On being old, and healthy, and in prison

Table of Contents pg.1 Introduction pg.2 The Tragedy of Mass Incarceration pg. 3 Penal Populism pg.8 Community Justice and Justice Reinvestment pg.10 Right on Crime pg. 11 Age and Aging pg.14 Aging Europe, Aging World-pg.22 Age, Disease and the Aging Prisoner pg.24 The Older Prisoner (UNDOC)-pg.25 The Older Prisoner (United States) pg.25 The Older Offender (Canada) pg. 39 After Bill-C10: Politics not Evidence-based Policy pg.41 The Older Offender (Australia) pg.45 The Older Offender (New Zealand) pg.54 The Older Offender (England & Wales) pg. 60 Older Voices in UK Prisons pg.65 Friendship pg.67 Existential Choice- pg.66 Resilience in the Prison pg.69 The Brains Neuroplasticity pg.70 A Good Age pg.72 Logotherapy pg-74 Healthpg.76 Wellness -pg.80 Well-Being- pg.83 Well-being and Health pg.77 The signifance of Wellness and Well-Being-pg.86 Salutogenesis -pg.85 The Quality of Life-88 Health Promotion-pg.90 The Ottawa Charter pg.92 Health Promotion Setting- pg.95 The Healthy Prison-pg.95 WHO Health in Prison Project pg.97 Prison Suicide pg.100 Penal Moderation-pg.100 Finland: From Mass Incarceration to Nordic Minimalism-pg.102 The Coming Age Wave-pg.108 Social Inequalities pg.109 References
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Introduction
Though the title of this review essay may seen ironic given the present situation, it is the intention of this essay to be both a review of the literature; and to also be a call to take the action necessary to make the prison into a true health promotion setting and prove the concept of a healthy prison is not an oxymoron. Until recently there was very little interest in the quality of prison life, especially for the ageing prisoner. Today the situation is changing rapidly with the need for applied research on the population of ageing prisoners starting to be seen as a real priority. The first reason is the public health impact caused by the American experiment , over the past 40 years, in mass incarceration (an experiment that is now being exported to, and replicated by, many countries world-wide) a negative impact that Ernest Drucker (2011) has called A Plaque of Prisoners. The second reason is the profound change in demographics with a dramatic increase in the size of the aged 65+ population. Never in human history have there been so many people ( 7 billion), nor have so many been old aged. Never have there been so many older prisoners with physical and mental health needs. In the European Union, prison systems are, or will be, dealing with a combination of An increase in the number of aging prisoners High rates of Incarceration due to Penal Populism Increasing Fiscal constraints HIV/AIDS and the increase in MDR-TB in Eastern Europe and Russia

as well as increasing cultural, racial and faith diversity in the prison population. This review essay looks at key concepts and concerns about the health and quality of life for the growing population of older prisoners age 50 and above. This review attempts to provide the reader both with the necessary information to better appreciate the implications of the changes in the prison population, and to also help to mobilize the political will to adequately response to this aging crisis (Aday, 2003)..

The Tragedy of Penal Populism and Mass Incarceration

The aging crisis in many prison systems is driven by a combination of a) penal populism leading to changes in penal policy and practices which then generate mass incarceration and b) changes in the demographics leading to a dramatic increase in number of older persons in the overall population. Together these two trends mean many more older prisoners in systems that were designed for a much younger population. These prison systems do not meet the physical and mental needs of older prisoners. Before looking at the quality of prison life for the aging prisoner in the different prison systems it is important take a look at one of the key driving forces behind this crisis- the tragedy of penal populism and mass imcarceration. A tragedy is defined as 2

