I remember the written response of the senior doctor in the prison in which I worked to an editorial in the British Medical Journal lamenting the difference between health care in prison and health care in the “community.” Yes, he replied, where else in the country but in prison could everyone get to see a doctor within an hour of complaining of something?
I thought of this as I read an article recently in the New England Journal of Medicine about Hepatitis C infection and the American correctional system.
About 3 million Americans are infected with the Hepatitis C virus, mainly because of having shared needles in intravenous drug abuse, but also through transfusions before blood was screened for the virus. Those who are tattooed have two or three times the average rate of infection.
Ten-to-fifteen percent of cases of untreated infection (among males) will go on to get cirrhosis of the liver, and of them an increasing proportion will develop liver cancer as the years go by. Hepatitis C infection is now the largest single cause of the need for liver transplants.
Most intravenous drug abusers in America will pass through prison at some time in their lives, and at any one time one in six prisoners – that is to say upwards of 300,000 prisoners – are infected. Of them, 30–45,000 will go on to develop cirrhosis, and perhaps 5000 or more liver cancer.
Now as the article in the NEJM points out, it is part of the law that prisoners are entitled to health care equal in quality to that in the “community.” The same edition of the NEJM reports new treatment of Hepatitis C infection that eliminates the virus in 94 percent of cases within eight weeks. This is a great triumph of medical science, but unfortunately a potentially expensive one, for one of the drugs alone costs $84,000 per head. The authors estimate that if the prisoners in prison at this very moment were screened and treated, the cost would be $33 billion; if only half of those infected and who passed through the correctional system in a year were treated, the cost would be $76 billion. If all were treated, the cost would be $152 billion. In other words, soon we’ll be talking real money.
At any one time the great majority – 90 percent – of people infected with HCV are outside prison. Unless, therefore, screening of the whole population were carried out, incarceration would confer a considerable health advantage on those incarcerated – that is, if HCV screening were done in prison and treatment offered according to the results. (It would hardly be ethical to screen and not offer treatment.) While it is now accepted that prisoners should have as good health care as non-prisoners, should they have better?
In many cases they do already. In my experience, at any rate, some prisoners care for their physique but not many for their health. Once at liberty, many prisoners do not waste their time going to doctors, even when health care is free and even when they are ill or injured. Their lifestyle, moreover, is the opposite of what doctors recommend.
There is an interesting natural experiment revealing of human nature waiting to be done. The treatment of HCV eliminates the infection but does not confer immunity to it. In other words, once cured you can get it again. Knowing that there is a cure, and having been once cured free of charge, will prisoners get it again? And if they do, will they be entitled to another cure?
With luck, by then the cost of treatment will be greatly reduced, like that of flat-screened televisions.