Public Safety Committee on Oct. 20th, 2011

[The Chair, Conservative, Kevin Sorenson]

Good morning. We'll be broadcasting live again today.

We apologize to those who are so patiently waiting via teleconference. There was a vote in the House of Commons this morning and we were unable to begin earlier.

We're going to continue our study on drugs and alcohol in prisons. We are specifically examining how drugs and alcohol enter prisons, the impacts they have on the rehabilitation of prisoners, the safety issues related to the correctional officers within our institutions being surrounded by drugs in prisons, and the consequences of crimes taking place in prisons.

Our first panel of witnesses is with us by video conference from Toronto, Ontario. Our committee members appreciate very much witnesses testifying before us with this relatively new technology.

From the Canadian HIV/AIDS Legal Network we have Sandra Ka Hon Chu, senior policy analyst. From the Prisoners with HIV/AIDS Support Action Network we have Seth Clarke, community development coordinator.

I understand that each of you may have some opening statements, and then we will proceed into a round of questioning. This will be approximately 35 minutes. We've had to cut it short because of other witnesses coming later and the votes this morning.

Welcome, and thank you. We look forward to your comments.

[Sandra Ka Hon Chu, Senior Policy Analyst, Canadian HIV/AIDS Legal Network]

Thank you, Chair.

I'll begin, if that's okay.

Thank you to the standing committee for allowing us to make this submission. I'm with the Canadian HIV/AIDS Legal Network. We're a national non-governmental organization working to promote the human rights of people living with and vulnerable to HIV/AIDS in Canada and internationally, through research, legal and policy analysis, education, and community mobilization. We have 150 members across Canada. Many of them are AIDS service organizations.

For many years we have worked on the issue of HIV in prisons, most recently focusing on federal institutions. Two years ago we released a report documenting the experiences of prisoners and former prisoners with injection drug use. Because of the proven linkages between injection drug use and HIV and hepatitis C epidemics behind bars, we have also studied the issue of prison-based needle and syringe programs. In 2006 we released the most comprehensive international report on this issue, looking at the international experience. Last year I testified before this committee on the pressing need for these programs in relation to the study of mental health and addiction in prisons.

I'm going to go into the research now quickly. What it demonstrates is that despite the sustained efforts of prison systems to keep drugs out, people in prison use drugs. And they do enter the prison system. This has been confirmed by all of the witnesses to this committee in previous meetings, including those who work in corrections. While positive urinalysis test results may be down, rates of HIV and hepatitis C behind bars are increasing. The 2010 figures released by CSC indicated a self-reported HIV prevalence rate of 4.6 % among prisoners. This is 15 times the HIV prevalence in the community. Aboriginal women reported the highest rate of HIV, at 11.7%. Among those ever tested for hepatitis C virus, 31% reported a hepatitis C positive test result, which is 39 times greater than the rate in the community. Again, aboriginal women reported the highest hepatitis C rate, at 49.1%. That's almost one in two aboriginal women testing positive for hepatitis C.

These prevalence rates rival those in sub-Saharan Africa. Significantly, people are not only coming to prison infected with HIV or hepatitis C, but they are also sero-converting inside, and I know a number of prison physicians will attest to this.

In our interviews with prisoners and former prisoners across Canada, many confirmed the accessibility of drugs, the extent of addiction, and the pervasiveness of injection drug use in prison. Because of the scarcity of injection equipment in prison, people who inject drugs, including those with addictions, are more likely to share injection equipment than those in the community, thereby increasing their risk of contracting HIV and hepatitis C.

The 2010 CSC report that I just referred to indicated that 17% of men and 14% of women injected drugs in prison. About half of those people who injected drugs shared injection equipment, including with people who they knew had HIV, hepatitis C, or unknown infection status.

Though these figures are high, they are likely understating the pervasiveness of this practice, given the repercussions for those who admit to this illegal behaviour. Moreover, these numbers represent an increase in reported injection drug use since a 1995 CSC survey. In 1995, this survey indicated 11% of prisoners reported drug use by injection. So it's quite a significant increase.

