The Sick-Prisoner Dilemma

Why is it so hard to provide health care to El Salvador’s prisoners?

Launch slide show.

SAN SALVADOR, El Salvador—The courtyard of Centro de Readaptación de Mujeres de Ilopango is cheerful and airy, with a pleasing veranda where it might be nice to sit with a good book. On the shaded passageways, women sit and embroider projects for their families, a homey sight. But appearances are somewhat—perhaps entirely—deceiving: The women’s rehabilitation center is a prison in one of the poorest countries in the Western Hemisphere. Like many penitentiaries in El Salvador, the centro is overcrowded, run down, and likely to stay that way for the foreseeable future. The women are excited to have visitors, they tell us, because it means they get to feast on chicken and cola, instead of their usual meal of rice and beans.

Bad food is among the least pressing of the problems facing the Salvadoran prison system: It is famously violent, with riots killing 31 in 2004 and 21 in 2007. Murders are not uncommon—an inmate was slain just last week. Much of the fighting is related to El Salvador’s brutal gang wars, led by Mara Salvatrucha (also known as MS-13) and 18 (or the 18th Street Gang), which were founded in Los Angeles and spread to El Salvador as members were deported in the 1990s. The overstretched prison system has the sixth-highest occupancy rate in the world, as it houses more than 250 percent of the population it was constructed to hold: There are approximately 24,000 inmates—one-third are affiliated with a gang—crammed into a system meant for 9,000 people. The country also ranks among the top 20 out of 217 nations when it comes to incarceration rates. (The United States has the dubious honor of holding the No. 1 spot.)

In April, I was part of a group of international journalists visiting El Salvador to learn about health programs to combat HIV and tuberculosis among the poor and underserved. We were scheduled to visit two men’s prisons, Apanteos and La Esperanza, but the outing was canceled: Riots had broken out in six other facilities, as inmates, who refused to enter their cells, protested overcrowding and poor conditions.

But if prison is dangerous for most of the Salvadoran personas privadas de libertad (persons deprived of freedom), it is, perhaps expectedly, worse for those living with HIV and other chronic illnesses. The U.N. Office on Drugs and Crime notes  that factors contributing to the virus’s spread among prison populations include “overcrowding, unsafe sexual activities and injecting drug use, violence, gangs, lack of protection for the youngest, female and weakest inmates, corruption and poor prison health services”—all of which are not only present but pervasive within El Salvador’s 23 correctional facilities for adults. Delivering medical treatment to HIV-positive patients and other sick inmates in an overcrowded, gang-filled system is an immense task, complicated by the country’s poverty, the dangers of bringing health workers into the prison environment, stigma surrounding HIV and homosexual activity, and inmates’ own resistance. But new programs may create a safe zone for HIV-positive inmates and allow for better education and treatment.

With approximately $15,000 to $30,000 per year from the Global Fund To Fight AIDS, Tuberculosis, and Malaria, the Salvadoran Ministry of Health and Social Assistance, which oversees the prisons, has been able to implement a widespread testing program to identify HIV-positive inmates and educate those willing to listen; other funds from the Ministry of Health provide treatment, including anti-retroviral therapy.

When Dr. Ana Estela Parada began working with prisoners in 2005, officials had identified fewer than five HIV-positive inmates. But since testing has begun on a wide scale, that number has climbed to more than 200—certainly a underestimate, given that only 55 percent of inmates have agreed to be tested. Working with some of Central America’s most dangerous felons seems like an odd career choice for the slender, well-coiffed Parada; I wondered how many prisoners took the time to appreciate the French pedicure that peeks through her open-toed pumps. But she speaks with such authority and dynamism that it’s no wonder even hardened criminals listen up—at least sometimes.

Parada says her main challenge comes from prison officials who aren’t terribly interested in implementing innovative programs to keep the inmates healthy and educated. “The authorities want them to do their time, not kill each other, and not annoy them,” she says. There is high turnover among the brass, and those who do stick around frequently block new plans. For instance, Parada wants to distribute condoms among the prisoners—but the authorities are reluctant since this would be a tacit admission that sex between men happens behind the penitentiary walls.

