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Fadi Meroueh: responding to the health needs of prisoners Fadi Meroueh talks to Andréia Azevedo Soares about ensuring health equity and harm reduction services in prisons, and the challenges presented by the COVID-19 pandemic.

Q: What are the main differences you have encountered working as a doctor Fadi Meroueh is dedicated to ensuring the health and outside and inside prisons? supporting the health rights of prisoners. Head of the A: For me one of the biggest differ- health unit of the Villeneuve-lès-Maguelone prison, ences is the way doctors are pressured in Montpellier, France, he is also president of Health into different and often conflicting roles Without Barriers, the European Federation for Prison inside correctional facilities. This can Health, which represents prison health professionals, make it difficult for the doctor to retain supports evidence-based health-care practices and independence and loyalty to the patient. advocates for prisoners’ rights to health. A researcher

For example, magistrates may ask doc- Meroueh Courtesy of Fadi tors to certify that an inmate can make Fadi Meroueh with 30 peer-reviewed articles to his credit, and 23 years a court appearance. In my view such re- working on prevention and treatment programmes quests should be refused. If a judge or a inside prisons in Europe and Africa, he is also a member of numerous lawyer wants to know whether a patient prison health expert panels including those convened by the World Health is prepared to go to court, he should hire Organization (WHO) and the United Nations Office on Drugs and Crime. He an expert in such matters to make that received his medical degree from the University of Tours in 1991, and master’s assessment. Similarly, prison guards degrees in forensic medicine, medical ethics, and addiction risk prevention from have a tendency to ask for information Montpellier University (2003), University of Paris V (2006) and the University of about a prisoner’s health as though the Besançon (2009). doctor were part of the prison’s security staff, something I find completely unac- ceptable. Q: You were elected president of Health Q: Does that often happen? Without Barriers in 2019. What is the A: Absolutely. It has happened to purpose of that organization? Prisoners may me when I have called the guards to say A: Health Without Barriers was be deprived of a patient needs to go to the emergency created to bring together and repre- “ their freedom but room. They ask me what is wrong with sent professionals dealing with health not of their health the prisoner – usually because they care in prisons. Our mission is to have security concerns. But should I tell improve inmates’ health through the rights. them? No. Prisoners may be deprived promotion of good health practices of their freedom but not of their health and ethical standards for the safeguard ” rights. Medical privacy and indepen- of human rights in prison. We also dence of medicine are key principles, encourage and support research and and the struggle to maintain them in interdisciplinary collaboration in the Q: Prisons are often discussed as incu- prison has been going on for 30 years in field of prison health. We have a broad bators of infectious disease, including France. It is a long battle. Another differ- remit covering most health-care inter- diseases associated with needle use. ence is the way doctors and patients tend ventions from dental to mental, but key What is your perspective on that issue? to relate to each other inside prisons. areas of concern include drug addiction A: I think it’s important to un- When someone is incarcerated, they lose and the prevention of infectious disease derstand that – while the prevalence contact with friends and family. Their transmission. With regard to the latter, of HIV (human immunodeficiency lives become the penitentiary and they we are currently collaborating with sev- virus), HCV (hepatitis C virus), HBV are often enclosed in a cell which may eral European and global organizations (hepatitis B virus) and tuberculosis is measure just a few square metres. As a and are part of two European projects: higher in prison populations than in the result, there is a different doctor–patient the European Centre for Disease Pre- general population – in many instances, dynamic in the consulting room. It is of vention and Control project which is prisoners have a drug problem before course the doctor’s job to be concerned focused on the prevention of infec- they are incarcerated. Indeed, they are with the patient’s well-being, and to ask tious diseases in penal institutions; and often incarcerated because of problems about any physical or mental concerns the Prison and Hepatitis C in Europe deriving from their drug use such as they may have. However, the doctor is project that is working on developing drug possession offences, theft, etc. So, not there to be the patient’s friend. He the evidence base and implementing inevitably prisons tend to see a higher or she is the patient’s doctor and should effective diagnosis and management of concentration of needle users. behave as one would in the broader chronic hepatitis C among inmates in community. European prisons.

