Health in Persons Deprived of Their Liberty in South America: A Painful Reflection of Our Public Health

Objectives: To describe sociodemographic characteristics and health-related data in persons deprived of liberty (PDL) from South America in the last five years. Methods: Documentary descriptive study. Results: There are 1.5 million PDL in Latin America and the Caribbean; the average overcrowding is 64%; 58% do not sleep in beds, 20% do not have access to clean water and 29% do not receive medical care. In Peru, during 2021, there were 87,245 PDL and 69 penal institutions. The national average overcrowding is 120%, the second-highest in South America. In South America, the prevalence of tuberculosis is 2.0% SD = 0.64 and the median of illegal substances prevalence is 34.6 (IQR = 7.5–41.4). In Peru, the prevalence of tuberculosis has decreased since 2016 (4.3%), 2018(3.5%), and 2021(2.5%). Among the health problems by country, there were more data on substance use: 8/10, and tuberculosis, 7/10 countries. Cardiovascular diseases had the least available data. Regarding COVID-19, during the first wave in Peru, 54% of the total PPL were infected, and by the end of the wave, 446 PDL and 46 members of the prison staff had died. In Colombia, between April and October 2020, there were 16,804 cases (80 in ICU) and 136 deaths. In Brazil, up to March 2021, 340 people had died, and there were over 67,000 infections. Conclusions: Overcrowding is an unresolved problem; tuberculosis and substance use are the most frequent issues. Data are limited in quality, homogeneity and availability. Greater effort is needed from health authorities to improve health management and information systematization. Source: MesH.


INTRODUCTION
The COVID-19 pandemic, which has ravaged humanity, has highlighted the precariousness of the global public health system and its devastating impact on the most vulnerable individuals [1].In middle-and low-income countries like ours, this reality is even more evident [2].A special group is that of persons deprived of their liberty (PDL).The conditions in which they live-overcrowding, comorbidities, sanitation conditions, bureaucratic processes of any public entity-contribute to a compromised state of health [1,2].Two transcendental phrases by Nelson Mandela can serve as a summarized preface for this topic: "It is said that no one truly knows a nation until one has been inside its jails.A nation should not be judged by how it treats its highest citizens, but its lowest ones [3]." On the other hand, one of the fundamental principles of the medical profession, and of all healthcare personnel, is to offer, regardless of their beliefs, race, or social condition, the most suitable care to each person, respecting their dignity with justice and equity [4].In persons deprived of their liberty, these aspects are often violated.Concepts such as the doctor-patient relationship [5], shared medical decision-making [6], and patient-centered medicine [7] are not always viable in the reality of these individuals.
Being a vulnerable group with decreased decision-making capacity, multiple risk factors for illness, increasing numbers of the members of this group over the years, and a potential source of medical problems with an impact on society, and with few publications on the state of their health in Latin America and particularly in our country, PDL are an important topic for a report.The objective of the study was to describe aspects related to public health in PDL in Latin America, with emphasis on Peru, during the five last years.

ETHICAL ASPECTS
The data shown is available across the different databases.The Peruvian data is available as open access on the platforms of the National Penitentiary Institute of Peru: https://www.gob.pe/9625acceder-a-datos-estadisticos-del-inpe.A final copy of the article was delivered to the Teaching and Research Unit of the Hospital de la Amistad Peru-Korea Santa Rosa II-2, Piura-Peru.

I.1 Global demographic data
As of late 2021, there were 11.5 million PDL worldwide (93% male), with the United States leading the list with 2 million, followed by China with 1,690,000, Brazil with 811,000, and India with 478,000.In terms of incarceration rates per 100,000 inhabitants, the distribution of the top 5 is the following: The United States (629), Rwanda (580), Turkmenistan (576), El Salvador (564), and Cuba (510).The prison population has increased by 24.3% since 2020, with over 50% being in

I.2 Demographic data in Latin America and the Caribbean
There are 1,500,000 PDL.The incarceration rate has doubled since 2000, which means that there is a 120% increase (262 per 100,000 inhabitants), compared to 24% in the rest of the world.The elderly make up 6% of the population, and the average overcrowding rate is 64%.There is approximately 45% overcrowding per cell, with 58% not sleeping in a bed, 20% lacking access to potable water, 37% without soap, and 29% not receiving medical care [14].
On April 3, 2020, the Inter-American Development Bank (IDB) organized the III International Virtual Dialogue entitled "How to address the challenges in the prison system in the context of a public health crisis: Sharing experiences and lessons learned in Latin America and the Caribbean and the world for the management of the COVID-19 pandemic."Members of international organizations such as the International Committee of the Red Cross (ICRC), the International Corrections and Prisons Association (ICPA), the Conference of Ministers of Justice of Ibero-American Countries (COMJIB), and the Center for Studies on Innovative Prison Systems (IPS) from 15 countries in Latin America and the Caribbean participated in the dialogue as a way to harmonize solutions to this problem [15].However, the problems persist.

