Lancet Editorial :: Editorial Living in detention: a matter of health justice

Featured Journal Content

Lancet Public Health
Feb 2020 Volume 5 Number 2 e71-e126
Living in detention: a matter of health justice
The Lancet Public Health
About 11 million people are currently being held in custody across the globe and more than 30 million individuals pass through prisons each year, often for short but disruptive periods of time. According to the UN Global Study on Children Deprived of Liberty, 1·3 million children globally are deprived of liberty each year, with an estimated 410 000 living within the administration of justice. The health profile of the detained population is complex, often with co-occurring physical and mental health disorders, and a backdrop of social disadvantage. Detention can also expose people to new and increased health risks, yet the profiles of the population behind bars and their health needs have often been neglected. In this issue of The Lancet Public Health a series of reports look at detention through a public health lens.

Rohan Borschmann and colleagues review the health of adolescents in detention and report that they have poor health across a broad range of domains. Young people detained have a substantially higher prevalence of mental health disorders, suicidal behaviours, and self-harm than their peers, along with substance use disorders, neurodevelopment disabilities, and sexually transmitted infections. In a companion paper published in The Lancet Child and Adolescent Health, Nathan Hugues and colleagues examined the determinants of adolescent criminalisation. Neurodevelopmental disabilities, poor mental health, and childhood trauma and adversity can increase the risk of contact with the criminal justice system, and such risk is exacerbated by societal marginalisation and inequality. For Lauren Brinkley-Rubinstein and colleagues, the carceral contexts that young people are exposed to are most probably causing irrevocable harm to their health and wellbeing and, as such, the detention of children and adolescents should be used as a last resort.

While in detention, individuals are deprived of their freedom, not of their right to health. The WHO report on prison health in the European Region, stresses how much people involved in the criminal justice system disproportionately experience complex health issues, and continue to do so after release. Mortality among people released from prison exceeds that of those in the community, often due to preventable causes such as suicide, injury, and overdose.

Concerns have been raised about solitary confinement, which has been associated with post-traumatic stress disorders after release and with increased risk of reincarceration. In this issue, Christopher Wildeman and Lars Andersen look at the association between solitary confinement and mortality after release, and report that mortality among formerly incarcerated individuals who were placed in solitary confinement was much higher than for those not exposed, and almost 10 times that in the general population. These findings raise serious questions about how compatible solitary confinement is with the duty of care owed by prison authorities.

Angus Wallace, in his comment, sheds some light on the powerful lever that can be the European Court of Human Rights to improve the health of prison populations—mainly through Article 3 of the European Convention on Human Rights: the prohibition of torture and inhuman or degrading treatment or punishment.

Most people who are incarcerated will return to the community and so addressing their health needs can not only improve the wellbeing of the individual, but also impact that of their families and communities. For WHO “the health of people in prison is a critical part of broader public health.” Prison need not be a place where individuals’ health and wellbeing deteriorate. Time in detention can provide access to health services for people who often faced substantial barriers to accessing health care in the community, and deliver health promotion, health education, and disease prevention interventions.

Those with responsibility for governing societies must find a balance between keeping communities safe (by excluding those judged dangerous to community interests) and protecting the fundamental rights of everyone in society (including those who are incarcerated). Yet the evidence presented in this issue aligns with the conclusion of Arash Anoshiravani’s piece—namely, that addressing the health needs of young people involved with the justice system requires no less than a “reimagining of paediatric and adolescent primary care”. A radical transformation of attitudes and practices in favour of people living in detention is necessary, and public health institutions and practitioners represent a trusted frontline within which lie the origins of this urgent and necessary social change.


Scoping Review
The health of adolescents in detention: a global scoping review
Rohan Borschmann, et al
Adolescents detained within the criminal justice system are affected by complex health problems, health-risk behaviours, and high rates of premature death. We did a global synthesis of the evidence regarding the health of this population. We searched Embase, PsycINFO, Education Resources Information Center, PubMed, Web of Science, CINCH, Global Health, the Cochrane Database of Systematic Reviews, the Campbell Library, the National Criminal Justice Reference System Abstract Database, and Google Scholar for peer-reviewed journal articles, including reviews, that reported the prevalence of at least one health outcome (physical, mental, sexual, infectious, and neurocognitive) in adolescents (aged <20 years) in detention, and were published between Jan 1, 1980, and June 30, 2018. The reference lists of published review articles were scrutinised for additional relevant publications. Two reviewers independently screened titles and abstracts, and three reviewed full texts of relevant articles. The protocol for this Review was registered with PROSPERO (CRD42016041392). 245 articles (204 primary research articles and 41 reviews) were included, with most primary research (183 [90%]) done in high-income countries. A high lifetime prevalence of health problems, risks, and conditions was reported in detained adolescents, including mental disorders (0–95%), substance use disorders (22–96%), self-harm (12–65%), neurodevelopmental disabilities (2–47%), infectious diseases (0–34%), and sexual and reproductive conditions (pregnant by age 19 years 20–37%; abnormal cervical screening test result 16%). Various physical and mental health problems and health-risk behaviours are more common among adolescents in detention than among their peers who have not been detained. As the social and structural drivers of poor health overlap somewhat with factors associated with exposure to the criminal justice system, strategies to address these factors could help to reduce both rates of adolescent detention and adolescent health inequalities. Improving the detection of mental and physical disorders, providing appropriate interventions during detention, and optimising transitional health care after release from detention could improve the health outcomes of these vulnerable young people.