Programs that ensure access to sterile injection equipment are therefore an important component of a comprehensive approach to reducing prisoners’ vulnerability to HIV and hepatitis C infection. To date, these programs have been introduced in more than 60 prisons in at least 11 countries. They're mentioned in my report, but I'll just give you a quick rundown: Switzerland, Spain, Moldova, Belarus, Kyrgyzstan, Tajikistan, Germany, Luxembourg, Iran, Romania, and Armenia. We know they're operating in well-funded prison systems and severely under-funded prison systems, in civilian and military prison systems, in institutions with drastically different physical arrangements for the housing of prisoners, in men's and women's institutions, and in prisons of all security classifications and sizes.

They also use different methods for distributing the equipment. They use hand-to-hand exchange by nurses or the prison physician; distribution by one-for-one automated syringe dispensing machines; peer outreach workers and other prisoners who are distributing the equipment; and external NGOs or other health professionals who come in and do the distribution.

The best available evidence all points to the fact that these programs work. They reduce risk behaviour and disease; they don't increase drug consumption or injecting; they do not endanger staff or prisoner safety—and I think that's really an important point, because I know a correctional officer has previously testified about his concern about this posing a risk to his staff—and they have other positive outcomes for the health of people in prison, including increasing referrals of users to drug addiction treatment programs.

Since the first program was introduced in a Swiss prison in 1992, there has not been a single reported case of injection equipment being used as a weapon against either a staff member or another prisoner. Prisoners are usually required to keep their equipment in a predetermined location in their cells. This assists staff when they enter the cell to conduct searches and has decreased accidental needle stick injuries. Staff are much less likely to encounter used needles that are hidden in prisoners' cells and to be accidentally pricked with a needle that has been used countless times by countless people. These findings were all confirmed in a review by the Public Health Agency of Canada called Prison Needle Exchange: Review of the Evidence. It was done in 2006 at the request of Correctional Service Canada.

A focus on drug interdiction and abstinence, especially in a federal prison context where there are waiting lists for substance abuse treatment programs, ignores a substantial body of research that demonstrates that addiction is a chronic and relapsing condition shaped by many behavioural and social contextual characteristics. By refusing to implement prison-based needle and syringe programs, CSC unnecessarily places individuals with the most severe drug dependence at risk of hepatitis C and HIV infection.

Many have relied on these programs in the community. I know that all of you are aware there are over 200 needle and syringe programs operating in communities across Canada, with more in development. They've had the support of all levels of government, and the evidence shows that they work.

Denying these programs to prisoners also discriminates against people who inject drugs in prison and aggravates the public health by contributing further to the harms associated with unsafe drug use. As we discussed in our written brief, prisoners disproportionately embody multiple characteristics recognized as traditional grounds on which discrimination is prohibited. In particular, the denial of these programs to prisoners disproportionately affects aboriginal communities, which are disproportionately represented already in Canadian prisons, and among people who inject drugs and people living with HIV in the population as a whole.

The denial of these programs to people in prison also disproportionately impacts women. Though they constitute a minority of those incarcerated in Canada, a significant percentage of women were incarcerated for offences related to drug use often linked to underlying factors such as experiences of sexual and physical violence and abuse. A previous history of injection drug use is also consistently found more frequently among women than men in Canadian prisons.

Already HIV and hepatitis C prevalence is significantly higher among incarcerated women than men in Canada. As the Canadian Human Rights Commission has concluded, “Although sharing dirty needles poses risks for any inmate, the impact on women is greater because of the higher rate of drug use and HIV infection in this population”, an impact that “may be particularly acute for federally sentenced aboriginal women”.

With increasing rates of HIV and hepatitis C in prison, society also bears the cost of treatment for those who are infected. According to Correctional Service Canada, treating a prisoner with hepatitis C costs $22,000, and treating a prisoner with HIV costs $29,000 per year. This is a lifetime cost. It is far more cost-effective to provide prisoners with sterile injection equipment than to treat their HIV or hepatitis C infection.

The World Health Organization actually provided an informal quotation for the unit cost of this equipment, and it came to $4 to $10 U.S. per person per year. These costs are for programs in the community, but I think they're applicable in the prison context as well.

In 2006, more than 2,000 people were released from prison into the community with hepatitis C and more than 200 people were released into the community with HIV. Prison health is public health. There is no reason to treat prisoners differently from people in the community who are struggling with addiction. By reducing the risk of HIV and of hepatitis C infection among prisoners who inject drugs, the majority of whom return to the community upon release, the health of the Canadian public is also better protected.