El Salvador is a heavily Catholic, conservative country (its abortion laws are perhaps the harshest in the world). Sex between men remains largely taboo, and officials have raised every possible objection to handing out condoms. They have suggested prisoners could use condoms to smuggle in cell phones (though a lack of condoms certainly hasn’t squelched prisoner cell phone use—one of the ways the April riots spread was via mobile phones). Even less credibly, they claim that inmates could use the condoms to commit suicide.

Ralf Jurgens of the Global Fund dismisses these arguments: “A review of the evidence … has shown that where condoms have been provided, they have not been misused; there have been no negative consequences for the prisons, either for the prison staff or fellow prisoners.” He points to Moldova, which also offers inmates methadone and needle exchanges, an a model of poor countries providing prophylactics for inmates. Even the religious nation of Iran has implemented a condom distribution program. But the only way the Salvadoran administrators would permit widespread condom distribution? If someone would go through the prisons to pick up and dispose of the used rubbers—hardly a sought-after gig.

Although distributing condoms has proved difficult, peer-to-peer groups have had some success. A peer-education group within the notorious La Esperanza prison, aka Mariona—site of the 2004 riots that led to 31 deaths—is a particular point of pride for Parada. Inmates who complete the program, in which they learn about prevention, risky behavior, co-infection with tuberculosis, drug resistance, and more, are awarded with a diploma that goes into their file to demonstrate good behavior. The goal is to help motivate other prisoners “to stop being afraid and get tested,” using conversations within the prison and hand-made signs. Other groups provide support for patients who have tested positive.

The efforts to educate the prisoners has had another benefit beyond identifying HIV-positive patients and helping them understand that their diagnosis is not a death sentence, a common misconception in a country that has only recently started to address the virus on a national scale. While Parada was meeting with one group of Esperanza inmates, whose members included representatives from both MS-13 and 18, the men began arguing. She says that she stood up and yelled, “There’s something here that unites the two groups, and that’s HIV.” Some of those present were already ill; she says her admonition helped them see past their different affiliations and begin to recognize their shared experiences. “The support group is what makes them change their mentality,” she told us. In fact, the groups are so successful that when one Guatemalan prisoner was offered the opportunity to transfer to a facility in his native country so that he would be closer to his family, he elected to stay behind—his new facility would not have offered a support group. (He may have had other motivation: Guatemala’s prisons are also quite dangerous. Recently, four severed heads were found in Guatemala City, bearing messages complaining of “the mistreatment and the injustices in the country’s jails.”)

Though the changes taking place within the system are meant for their benefit, prisoners are displeased with certain side effects. When one Salvadoran prison established facilities that would allow inmates to receive some health care treatment on-site instead of being transferred to a local hospital, 20 HIV-positive men objected. They enjoyed their field trips to the outside medical facilities: Frequently, they could return with smuggled cell phones, SIM cards, and other goodies. One man, a convicted kidnapper, managed to escape during a trip to the hospital.

At the women’s prison, the focus is on the next generation. There, too, a support group tries to provide women with information about their health and, frequently, that of their children. In a hot room, as women share their stories about contracting and living with HIV, a toddler babbles and cries. His mother was six months pregnant when she arrived at the facility, but at first she didn’t tell the group she was living with HIV. “I was embarrassed,” she says. Eventually, she talked about her status and was taken to the hospital, where she began anti-retroviral treatment. Her son was born HIV-free, something she is proud of. The importance of keeping children safe is a theme that crops up again and again as the women speak, sometimes tearfully, about their incarceration and their disease. “I want to live for my daughter,” says Estela, who found out she had HIV four years ago. “I have sons, and I have to fight for them,” echoes Carolina, who tested positive in July 2009, four months before she entered the prison.

Usually, it’s hard to pinpoint the purpose and benefit of prison, particularly for those living in the infamous facilities of Central American countries like El Salvador. But for those inmates who are learning to take better care of themselves and to overcome their own anxieties about an HIV diagnosis, perhaps some good may come from incarceration.

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