I.3 Peruvian demographic data
In Peru, there are currently 87,245 PDL distributed in the eight regional offices of the National Penitentiary Institute, located in 25 cities and in 69 correctional centers (CC) as of 2021.According to the data from the first National Penitentiary Census (2016), in relation to the conditions of the sanitary facilities, 30.1% of PDL claimed they were "slightly clean" and 14.6% "not clean at all"; 59.7% reported that the quality of food was poor/very poor, and 17.8% reported feeling discriminated against [16].On the other hand, in an inspection carried out by the Peruvian Ombudsman's Office in 2018, it was found that only 64 physicians worked in the 69 CCs for a total of 82,492 PDL, a figure similar to that of 2006.Of these, 41 worked in Lima (the capital) and the region with the highest deficit was San Martin with one physician for every nine correctional centers [17].According to the World Health Organization, a ratio of 44.5 doctors per 10,000 inhabitants would allow adequate public health care [18].If these figures were extrapolated to PDL in Peru, there should theoretically be at least 400 doctors in charge of this population, distributed throughout the country.
Table 1 shows the sociodemographic distribution, highlighting males being most of the population, almost half the PDL as between 35-59 years old, almost 70% with a secondary education level, almost half incarcerated in Lima, and over a third population still awaiting conviction and/or sentencing.Table 1 also shows that the most overcrowded office is South Arequipa, followed by Center Huancayo.
The national overcrowding average (by regional offices) is 120% SD = 65.8.
Table 2 shows the number of CC by department and its evolution over time.
As we can see, from 2011 to 2021, only four net correctional centers have been added after accounting for closings (raising the total from 65 to 69), with only Callao (1), Ica (1), Junín (1), San Martín (1), Loreto (1), La Libertad (1), and Pasco (1) increasing the number of centers.In addition, the number of facilities has decreased in Huánuco, Lima, and Piura.Arequipa, the most overcrowded, has not increased the number of correctional centers.Table 3 shows the prison population by department.
The penitentiary facility in Chanchamayo has an overpopulation rate of 477%, the highest in Peru [15].León

II. INTERNATIONAL REGULATORY STANDARDS
There are many documents that ensure the integrity of PDL.There are international documents and each country has its own, as well.Below is a summary of different international regulations and the sections related to public health aspects for PDL: DEPARTAMENT

International regulations on the health of persons deprived of liberty
1. Principles and good practices on the protection of persons deprived of liberty in the Americas, OAS/IACHR, 2008 [19] Principle XII: access to an individual bed, appropriate bedding, and conditions for nighttime rest; access to hygienic sanitary facilities and private and dignified spaces.Principle XVII: Overcrowding is prohibited by law.

Standard minimum rules of the United Nations for the treatment of prisoners (Nelson
Mandela Rules), United Nations, 2015 [20] R12: Having two prisoners in one cell shall be avoided.

R13:
All sleeping accommodations shall meet all hygiene requirements.
R18: Personal hygiene shall be required for prisoners and they shall be provided with water and with such toilet articles.
R22: Every prisoner shall be provided food of nutritional value and of wholesome quality, well prepared and served.
R24: Prisoners should enjoy the same standards of health care that are available in the community, and should have free access to health care.Every penal facility shall have a healthcare center to assess, promote, protect, and improve physical and mental health.
(Contd.)León-Jiménez Annals of Global Health DOI: 10.5334/aogh.4171 Regarding the OAS/IACHR document, Principle XII coincides with the Mandela Rule number 13, point 4 of the joint UNODC and WHO declaration, and the Red Cross document regarding the personal space of prisoners.There has been much written about this problem and how to define it.Its presence is a risk factor for infectious diseases.The most commonly used term is overcrowding.Below we will develop some aspects found in the search for information and mentioned in the aforementioned regulations:

Overcrowding
In the literature, the term hacinamiento (in Spanish) or overcrowding is the most commonly used by academics and politicians to refer to this issue; it is one of the most used standards for determining the severity of overpopulation.Overcrowding occurs when the prison population exceeds maximum capacity by 20% [25].According to the Institute for Crime and Justice Policy Research at the University of London, the country with the highest overcrowding is Congo = 616.9%,followed by Haiti = 454.4% (the highest in the Americas); in South America, Bolivia tops the list with 263.6% and Peru is the second: 212.2% [12,26].The following graph 1 shows the percentages of overcrowding by country in South America.