Thank you.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much.

We'll now move to the next presentation.

Mr. Clarke.

[Seth Clarke, Community Development Coordinator, Prisoners with HIV/AIDS Support Action Network]

Thank you.

I would like to start by thanking the committee for inviting me here to speak with you today.

PASAN is a community-based organization that provides support and prevention education services to prisoners around infectious diseases, with a focus on HIV/AIDS and hepatitis C.

My comments today will be focused around drug use and drug dependency in prison and its connection to prisoners' pain management needs and issues.

The federal prison population is comprised of a diverse spectrum of people, and within it there are disproportionate numbers of people of low income, racialized communities, people with disabilities. And obviously, as you well know, it is hugely over-represented by indigenous people, many of whom are suffering from trauma and have been survivors of the residential school program. Prison also has many people with diagnosed and undiagnosed mental health issues, substance abuse habits, and dependencies. Obviously, there are many people in prison with drug-related convictions, going from possession to possession for the purposes of trafficking, but also many people are in prison with convictions for fraud or theft, which are related to their drug use habits.

I want to start by clearly saying that there is a level of trauma and all kinds of issues that prisoners are dealing with as they come in. Also, there's the fact that they're in prison and isolated from their family and from their communities. Obviously, they're in an environment where there's some hostility, and trust and support is quite hard to access for prisoners. These things all play a role in terms of a prisoner's ability to maintain a level of good health.

Just a few notes about how this has been studied over a period of time....

A report was commissioned by CSC. It was a health care needs assessment of federal inmates in Canada that found that inmates were thirty times more likely to inject drugs than people outside, two to ten times more likely to have an alcohol or substance use or abuse disorder, more than twenty times more likely to have been infected with HCV, ten times more likely to be infected with HIV, more than twice as likely to have any mental health disorder, and four times more likely to die of suicide than people on the outside.

These figures point to the fact that prison is not a place where it's easy to maintain a level of health. Also, the correctional investigator's report from 2009-2010 stated that hepatitis C rates have increased by 50% between 2000 and 2008, and also stated that it is a fact that HIV and HCV are acquired, transmitted, and spread in prisons.

I want to talk a little bit about pain management issues in prison generally. Prisoners, like people in the community, are going to have different pain management issues in their lives. This can be based on physical pain, emotional and psychological pain, and distress. As I said earlier, many prisoners are survivors of trauma and abuse in their past. One of the difficulties in terms of drug use in prison and pain management in prison is that a lot of prisoners, as I said earlier, will come into prison already with drug use habits that they need to deal with. The process that the prison service goes through with people is one in which the first response to a drug use situation is often a punitive response rather than a therapeutic response. The policies in prison are ones that obviously try to reduce drug use and try, first and foremost, from a security perspective, to control that situation.

Also, on both sides, prisoners and staff, there is a degree a suspicion, which is a part of the culture of the prison environment. Trust levels are low on both sides.

Often, prisoners who are presenting with pain management needs of all types are at risk of being labelled as having drug-seeking behaviour and are at risk of having a higher level of scrutiny from the guards and the correctional system because they are considered to be a potential risk.

Again, the fact that prisoners know this means that oftentimes there is a greater likelihood that the prisoners are going to become involved in more risky practices—if they are using drugs, they will use them more quickly—and the lack of effective harm reduction materials and services means that prisoners are in a situation in which they are at much greater risk of contracting and spreading infectious diseases.

There is also the allegation that prisoners with the label of potentially being drug-seeking might divert drugs to other prisoners. Again this brings greater scrutiny on prisoners. There are many consequences for suspicion of drug use or diversion, and also the potential that somebody might have a positive urine analysis test. These consequences include potential loss of institutional work, movement within an institution or transfer out of an institution, possibly a period of time in segregation, loss of visits and so more isolation from family, and also potential institutional charges.

The existence of this as a part of the drug strategy again makes it less likely that prisoners are going to come forward looking for support treatment around drug-use types of issues and around self-medication types of issues.

One of the things that is key around this is that in spite of addiction being as a disability, as I said, the first response often tends to be punitive rather than therapeutic. Programming that is available in prison for prisoners around drug use and treatment-type issues tends to be limited. There tend to be fairly long waiting lists to get into the programs that exist.