A drama or literary work in which the main character is brought to ruin or suffers extreme sorrow, especially as a consequence of a tragic flaw, moral weakness, or inability to cope with unfavorable circumstances. The First World War (1914-1918) was an unplanned tragedy which ripped Europe apart. The Second World War (1939-1945) was planned aggression though the results were also tragic. Mass Incarceration The American experiment in mass imprisonment was not planned. Instead it was the result of several social forces such as : the profound social unrest of the 1960s and the protest over the American Vietman War; the criminal justice evaluations of the early 70s which suggested that both policing practices and the rehabilitation of prisoners had failed to make a difference; followed by the liberal attack on rehabiltation as a justification for major penal reform; and then the successful conservative acceptance of the failure of rehabilitation linked with a renewed emphasis on the use of the prison as a tool for maintaining social order. Punishment and containment became the main justification for the prison, rehabilitation was at best a secondary goal. In 2001 David Garland wrote the classic The Culture of Control: Crime and Social Order in Contemporary Society to argue that the dramatic increase in the prison population over the past 40 years was pushed by two underlying social forces: the distinctive social organization of late modernity and the neoconservative politics that came to dominate the United States and the United Kingdom in the 1980s. document . attempt to reduce the use of incarceration because of the rehabilitation . He also edited Mass Imprisonment: Social Causes and Consequences (2001), a collection of papers that documented the profound social impact of this radical change in penal policy. Until the mid-70s Americas imprisonment rate had fluctuated around a stable mean of about 110 per 100,000. In 1973 the rate began to increase and it has continued to increase in every single year since. During the 1990s the decade of widespread and sustained reductions in American crime rates prison growth accelerated and the already high prison population was doubled. Garland argues that this phenomenon had no parallel in the western world. One had to look to Nazi Germany (1933-1945), or Stalins rule, or to todays China and Russia to get comparable incarceration patterns. Garland believes that this phenomenon needs to be differentiated from imprisonment rate as it occurs in other comparable nations. Just as the Soviet Union had its gulag archipelago, America now has mass imprisonment a new name to describe an altogether new phenomenon. Garlands mass imprisonment has two defining features. Garland writes that these are: One is sheer numbers. Mass imprisonment implies a rate of imprisonment and a size of prison population that is markedly above the historical and comparative norm for societies of this type. The US prison system clearly meets these criteria.

The other feature is the social concentration of imprisonments effects. Imprisonment becomes mass imprisonment when it ceases to be the incarceration of individual offenders and becomes the systematic imprisonment of whole groups of the population. In the case of the USA, the group concerned is, of course, young black males in large urban centres. 1 in 3 black men aged 20 to 29 years of age is currently in penal custody or under penal supervision. If current trends continue, 30 percent of all black males born today will spend some of their lives in prison. (The comparative figure for white males is 4 percent and for Hispanics 14 percent.) This means that imprisonment has become one of the social institutions that structure this groups experience. It becomes part of the socialization process. Every family, every household, every individual in these neighbourhoods has direct personal knowledge of the prison through a spouse, a child, a parent, a neighbour, a friend. Imprisonment ceases to be the fate of a few criminal individuals and becomes a shaping institution for whole sectors of the population. We do not currently know what mass imprisonment will mean for the society in which it develops, or for the groups who are most directly affected. As Frank Zimring and Gordon Hawkins (1991) have pointed out, we do not have a jurisprudence of the scale of imprisonment. For all of our philosophizing about the purpose of imprisonment, we have scarcely begun to address the question of its extent. We have libraries of criminological research about the impact of imprisonment upon the individual offender, but scarcely anything on its social impact upon communities and neighbourhoods (all emphasis added, 2001b:1-3). There is now a fairly well developed and consistent literature that provides a critical analysis of the political reasons behind mass incarceration in the United States (Gottschalk, 2006; Abramsky ,2007; Barker, 2009; Hagan, 2010) that is best summed up by the title Governng through Crime (Simon, 2007). Tonrys Thinking about crime (2004) is an excellent discussion of the different competing models-including Garland- but the why the radical change in the rate of incarceration happened, that still remains unclear. Perhaps the historian Barbara Tuchmans concept of a government march of folly is the best description of why there has been such a tragedy. It is clear that the rate of incarceration in a society is determined by cultural and political dynamics, not by the amount of crime. It is also now clear that there have been massive social costs resulting from the move to mass imprisonment. In 2001 Garland wrote that We are only now beginning to glimpse the social and financial costs of this institution in terms of: reduced state budgets for other spending; the alienation of whole sectors of the population; the normalization of the prison experience and the transfer of prison culture into the community; the criminogenic consequences of custody for inmates and their families and their children; and the disenfranchisement of whole sectors of the community. Particularly troubling is the way in which penal exclusion has been layered