Healthcare standards
According to Mandela Rule 24 and Article 76 of the Peruvian Penal Execution Code, the level of healthcare should be equal to the national standard.However, the current prison reality, Article 80: Prisoners can request, at their expense, the services of healthcare professionals external to the penitentiary center.
Article 82: Inmates who need specialized medical care out of the correctional center shall request it from the Penitentiary Technical Council, who have to respond to the request in no more than three days.In places where there is not the required number of physicians, the number of professionals is completed with professionals working for the state.Only in a case where there is no possibility to establish this is it completed with the available physicians.overcrowding, and the assigned budget do not allow this.Nevertheless, it is known that, globally, and with greater emphasis in low-and middle-income countries, the urgent need for an approach taking into account social determinants of health and primary care is the most cost-effective measure.This could save at least 60 million lives, increase life expectancy at birth by 3.7 years, which require an injection of $200-370 billion annually.Only the improvement of global healthcare systems can impact other vulnerable groups such as PDL, and subsequently manage to make their healthcare meet the national standard [27].

Characteristics of healthcare
As mentioned, public health in PDL in Latin America is deficient, asymmetric, and information is fragmented and heterogeneous.Below, at table 4 are some data on the prevalence of some diseases according to being infectious, chronic non-communicable, and mental health diseases in 10 Latin American countries.
In regard to tuberculosis, the frequency is 2.0 (SD = 0.64).In relation to illegal substances, the summary measures are the following: median = 34.6 (IQR = 7.5-41.4).Among other striking data found, the prevalence of pulmonary tuberculosis is 81 times higher than that of the general population [14].On the other hand, in the period between 2000-2022, in Latin America, 23 PDL died from HIV/AIDS-related causes and 1,042 from tuberculosis [28].
In Ecuador, 1 out of 5 PDL have depression/psychosis, which was found using the MINI screening tool.
The data on 4.0% frequency of HIV infection in Venezuela was based on data collected between 1998-2001.There is no additional information.
Sánchez A. et al., through a Brazilian study analyzing causes of mortality in PDL, between 2016-2017 in CC of Rio de Janeiro, found that the causes of mortality were infections (30%), heart disease (22%), and external causes (12%).Infectious causes included HIV/AIDS (43%) and tuberculosis (52%).Only 0.7% of the deceased had access to health services outside the prison.Mortality due to infections was 5 times higher, due to tuberculosis 15 times higher, and due to diabetes and heart disease 1.5 and 1.3 times higher [47].
Bolivian data are scarce, but the following stand out: According to the 2019 Prison Census, only 52% of PDL receive dinner; 18.29% of PDL do not know if there is a health area in their center, and of those who knew, only 17% knew that there was a physician and 67% knew that there was a first aid kit; only 35% received medical treatment [49].In regard to pharmacological treatment, the frequency with which PDL received treatment was the following: 82% of patients with HIV/AIDS, 53.1% with tuberculosis, 68.7% with diabetes, 61.6% with hypertension, 48% with chronic lung disease, 49.6% with cancer, 53.3% with depression, and 45.5% for substance use.Of a total of 28,823 episodes of illness, 78.9% were treated on an outpatient basis.The most frequent reasons for not receiving treatment were "not having money" or "lack of medication at the health center."Moreover, at that time, the frequency of affiliation to the National Health Insurance System (SIS in spanish) was 50.5%, with a predominance in women: 71.4% vs 49.2%.
Additionally, 38.1% had an illness/disease during their stay in prison, 15.9% had difficulty seeing even with glasses, and 9.7% reported difficulty in mobilizing [16].

Census
In 2018, there were 3,099 cases of tuberculosis (point prevalence: 3.5%), with 73.22% being new cases, 25.01%relapses, and 1.77% recovered abandonments.Of the total cases, 6% were extrapulmonary, 46.6% of patients consumed alcohol, 64.1% used drugs, and 47.7% smoked tobacco.In 1.2% of cases, the patients already had a diagnosis of HIV before being diagnosed with tuberculosis.HIV screening was performed on 96% of patients, with a reactive result in 2.8%, "no response in the system" in 4.1%, negative in 96.7%, and "pending result evaluation" in 0.4%.Diabetes was found in 1.3% of cases through glucose testing, and 1.1% had diabetes before being diagnosed with tuberculosis [38].

Data from 2021
In 2021, 53,220 people received medical attention and there were 309,117 medical visits, of which 1.5% were through telemedicine.In this year there already were 33 penal facilities incorporated to the National Telehealth Network (NTN) of the Ministry of Health.By December, 83,175 (95%) people were affiliated with Comprehensive Health Insurance.
There were 2,240 cases of tuberculosis (point prevalence = 2.5%) and the region with the highest number of cases was Lima, followed by North Chiclayo.In addition, 1,305 people had mental health problems (1.4%), 1,511 had diabetes (1.7%), and 1,811 had hypertension (2.0%) [17].
As we can see, the point prevalence of tuberculosis has decreased since 2016: from 4.3 in 2016 to 3.5 in 2018 and 2.5 in 2021.