But when I say “limited”, it is also often the case that people need a certain level of support in order to make changes in their lives. Often the treatment options available are of a certain type and do not recognize that people are struggling to meet their pain management needs at the same time as looking to make changes in their lives, hopefully, so that they have a better chance of staying out when they do eventually get out.

Security considerations often trump the health needs of prisoners around these kinds of issues. I would argue that there's no effective one-size-fits-all strategy around drug treatment for people generally. In the community there are usually greater options for people when they are looking at treatment and rehabilitation with regard to drugs. I think this is important, because we always want to look at the principle of equivalency, in terms of whether what is available to prisoners is as close to possible to being equivalent to that which is available in the community.

In terms of the broad things that are available in the community, from harm reduction services to support services to treatment services, there isn't the same access, and very importantly in terms of people being able to make different choices, it is important that a large proportion of the different options available to prisoners around drug use be provided, hopefully, by community organizations that are going into prisons to provide those services. That gives people different options, options that do not necessarily expose them to a system in which there are obvious concerns about the potential punitive repercussions people are going to face.

I just want to give a very quick example—

[The Chair, Conservative, Kevin Sorenson]

I'll just jump in here.

Could you conclude quickly? We have to move into some questions. We have a number of members who want to ask you some questions. Maybe in response to some of those questions you can fill in some of the things you didn't get to say and include them in your answers.

Are there a couple of sentences you want to conclude with?

[Seth Clarke]

I'll just say that a comprehensive drug strategy in prison would include a review of pain management procedures and of the drug formulary that exists for prisoners; an increase in harm reduction services, including prison needle and syringe programs; an increased level of support for treatment options for prisoners, including having community-based organizations provide them, and so developing partnerships between the institutions and community organizations.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much.

I thank you both, Ms. Chu and Mr. Clarke.

We'll proceed into the first round with Madam Hoeppner.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

Thank you, Mr. Chair. I'm going to be sharing my time with Mr. Norlock.

I have a very short amount of time, so my questions will be rather quick. I'm hoping you can respond with short answers to begin with, if that would be all right.

Ms. Chu, as part of our anti-drug policy our government has committed to a zero tolerance drug policy in prisons. We recognize that this is obviously a very difficult goal to aspire to, but we believe it's best to aim high.

Would you agree that a zero drug policy is probably the very best policy? Do you agree with that for prisons?

[Sandra Ka Hon Chu]

I think it's unrealistic. Although we have a zero tolerance policy for drugs outside in the community, we have needle and syringe programs in the community for people who are drug-dependent, to protect their health.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

It's prisons, though, that I'm wondering about. Prisons are places where there are other.... For example, tobacco is legal outside of prisons. There are different things that have different standards inside prisons from those outside prisons.

I'm wondering, specifically in prisons, whether you would agree with a zero tolerance drug policy.

[Sandra Ka Hon Chu]

I think it's laudable but unrealistic. These people are arguably suffering more greatly from drug dependence because, as Seth mentioned, many people are incarcerated for drug-related offences. The correctional investigator pointed out that 15% of people on any given day are actually on treatment.

You can aim for zero tolerance, but in the meantime people are going to be infected with HIV.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

I understand. Thank you. I've heard your presentation, so I do understand your position. I just wondered whether you would agree with that ideal, even though it obviously is very difficult to achieve. Ideally it would be great if there were no drugs in prison. Would you agree with that?

[Sandra Ka Hon Chu]

I think aiming for that will undermine people's health. I mean, without implementing other programs—

[Candice Bergen, Conservative, Portage—Lisgar, MB]

You would not agree with that, then. You're saying you would not agree with that. Is that correct?

[Sandra Ka Hon Chu]

I'm saying it's unrealistic. There's no prison in the world that has no drugs.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

Right. Okay, thank you.

The next point I want to talk about.... I have great concern with what seems to me a great imbalance towards helping inmates who are addicted to drugs being able to access more drugs and access paraphernalia to administer those drugs, against the safety of officers who are doing their job every day, putting their lives at risk.

They are law-abiding citizens. They have not committed any crimes. They may have had issues in their lives as well by virtue of which they could have made bad decisions, but these are individuals who are working on behalf of Canadians. It appears to me that their safety is, with your presentation, completely ignored.

