18 July 2023 News release
Reading time: 4 min (1106 words)
Health in prisons can be significantly improved if health professionals have the freedom to make independent decisions. WHO/Europe is underscoring this key message on Nelson Mandela International Day (Mandela Day), observed globally in honour of the late Nelson Mandela, who spent 27 years in prison before eventually leading post-apartheid South Africa. Mandela Day celebrates the idea that any individual, regardless of the most formidable circumstances and settings, has the power to bring about positive change and social justice. On this occasion, WHO/Europe shares the experience of Dr Fadi Meroueh, who heads the clinic in Maison d’arrêt de Villeneuve-lès-Maguelone, a prison on the outskirts of Montpellier, France. Through the efforts of Dr Meroueh and his team, this detention facility has effectively managed to prevent and control infections such as hepatitis C and HIV inside the prison walls. Overcoming fear means victory over infection “I think the main problem prisons have in the context of health is fear,” notes Dr Meroueh. “In many facilities, health professionals are very reluctant to make independent decisions without consulting prison authorities. I am convinced that doctors’ opinions should be respected no matter what. That leads to better health for people living in prisons and benefits the facilities’ authorities as well.” According to the latest estimates, in the WHO European Region – covering 53 countries across Europe and central Asia – around 14 million people are infected with hepatitis C. As the disease is often asymptomatic and left untreated, chronic hepatitis is a major cause of liver cirrhosis and primary liver cancer. In prisons, the risk of getting hepatitis is higher than average. People who inject drugs are particularly vulnerable to hepatitis, and in this context, the disease can often be followed by co-infection with HIV.The health-care system Dr Meroueh has established in the Montpellier prison has helped to break this chain of infection spread, resulting in the eradication of hepatitis C in the facility. A pro-health prison system People incarcerated at Montpellier prison get a full medical examination upon arrival, including tests for hepatitis C. As recommended by WHO, Dr Meroueh’s team offers 2 tests for hepatitis C at the same time – both antigen and RNA tests – which is known as integrated testing. Usually, RNA tests are recommended as a second-level diagnostic approach, but Dr Meroueh is well aware of the weak spots of prison health-care systems: the lack of time and the large number of people in need of a doctor’s attention. “We can’t wait until the results of first-level tests come in because we want to diagnose the infected people as soon as possible,” Dr Meroueh explains. “We need to have both test results at the same time to make faster decisions. It is also more convenient for patients, who may not want to come to the doctor several times.” In addition, the Montpellier prison’s health service makes available dried blood tests, which help to diagnose hepatitis C and HIV at the same time. This comprehensive testing approach is another good practice recommended by WHO. While gastroenterologists traditionally handled the prescription of hepatitis C treatment in France, direct-acting antivirals can now be prescribed by general practitioners who are operating in prisons every day and are well informed of the situation inside the prison walls. The implementation of simplified rules for managing hepatitis C, approved in 2019, was a major change that removed many of the earlier barriers. With the current system, detainees can access cost-effective treatment 2–3 days after test results. Moreover, individuals undergoing hepatitis C treatment have the freedom to consult with a therapist and a psychologist whenever necessary, thereby ensuring mental health needs triggered by stress linked to their diagnosis and overall situation are addressed. Breaking the chains of infection transition Another component of hepatitis C and HIV protection at the Montpellier prison is its syringe exchange programme. General practitioners give detainees new syringes, no questions asked, to help ensure that one of the major infection transition paths – injecting drugs – is stemmed. “I know a man who stayed at our prison for 5 months, and during that time he tested negative for hepatitis C. He got out, but after approximately a month we met in our prison again, and this time he tested positive. This was because he injected drugs with a used syringe at a friend’s house,” recounts Dr Meroueh. The needle exchange programme is complemented by the provision of condoms and regular check-ups, when people are also offered the opportunity to get tested for infectious diseases. Shaping rules for better health Many of the effective practices being implemented at the Montpellier prison are not yet part of the usual prison system in France. However, Dr Meroueh believes that this can be changed. He is confident that detention facilities’ health centres can transform into places that address the real problems of people living in prisons, and adapt to the most pressing challenges with the full support of prison authorities. “Insurance rules in France grant full access to health services to all people who arrive in prisons, even if they don’t have any identification papers. For some people, prisons are the first place where they get to visit a doctor,” says Dr Meroueh. “I truly believe that the context of prisons should actually be seen as an opportunity to protect the health of many vulnerable people, which will lead to better well-being for society as a whole.” This devotion to protecting people’s health in the prison setting earned Dr Meroueh the Johannes Feest Prize in June 2023, named after the noted German professor of criminal law and criminology who has long advocated for the rights of prisoners, including their right to health. “On Mandela Day, it’s all the more fitting that we are highlighting the accomplishments of Dr Fadi Meroueh,” says Dr Hans Henri P. Kluge, WHO Regional Director for Europe, who himself has extensive experience working in prison settings with a special focus on tuberculosis control. “Evoking the spirit of the late, great Nelson Mandela, who endured almost 3 decades in detention for his anti-apartheid activism, we remember his enduring words: ‘Courage is not the absence of fear – it’s inspiring others to move beyond it.’” Dr Kluge adds, “Dr Meroueh, through his work with one of our most underserved populations, is an example to all of us of someone who is ensuring that WHO’s vision and mandate of health for all are put into action. Mandela Day and Dr Meroueh’s contributions are a reminder to the whole public health community to ground ourselves in values of humanity and social justice – values that are applicable in all contexts, including the prison system.”