COVID-19 in South American prisons
According to Peruvian data from August 2020, 12,294 prisoners had been infected with COVID-19 and 212 prisoners and 15 prison officials had died as of June 2020.During the first wave, 54% of the total prison population was infected [54].On the other hand, at the end of the first wave, according to INPE data, 446 PDL and 46 prison staff had died [55].There are no more updated data.
In Colombia, the reality was similar.There were 16,804 cases (80 in ICU) and 136 deaths between April and October 2020 [56].In Brazil, by the end of March 2021, 340 people had died, and there were over 67,000 cases of COVID-19 in prisons [57].

DISCUSSION
The prison reality in Latin America is concerning.If we accept that the characteristics of prison health should be almost equal to those of their countries of origin, there are limitations to address.Latin America is a very diverse region, with the highest inequality in the world, limitations in primary healthcare, fragmented and segmented healthcare, and therefore, the conditions of social determinants of health would partly explain why CCs do not have adequate conditions [58].
In the case of Peru, the sustained increase over time in the number of prisoners and the lack of opening of more prisons is worrying.It is known that the solution does not lie in opening more Chile (house arrest and transfer to less overcrowded prisons) and Colombia (decongestion of prisons) have already adopted measures to reduce overcrowding in prisons since 2020 [59].Overcrowding (our country is second in South America, only behind Bolivia) is a variable associated with poor control of chronic and infectious diseases.
On the other hand, the management of prison health has many aspects that need improvement.We have not found, in the literature or national prison information, that any of the 69 national prisons have facilities for the necessary care of prisoners.The elderly and those with NCDs (6.9%: High blood pressure and 2.8%: Diabetes Mellitus) require necessary infrastructure improvements.Regarding human resources, the gap is significant, as at least 400 physicians for the 69 prisons are required.Delay times in external transfers to hospitals or health centers for surgical and acute cases are one of the limitations in the healthcare of these individuals.There is no published data on this, but it is common in hospitals for arrival times and illness times to be prolonged.This is a personal observation.However, we must mention that the continuity of treatments after hospital discharge is favored by telemedicine, present in several prisons.As of September 2021, 48/69 prisons already had this tool available [60].
Another priority area for improvement is the systematization of health data.INPE reports from different years: 2016 [16], 2018 [17], and 2021 [38] differed in some measurements due to the operational definition of diseases, such as self-report and standardized measurements, etc.This is a reality that is present in the majority of the analyzed countries.Real-time data systematization, interoperability actions, and process improvement will have an impact on measurements and, therefore, on the healthcare of these individuals.Once again, the pandemic provides an opportunity to improve these processes.
It should be noted that in the search conducted, the majority of health problems were found in Peruvian reports, except for cardiovascular diseases.Peru had the highest number of data found: 7/9, while Argentina had the highest frequency of missing data: 8/9.This could be due to differences in the budgets assigned to prison authorities or reports that could not be found during the search.
Among the health problems, substance use: 8/10, and tuberculosis: 7/10 countries, are the ones with the most information available.These two problems affect this population the most, and early diagnosis and training programs for both PDL and personnel in charge are necessary.Furthermore, given the comorbidity with HIV, early testing, case follow-up, and joint management by telemedicine with specialists (infectious disease specialists, pulmonologists, internal medicine physicians) are a priority for these patients.Long-term follow-up of pulmonary sequelae and physical therapy and rehabilitation programs are plans that should ideally be implemented as public health measures.
Cardiovascular diseases had the least available data: 1/10 countries, despite their high disease burden.This is a pending task for CC authorities.
It is noteworthy that the tuberculosis rate in Chile is the highest in South America [37].This may be a measurement bias rather than a higher prevalence of the disease.It could imply an efficient surveillance system for this disease compared to other countries.Additionally, the prevalence of HIV in a Colombian CC was 11%, which is a highly striking number and could also be a bias since it was self-reported in 2013 in Barranquilla [34].The prevalence of hypertension in Brazil was 24.4%, based on a self-report from 1,393 women between 2014 and 2015.This figure corresponds to that found in the general population and highlights the significant cardiovascular health problem in these women [51].In our country, the figure is not higher than 7%, lower than the reported rate in the general population: 22% according to a meta-analysis [61].There is likely a lack of knowledge among PDL of their hypertensive patient status, as has been reported in many studies, and this could be another self-report bias.

Table 1
General characteristics of the prison population in Peru, 2022.
Source: Correctional Centers and Regional Offices; Author: National Penitentiary Institute (INPE) -Unit of Statistics.

Table 2
Distribution

Table 3
Prison population by department and year.
prisons but in reducing the number of prisoners.Alternatives to this, given the context of COVID-19, include release/house arrest and the stratification of each prisoner based on age, comorbidities, type of crime, terminal illness, gestational stage, and the point of completion of the sentence.