I wonder whether you could please tell me—and I would ask you not to cite the Swedish study, because I don't have that in front of me—how you could practically.... Talk about unrealistic goals. How can you practically say and try to make us believe that needles would not be used as weapons against officers?

[Sandra Ka Hon Chu]

I absolutely agree that the safety of staff is paramount and important.

We work on an evidence base. We've looked at the needle-syringe programs that have existed since 1992. It's been almost 20 years that they've existed around the world, and as I mentioned, in multiple sites and in different contexts. There has not been a single case in which they have been used as a weapon.

There's one example I'd like to point out. In Germany the staff were also very much against it. They were concerned, and it's an understandable concern: needles can be used as weapons. But in that case they had the program implemented and the staff became wholly supportive of it, because they felt they were protected in the end. There's less chance for accidental needle injuries when the equipment is in a specific place in each person's cell. They know that when they search someone they're not going to be pricked. And if it does happen, God forbid, then it's not with a needle that has been passed around by numerous people and possibly infected with HIV or hepatitis C.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

Unfortunately, I don't know that this would be satisfactory to Canadians. If you're giving inmates who have already shown that they have trouble obeying laws, basic laws, and sometimes have trouble respecting the safety and rights of others.... I think it's very....

Again, talk about a difficult stretch, trying to think that needles would not be used as weapons; I really have trouble with that.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Ms. Hoeppner.

We'll now move to Madame Morin.

Ms. Morin, you have five minutes.

[Marie-Claude Morin, NDP, Saint-Hyacinthe—Bagot, QC]

Good afternoon. I want to start by thanking the witness for her presentation; it was very informative.

Your remarks once again confirmed for me that harm reduction is much more effective than zero tolerance, given that it is less repressive for inmates. When that approach is taken, inmates are much less likely to turn against guards using syringes as weapons since they do not feel quite as suppressed.

Could the syringe programs we were talking about earlier become a necessity in order to keep the public safe? I will explain. Given the long wait times for psychological support and substance abuse treatment programs, could someone who is released from prison have contracted HIV/AIDS while in prison and not know? If so, there is a greater likelihood of that person infecting the public. With that in mind, could we say that a syringe program is a necessary measure in order to protect the safety of the public, as well as the safety of guards?

[Sandra Ka Hon Chu]

Absolutely. We always underscore the fact that prison health is public health.

I've spoken to a number of prison physicians who work in Canada and who treat people with HIV and hepatitis C who say they are 100% certain that people are being infected inside while they're on waiting lists for treatment. Over 90% of the prison population in Canada are released into the community. It's not as though we throw people into prison and then walk away and forget about them. The health of people in prison is very intimately linked to the health of the community.

[Marie-Claude Morin, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you.

My next question is for Mr. Clarke.

I was quite struck by what you said earlier about a comprehensive strategy being a good way to, at least, reduce the incidence of drugs in prisons and thereby make those facilities safer. Could you elaborate on that a bit further since you did not really have enough time before?

[Seth Clarke]

I'm sorry; could I just have the first part again? What strategy do you mean? Is it the drug strategy?

[The Chair, Conservative, Kevin Sorenson]

Yes, the first part was dealing basically with the drug strategy.

[Seth Clarke]

What I'm proposing is that an effective drug strategy would involve dealing with prisoners' pain management issues, and not purely physical pain management issues but pain management issues that basically speak to people's experience in some cases before they come into the institutions. Many people, when they start to use drugs, are trying to mask something; they are self-medicating, and there are underlying issues that might need psychiatric support. In many cases people are in that situation both before they come in but also through their experience in the institution.

As to levels of isolation, I've always argued that if people do not have mental health issues when they come into prison, if they're doing a federal sentence they are likely to have mental health issues when they leave.

So a drug strategy should definitely look at people's pain management issues and people's mental health needs in the institution and would include broader options for treatment and programming, many of which, I would argue—and this is partly to get past the issues of trust and fear—should be provided by community organizations that are relocating their services into the institution. Again, that would support the principle of equivalency, in terms of people having comparable services for health available to them in prison to those that exist in the community.

A part of that effective drug strategy would also involve comprehensive harm reduction services available to prisoners, hopefully lowering the risk to prisoners—and eventually to the community as prisoners get out—from there being much higher rates of HIV and HCV among the prison population.