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Q: You started a needle and syringe wait for severe symptoms to initiate VID-19 has been reduced to 7 days from exchange programme at Villeneuve-lès- treatment. By beginning treatment 14 has also helped, and we now have Maguelone. Could you tell us about that early, we not only improve outcomes, rapid antigen tests that in 15 minutes experience? we also improve treatment adherence. give reasonably reliable results if they A: When I started the needle ex- People who have made a start in prison are used within 5–7 days of the onset change programme here in 2010, I tend to continue outside. Of course, the of symptoms. We are still being very realized that there would be little point arrival of new antiviral treatments since strict about masks with everybody be- in treating prisoners with HIV, HCV 2014 has also revolutionized treatment, ing obliged to wear a mask all the time. and HBV without providing them with making it possible to complete the full Also, everyone arriving from the outside clean syringes. However, despite French course in two months. has to go into quarantine. So far these laws regarding the implementation of measures are working quite well. As of needle exchange programmes in pris- mid-November 2020, only two of the ons, many doctors wait for a go-ahead People inmates had tested positive in the second from the prison administration to start half of the year. implementation. We didn’t do that here. considered“ vulnerable We order needles in the same way we to severe COVID-19 Q: What are your main concerns going order other medical supplies because who hadn’t committed forward? we take the view that harm reduction is serious crimes were A: Making sure we continue to be a legitimate evidence-based health in- released. vigilant with regard to COVID-19 trans- tervention. Unfortunately, penitentiary mission. We cannot let our guard down, staff are still resistant. ” regardless of recent developments with vaccines. We also need to make sure that Q: Why is that? prisons get the resources they need. Be- A: For different reasons, but one of cause of the impact of response measures them is the fear of staff being attacked Q: How has COVID-19 impacted your on the economy, an economic crisis is with infected needles. The fear is rooted prison? around the corner which is going to put in an incident that happened in Austra- A: It has been challenging. We knew tremendous pressure on the government lia in 1990 at the Long Bay Jail in Sydney, we had to take it very seriously because to cut costs. We have to make sure that when a guard was stabbed with an HIV- like any other prison we bring together we do not try to save money at the ex- infected syringe and subsequently died a large group of people in an enclosed pense of prisoners' health. First because of an AIDS-related illness. Since then, space and are thus vulnerable to the health is their right. Health is health for politicians and other decision-makers transmission of any respiratory disease. all. But even at the more pragmatic level have refused to talk about needle and Moreover, we were about 50% over- of good health-system governance, it is syringe exchange programmes. It really capacity at the beginning of 2020, with clear that prisoners’ health should be a is taboo. The reality is that the risk of around 900 inmates under our roof. We concern for everyone. Most prisoners needle-stick injury for prison staff will actually had people sleeping on mattresses eventually rejoin society and their suc- exist as long as needles are in circulation, on the floor! Starting in March 2020, we cessful reintegration depends in part on regardless of whether needle exchange implemented strict transmission preven- their good health. If former detainees programmes are in place. My argument tion measures. Visits and activities were return to society with an infectious is always the same: the day needles cease suspended, and detainees had to spend disease, they are likely to increase dis- to be used, needle exchange can stop. Re- most of their time in their cells, which was ease transmission and the community’s sistance to needle exchange is not solely very hard on them psychologically. We overall disease burden. And they will still a French phenomenon, of course. Since also took steps to reduce overcrowding. require treatment. So why not make sure 1993, when WHO gave its support to Detainees with sentences up to 2 months they are treated in prison? this type of harm reduction programme were released earlier, and people con- There also needs to be more invest- in detention centres, only a handful of sidered vulnerable to severe COVID-19 ment in mental health treatment capac- countries have implemented them. who hadn’t committed serious crimes ity, including in the facilities required were released. We managed to get the to accommodate the people who need Q: You and your team have managed population down to 729 detainees, which them. We have to stop using prisons for to eliminate Hepatitis C at Villeneuve- is still above maximum capacity but is a patients with psychosis or schizophrenia lès-Maguelone. What was the key to significant improvement. As a result of who have committed minor offences. your success? these efforts, in the first half of 2020 only Another concern with regard to the A: Having a proactive treatment two inmates tested positive for the virus. coming downturn that most economists policy. We used to wait for patients to In the second phase of restrictions, are predicting is that it is likely to impact be released from prison before ensuring which was instituted in November 2020, the marginalized hardest. Many of the that they were treated outside because we were better prepared and were able to people who come to prison, come in treatment took from six months to one be less restrictive of people’s movement precisely because they are marginalized year and many of our inmates serve and were also able to maintain visits, and suffering from inequities. If we do terms shorter than that. Since 2003 we which is very important from the point not try to address socioeconomic mar- have been treating every patient infected of view of prisoners’ mental well-being. ginalization with investment in educa- whether they are staying in prison for The fact that the quarantine period for tion and job creation, people will keep one month or a year. Also, we do not people who have been exposed to CO- being incarcerated. ■

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