France — In light of the French International Prison Observatory’s (OIP) report published last summer on the findings of a months-long inquiry concerning access to specialist care in prison, we interviewed 54-year-old Béatrice Carton, MD, chair of the French association of healthcare professionals working in the prison service (APSEP), on her experience working in a detention center.
Having a wealth of experience in the prison service, this family physician, who practices as an independent physician at the Bois-d’Arcy detention center and at the Versailles women’s detention center, explained how prison doctors work in the prison service. She also discussed access to care during the COVID-19 pandemic and the difficulties in recruiting new prison doctors. Despite difficult conditions, she described her position as “a fantastic job” and explained why.
Medscape: How did you come to work as a prison doctor?
Carton: I initially worked in the medical department in a hospital as a resident, also providing cover as a GP in the community on several occasions. Like many of my colleagues working in the prison service, I ended up here by chance. Our role is to be independent physicians working in healthcare units in the prison service. A post came up. I said I’d give it a go for a few years and here I am, 21 years later!
Medscape: What did you think when you first entered a prison?
Carton: You have to remember how you felt when you first set foot in a prison, otherwise it’s hard to understand how some of our patients must feel. When you go through the doors of a prison, you find yourself in a timeless place, cut off from the rest of the world. There are lots of noises that are different from the ones you might hear outside prison: keys and doors clanking, as well as shouting. The inmates often talk to each other from one end of the prison to the other by shouting. In the midst of all that, the medical department is like a bubble. Our aim is for this space to be seen as a hospital and not a prison.
Medscape: What types of prison do you work in?
Carton: I work in the Bois-d’Arcy detention center and at the Versailles women’s detention center in Yvelines. These facilities house inmates who’ve been given a short sentence, prisoners on remand and those who’ve been handed a long sentence who are awaiting a place in a centrally based prison. The level of overpopulation is very high. At Bois-d’Arcy, there are 900 inmates for 500 places. The occupancy rate is permanently 180%. This situation isn’t unique to Bois-d’Arcy. For example, the occupancy rate at the Bordeaux detention center is 220%. It goes without saying that cramped, overpopulated prisons result in psychiatric problems, dilapidated buildings, hygiene issues, et cetera.
Medscape: When a prisoner arrives at the detention center, what sort of medical care does he or she receive?
Carton: They’re routinely offered an appointment with a medical professional. It isn’t compulsory. In this “arrival phase,” the inmate will see a nurse, a doctor, and a dentist. The aim is to find out about his or her current state of health, to arrange any follow-up appointments if necessary, to introduce them to the service, and to direct them towards any specialist care, should this be needed.
Medscape: On leaving prison, or after a transfer, are patients lost to follow-up?
Carton: When a person is transferred from one facility to another, we transfer his or her medical records to the doctor (not to the prison administration) for continuity of care. If the person is leaving prison, we try to give them as many documents as we can so that they can continue their treatment on the outside. In detention centers, the concern is that inmates may leave overnight without any notice. When prisoners are sent back into the community without any support from the prison service, this poses a real problem for us.
Medscape: What are the main healthcare problems you deal with?
Carton: Psychiatric conditions are overrepresented. There are also very high rates of anxiety and trauma. Due to our patient population, we often deal with addiction problems. But, as a rule, we mostly practice general medicine. Our patients have the same conditions as those seeing their family physician in the community.
Medscape: If an inmate requires a specialist consultation, how does this happen?
Carton: An ophthalmologist is available in my department every fortnight. For all other specialties, I have to see the patient externally in my affiliated hospital in Versailles.
Medscape: The OIP recently reported that prisoners may have to wait several months before seeing a specialist. Is that true?
Carton: Wait times depend on which specialist physicians are available in the prison service sector. But it’s true that in prison we have some specific difficulties. Once we know a patient requires a specialist consultation, we have to get together a team of prison wardens who are available to accompany them, stay with them for as long as the hospital appointment takes and then take them back again.
This is a relatively dignified process for the prisoner, depending on how dangerous he or she is and on the wardens accompanying them. At a minimum, he or she will have to be handcuffed. Now, understandably, most prisoners don’t want to walk down a hospital corridor surrounded by prison wardens, wearing handcuffs or possibly even shackles around their ankles. Some of them refuse, which ultimately means that they forgo any treatment they could have received.
Medscape: The OIP reports particular difficulties with accessing gynecology and dental care. Are some medical specialties particularly stretched?
Carton: The main issue is that it’s hard to recruit people to work in the prison service. We already have a recruitment crisis for doctors, nurses, and paramedical healthcare professionals. And then there’s the prospect of working behind bars, in the middle of nowhere, miles from anywhere. New prisons are very cold and unpleasant, and older ones are very dilapidated. It’s not very enticing! Despite all that, it’s a fantastic job. Looking after people who were often out of reach of healthcare professionals on the outside is very interesting. As a doctor, you can spend more time with each patient. And it’s easier to follow-up patients in a prison setting.