on top of economic and racial exclusion, ensuring that social divisions are deepened, and that a criminalized underclass is brought into existence and systematically perpetuated. To understand the negative impact of mass incarceration it is useful to compare a community to a sweater. Lose a thread, not important, it can be repaired. Too many threads then there is a hole, and then several holes, and the sweater is no longer useful. In the same way, a few people going to prison doesnt harm the overall social health of the community. But too many, too often, and then the network of families, friends, connections etc., is ripped open. Communities with a concentration of social problems are very vulnerable to the negative impact of mass incarceration. In the United States that has been communities with a majority of young Black and Latino men in the urban centres. In Canada and New Zealand it has been the Aboriginal communities. Whether the discrimination- race, gender, faith, social-economic class, sexual orientation- is not as critical as the tendency to focus on the target population- a tendency that is highlighted when there is mass incarceration. The unintended consequences of incarceration have been a topic of debate since the early 1990s (Vera Institute of Justice, 1996). There are significant collateral consequences for the families and children of the prisoners, and for their communites These collateral consequnces (Mauer & Chesney-Lind, 2002; Murray, 2005 ) are a secondaryinvisible punishment of the innocent bystanders (family and community) in addition to the intended primary penal harm to the individual offender(Clear, 1994, 1999; Stemen, 2007). In Imprisoning Communities: How Mass Incarceration Makes Disadvantaged Neighborhoods Worse (2007) Todd Clear makes the following key points: The extraordinary growth in the U.S. prison system, sustained for over 30 years, has had, at best, a small impact on crime. The evidence that the prison can have a deterrent or incapacilitation effect on the rate of crime is quite weak The growth in imprisonment has been concentrated among poor, minority males who live in impoverished neighborhoods. Concentrated incarceration in those impoverished communities has broken families, weakened the social-control capacity of parents, eroded economic strength, soured attitudes toward society, and distorted politics; even, after reaching a certain level, it has increased rather than decreased crime. Any attempt to overcome the problems of crime will have to encompass a combination of sentencing reforms and philosophical realignment....We will have to make community well-being a central objective of our penal system. We will have to embrace an idea of community justice.

Community justice broadly refers to all variants of crime prevention and justice activities that explicitly include the community in their processes and set the enhancement of community quality of life as a goal ( Clear & Karp, 1999; Karp & Clear, 2000). Clears concept of community justice as basically a restorative justice process operating at the level of the community as a whole that is aimed at healing the harm done by mass incarceration (Bruce, 2010).

