situation to change, the first step is to improve basic living conditions in prisons, followed by supplementing the nursing workforce in prisons, and subsequently building a comprehensive prison medical system. At first glance, these measures may consume taxpayers' money, but in the long run, they might actually save tax revenue. Because with improved basic living conditions, inmates are less likely to fall ill, which in turn can reduce National Health Insurance expenditures. If inmates receive proper medical care in prison and do not leave with a host of illnesses due to a lack of adequate treatment while incarcerated, the burden on medical resources may also be reduced over the long term. Since the Ministry of Justice is ultimately not the competent authority for public health and medicine, creating a healthy prison environment should involve incorporating the Ministry of Health and Welfare—which oversees this portfolio—to jointly promote reforms. We look forward to the government investing more resources into safeguarding the health of inmates, which, in the long run, should prove to be a win-win approach.