Medscape: Do you become attached or feel empathy for your patients because of their situation?
Carton: You feel empathy, yes, but not for everyone. It’s the same as in everyday life. I personally don’t ask about their criminal past, but they might spontaneously decide to tell me about their history. A doctor in the community doesn’t know everything about his or her patient, but that doesn’t stop them from treating them. It’s the same for me. I feel somewhat attached to those who are often socially or economically isolated, or even both. They’re met with a bit of consideration in our department. In return, we get a bit of gratitude.
Medscape: Could telemedicine improve access to medical care in prison?
Carton: Its usage is growing, but often at a much slower rate than we would hope. We’ve been using telemedicine here since 2014. We’ve set up specialist teledermatology and telemedicine in anesthesia services. But we’re finding it difficult to develop it further. We’d have liked to set up a telecardiology service, but we couldn’t find a cardiologist to take on the role. Another problem is that our IT services are very poor and often outdated. So, I am very cautious about telemedicine. It improves access to healthcare, but it can’t fix all our problems. Also, it shouldn’t be a replacement for doctors physically onsite within the prison service. Patients are already very isolated. It would be hell if they stopped seeing doctors in person.
Medscape: How is it during the COVID-19 pandemic? Did inmates have access to masks and the vaccine?
Carton: They had access to masks, eventually. A vaccination program was set up, but we live in a world full of rumors, where fake news circulates easily. We’ve tried to adapt. The situation outside was very anxiety-inducing; the situation inside was even worse, with visiting rooms closing their doors and contact with family members stopped. We had to manage all of this with existing resources. Organizing a vaccination program for 900 people (although only around 100 turned up to be vaccinated), without additional resources and screening under the same conditions, wasn’t easy. Honestly, it was no laughing matter.
During the first and second waves, we didn’t have any big outbreaks of COVID in the detention center. However, we had lots of sick inmates during the later waves, when COVID measures were relaxed. During this time, COVID cases were high, with numerous cases in fall 2021 and early 2022. But we didn’t have any serious cases. When you have 95 patients to care for over a 2-week period, it’s not easy. You have to constantly adapt, that’s another attraction of the job.
Medscape: How did you manage to isolate these sick patients?
Carton: We worked hand in hand with the center’s management department. In some parts of the prison, we created sort of neutral areas to which nurses were assigned to treat patients and see them once or twice a day.
Medscape: Have you had difficulty accessing treatments for hepatitis C in prison?
Carton: Initially, we had problems caring for patients with hepatitis C, due to the cost of treatment. But this is no longer the case. The public authorities have taken stock of the problem. Nowadays, a general practitioner can prescribe hepatitis C treatment, and the medication is reimbursed. So the situation has improved, although it’s still not perfect.
We collect the treatment monthly and issue them to patients daily or weekly. When they’re due to be released, we give them their medication and their prescription, if necessary. Problems arise when an inmate is released sooner than expected. Yet again, we find ourselves having to adapt and tweak our procedures. Under these conditions, we tend to treat people who we know are going to spend 2 or 3 months in our center.
Medscape: Twenty or so years ago, Véronique Vasseur, MD, PhD, published a bombshell book on healthcare in prisons. Have things improved since then?
Carton: At the time she was working in prisons, care was dispensed by doctors who answered to the prison’s administrative department. Since then, medical provision in the prison service has switched to the care of the department for health. Although we’re on prison premises, we’re not responsible for seeking justice, which gives us a bit more autonomy. In this regard, the situation has improved massively.
However, for the past few years we’ve found ourselves going backwards: we have fewer resources, and the “safety above all” attitude is affecting how we work. Let’s just say that the health department is less vocal than the justice department. For several years, we’ve been under pressure to examine inmates in the presence of wardens, even though we’re inside a prison and our units are organized so that medical confidentiality is respected, and rightly so. We’ve managed to reject the wardens, but it’s an ongoing battle that is becoming tiresome.
Medscape: As chair of the French association of healthcare professionals working in the prison service, what are your current complaints?
Carton: Alongside APSEP, we’d like to educate people on how we work, try to make our jobs look more attractive, and receive sufficient resources to fulfill our roles. My colleagues and I are all convinced that if we complete our mission of care correctly, we’ll also be able to carry out our other mission of promoting and educating about healthcare. It’s something that we can’t measure or profit from immediately, but it’s important for those being released from prison.
For example, in our detention center, we have a smoking rate of 70%. Outside the prison walls, this figure is 30%. So, education about smoking is a huge factor. Another example is our diabetic patients, who all have poorly controlled blood sugar levels. Some have reached a glycated hemoglobin level of 12%. We need the resources to provide healthcare education, but unfortunately there just aren’t enough of us.
This article was translated from the Medscape French edition.