More recently Ernest Drucker is writing about A Plague of Prisons ( 2011), and applying a public health model to the epidemic of mass incarceration. He notes that : The population involved is diverse: men and women, adults and children, different social classes. The onset was very rapid -- in thirty-five years the population directly affected by this epidemic increased tenfold, from 250,000 in 1970 to 2.5 million by 2009. The effects of the epidemic extend beyond actual cases -- over 30 million have been affected in the last thirty years. Young minority men have been affected most severely: although they make up only 3 percent of the U.S. population, young black and Hispanic men constitute over 30 percent of the cases. While this epidemic is nationwide, most cases have occurred in the poorest neighborhoods of America's urban areas -- in some communities, over 90 percent of families have afflicted members. Individuals who are afflicted are also socially marginalized and often become incapacitated for life -- unable to find decent work, get proper housing, participate in the political system, or have a normal family life. The children of families affected by this new epidemic have lower life expectancy and are six to seven times more likely to acquire it themselves than the children of families not affected. Drucker argues that although no known biological agent is involved, as with cholera and AIDS, this new epidemic this plague of prisoners - exhibits all the characteristics of an infectious disease -- spreading most rapidly by proximity and exposure to prior cases. Drucker links the onset of this plague of prisons to the penal policy of a war on drugs which lead to new drug laws. In 1973 the State of New York passed a set of laws that required judges to impose sentences of 15 years to life imprisonment for anyone convicted of selling two ounces (57 grams) or possessing four ounces of narcotic drugsusually cocaine, heroin or marijuana. These laws were known as the Rockefeller laws, after New Yorks then-governor, Nelson Rockefeller. They sent New Yorks prison population soaring, from an average of fewer than 75 inmates per 100,000 New Yorkers between 1880 and 1970 to five times that rate by the end of the century. Between 1987 and 1997 drug cases accounted for 45% of new prisoners. These new laws quickly spread first to the other American states, and then globally. It has also been argued that the penal policies such as the war on drugs are also motivated by political considerations. In the United States, the defeat of Michael Dukakis in the 1988 US Presidential election, has had a long-lasting impact on electoral politics in the USA but also on penal policies and practices in the UK and elsewhere. The Bush smear tactic linked Willie Horton, a convicted murderer who had terrorized a couple, raping the woman, in 1987 while on a weekend furlough program that was being supported by the then Governor Michael Dukakis. The Bush tactic pretty much destroyed Dukakiss presidential campaign in 6

1988 with ads showing Hortons picture and images of inmates going through a revolving door. Politicans now know that it is critical to be seen as being hard on crime, and political suicide to be seen as being soft. Criminal justice policy has become politicized. Until recently any public discussion of penal reforms was politically unadvisable. In the USA, and in many other countries, this epidemic of mass incarceration has become self-fulfilling. There is a massive investment in infrastructure and human resources. Many smaller communities are economically dependent on the local prison. Incarceration has grown despite declines in the amount of crime. In the USA, each year at least 630,000 men and women will re-enter society after a period of incarceration in Federal prisons, and then 60% of them will be re-incarcerated within two years often for violation of the parole conditions rather than new offences. A 2002 report to the US Congress stated that each year the American network of Federal and State prisons and jails release more than 11.5 million inmates. As a result vulnerable communities are being torn apart by the re-entry cycling and the related collatoral damage to families, friends and community. Todd Clear talks about reentry cycling Reentry must be thought of as a cyclical process in two ways: (1) every reentry was preceded by a removal and (2) many (or most) reentries will be followed by a removal. Some analysts have called this process churning to emphasize the high rate of return among recent prison and jail releases. But the term churning places emphasis solely on the return to prison or jail, suggesting that the original removal is not equally important. We refer to reentry cycling to include the equal numbers of removals. The idea of reentry cycling describes the mutual processes of removal for imprisonment, return after the sentence has been served, and high risk of eventual removal for failure to succeed during reentry ( Clear, Waring &Scully, 2005: 183)

Problem: reentry cycling

Criminal Event Social Exclusion

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Todd Clear believes that the present mass incarceration policies are a stunning impediment to social justice ....( and) it is nearly impossible to address problems of racial injustice and social inequality withoutfirst overcoming one of their main engines: concentrated incarceration . 7

Many criminologists and Black and Latino activists would agree with him. In The New Jim Crow: Mass Incarceration in the Age of Colorblindness (2010) Michelle Alexander argues that America is still struggling with the issue of race caste. She writes that In the 18th century it was the transatlantic slave trade, in the 19th century it was slavery, in the 20th century it was Jim Crow. Today it is mass incarceration. Angela Davis asks Are Prisons Obsolete? (2003) In thinking about the possible obsolescence of the prison, Davis writes, we should ask how it is that so many people could end up in prison without major debates regarding the efficacy of incarceration. It is clear that Mass Imprisonment x Aging Population = A Lot More Older Prisoners. It is possible to argue over the reasons for the mass incarceration but the impact has become clear. And now prison systems in most countries world-wide must respond to the changing demographics. The American experiment in mass incarceration over the past 35-40 years along with the overall ageing of the American population as a whole has meant that During the past decade, the number of elderly and infirm inmates in state prison systems has increased dramatically. From 1992 to January 1, 2001, the number of state and federal inmates age 50 and older increased from 41,586 to 113,358, a staggering increase of 172.6 percent (Correctional Health Care, 2004)

Penal Populism
In 1993 Anthony Bottoms coined the now ubiquitous phrase "populist punitiveness". By this he did not mean public opinion per se, but "the notion of politicians tapping into, and using for their own purposes, what they believe to be the public's generally punitive stance" (Bottoms, 1995, p. 40). As mentioned, penal policy has become highly political. 8

John Pratt has written about both penal populism (2007) and also Scandinavian Exceptionalism (2008). He is clear that it is more complex than just the manipulations of politicans. Pratt writes that penal populism involves a dramatic reconguration of the axis of penal power, with the strategic effect of reversing many of the previous assumptions that had hitherto informed post-war penal policy. There should thus be more prisons rather than fewer; punishment should be turned into a public spectacle rather than take the form of a bureaucratic accomplishment hidden from public view; popular commonsense should be prioritized over the expert knowledge of criminal justice ofcials. By the same token, because of the much closer linkages between governments and those individuals or organizations who claim to speak on behalf of the public at large, and the much weaker linkages between governments and their own bureaucratic advisers, there is now a much greater likelihood of this collection of ideas being translated into policy (2007:35). Ernest Drucker is right about the rapid spread of penal populism which has resulted in mass incarceration in many countries, and there does seem to be a world wide increase in the use of incarceration (Walmsley, 2003,2009). But the increase has been striking in some countries (Unites States of America, New Zealand, Australia, England and Wales) while others are more moderate (Germany) and the Scandinavian countries have proven to be the expection to the overall tendency (Pratt, 2006)

It is clear that the other English speaking countries (New Zealand, Australia, England & Wales) have followed the same pattern of a high rate of incarceration as the United States while the Nordic countries have maintained a more moderate rate. Finland did have a high rate but it has now declined to the moderate level of the other Scandinavian countries.

It could be argued that mass incarceration is a danger to any society because of both the collatoral damage that it can cause to a community and also the reality of offender re-entry cycling. The role of the prison and the high rates of incarceration in the United States and in the United Kingdom have become the focus of great public debate. It is now a savage debate in Canada as the new Conservative government makes changes that will dramatically increase the prison population. There is no similar debate in most of Eastern and Central Europe. Belarus Latvia Lithuania Estonia Hungary Finland 385 314 260 256 163 60

Rate of Incarceration per 100,000 (http://www.prisonstudies.org/info/worldbrief/) After the destruction of Dukakiss presidential campaign in 1988, few politicans wanted to risk being labelled as being soft on crime but that situation is starting to change. In the United States there is now a discussion about justice reinvestment and also in New Zealand, Australia, England and Wales. Community Justice and Justice Reinvestment Since the late 90s Todd Clear has been writing about penal harm and the need for a community focus. He has argued that any solution would reuire a combination of sentencing reforms and philosophical realignment. Given the evidence for the collatoral damge to the community, Clear believed that community well-being must become a central objective of the penal system. By community justice Clear meant all the variants of crime prevention and justice activities that explicitly include the community in their processes and set the enhancement of community quality of life as a goal ( Clear & Karp, 1999; Karp & Clear, 2000). This concept of community justice is basically a restorative justice process that is operating at the level of the community as a whole in order to heal the harm done by mass incarceration (Bruce, 2010). A very similar concept to Clears community justice, is the Open Societys concept of justice reinvestment. In 2003, in Ideas for an Open Society (Volume 3 Number 3) there was a short article on justice investment. The article was very clear- the failures of prison fundamentalism required a fundamental shift in the way we think about public safety in America . The goal of justice reinvestment is to redirect some portion of the $54 billion America now spends on prisons to rebuilding the human resources and physical infrastructure the schools, healthcare facilities, parks, and public spaces of neighborhoods devastated by high levels of incarceration. Justice reinvestment is, however, more than simply rethinking and redirecting public funds. It is also about devolving accountability and responsibility to the local level. Justice reinvestment seeks community level solutions to community level problems (2003:2).

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The concept of justice reinvestment seems to have been marketed in the United States of America in the right way at the right time, and there is great interest in the UK, New Zealand, and Australia. The discussion about ways to change the penal system has now started to open up again after almost 25 years of political silence following the effectiveness of the Bush attack ads that destroyed the Dukakiss campaign. It is ironic that just as America is starting to move out of the epidemic of mass incarceration, Canada is getting into mass incarceration after 40 years of resisting the American influence. In the EU, Finland is in fairly good shape to deal with the population of aging prisoners because it has already worked to reduce the size of its prison population . It has now maintained a low rate of incarceration ovr the past few decades. Finland has one of the fastest aging populations in the EU. The countries which still have a high rate of incarceration and the challenge of a rapidly aging populaiton are facing a much more difficult situation. The American example- the failure of prison fundamentalism- as well as the new interest in alternatives such as justice reinvestment should provide an impetus for change in the systems with a high level of incarceration to take action to reduce the size of the prison population as soon as possible. Dr. Becker has written about a plague of prisoners - and given the health risks such as MDR-TB, and the related collatoral damage to vulnerable communities , he may be quite accurate in comparing mass incarceration with other plagues such the Black Death and todays HIV/AIDS and MDR-TB.

Right on Crime: Conservative Penal Reform?

In the US, and many other countries, for about three decades , the word commonly used to describe a politician who publicly announced he wanted to send fewer criminals to prison was loser the Dukakis curse. It didnt matter if the politician was liberal or conservative. To be elected, or to stay in office, one must be seen as being hard on crime. As the British Prime Minister, put it, his New Labour would be Tough on Crime, Tough on its Causes. There are now signs of a small but real sea change in American politics. There is a new organization, Right on Crime, which has a set of principles that are rational, just and even sound vaguely liberal. Applying the following conservative principles to criminal justice policy is vital to achieving a cost-effective system that protects citizens, restores victims, and reforms wrongdoers. 1. As with any government program, the criminal justice system must be transparent and include performance measures that hold it accountable for its results in protecting the public, lowering crime rates, reducing re-offending, collecting victim restitution and conserving taxpayers money. 2. Crime victims, along with the public and taxpayers, are among the key consumers of the criminal justice system; the victims conception of justice, public safety, and the offenders risk for future criminal conduct should be prioritized when determining an appropriate punishment.

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3. The corrections system should emphasize public safety, personal responsibility, work, restitution, community service, and treatmentboth in probation and parole, which supervise most offenders, and in prisons. 4. An ideal criminal justice system works to reform amenable offenders who will return to society through harnessing the power of families, charities, faith-based groups, and communities. 5. Because incentives affect human behavior, policies for both offenders and the corrections system must align incentives with our goals of public safety, victim restitution and satisfaction, and cost-effectiveness, thereby moving from a system that grows when it fails to one that rewards results. 6. Criminal law should be reserved for conduct that is either blameworthy or threatens public safety, not wielded to grow government and undermine economic freedom. Bur Right on Crime is very far from being a liberal organization. This is an initiative from the (very conservative) Texas Public Policy Foundation in cooperation with Prison Fellowship a very Conservative Christian organization that is active in faith-based programs for offenders. Right on Crime provides its own short history on how the present situation of mass incarceration came about. Basically it blames liberals who forced conservative politicans to take action to save the United States. It is true that in the early 70s liberal penal reformers were attacking the indeterminate sentence and its rehabilitation premise. The reformers goal was to further reduce the use of the prison. It is also true that conservative politicians agreed with the liberal penal reformers about the limits of rehabilitation but then advocated for the massive use of incarceration to control or at least to incapacitate the dangerous elements. The conservatives were successful in their efforts to direct penal policy. By the 1980s the liberal reformers were talking about the need to reaffirm rehabilitation but in the 70s they had made a massive tactical error in their peanl policy which was seized upon by the conservatives. Back to the Conservative version: HISTORY (HOW DID WE GET HERE?) In the 1960s, the United States experienced a notorious crime wave. Liberal theories on crime posited that criminals were inevitable products of oppressive societies and, given the correct resources, virtually all offenders were capable of curtailing their criminal behavior. These attitudes did little to limit criminality and, in fact, crime rates continued to swell into the 1970s. Then the pendulum swung in the opposite direction. Conservative politicians argued that criminals generally could not be rehabilitated, it was pointless to attempt most treatments, and the only realistic solution was to incapacitate a criminal through the use of incarceration. This was often caricatured as the lock em up and throw away the key approach.

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WHATS GONE WRONG Under the incarceration-focused solution, societies were safer to the extent that dangerous people were incapacitated, but when offenders emerged from prison with no job prospects, unresolved drug and mental health problems, and diminished connections to their families and communities they were prone to return to crime. While the growth of incarceration took many dangerous offenders off the streets, research suggested that it reached a point of diminishing returns, as recidivism rates increased and more than one million nonviolent offenders filled the nations prisons. In most states, prisons came to absorb more than 85 percent of the corrections budget, leaving limited resources for community supervision alternatives such as probation and parole, which cost less and could have better reduced recidivism among non-violent offenders. Illustrating the failure of the entire corrections system, two-thirds of individuals now entering prison are offenders whose probation or parole was revoked, and half of these revocations are for technical violations such as not reporting to a probation officer, rather than for new crimes. Parole and probation reporting are critical elements of community supervision, but it is worth asking whether re-incarceration is a sensible sanction for such violations. COST TO THE TAXPAYER As recidivism increases, taxpayers pay ever-larger sums to support a growing corrections system. In some states, criminal justice budgets quadrupled over a twenty year period. In part, this is because prison is terribly costly. At the low end, in a state such as Mississippi, incarceration can cost approximately $18,000 per year per prisoner. At the high end, in a state such as California, it can cost an astonishing $50,000 per year per prisoner. According to the Pew Center on the States, state and federal spending on corrections has grown 400% over the past 20 years, from about $12 billion to about $60 billion. Corrections spending is currently among the fastest growing line items in state budgets, and 1 in 8 full-time state government employees works in corrections. How is it conservative to spend vast amounts of taxpayer money on a strategy without asking whether it is providing taxpayers with the best public safety return on their investment? After three decades of active conservative promotion of incarceration as the solution to crime - just incapacitate all the criminals - a promotion which included the war on drugs, three strikes and youre out and other repressive measures, now the conservatives have discovered the value of offender rehabilitation and also the need for justice reinvestment. Basically the Right on Crime is a Conservative admission that they went too far and for too long in their promotion of new laws to better control and to incarcerate the dangerous classes. The first sign of this remarkable change was the support for prisoner re-entry in the Second Chance Act which was signed into law on April 9, 2008. It was designed to improve the outcomes for people returning to communities from prisons and jails. This first-of-its-kind legislation authorized federal grants to government agencies and nonprofit organizations to

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provide employment assistance, substance abuse treatment, housing, family programming, mentoring, victims support, and other services that can help reduce recidivism. We know from long experience that if [former prisoners] cant find work, or a home, or help, they are much more likely to commit more crimes and return to prison. America is the land of the second chance, and when the gates of the prison open, the path ahead should lead to a better life. President George W. Bush The reforms that the Right on Crime project suggests may be motivated by political considerations, and by an overarching concern about economic efficiency, but on many points, such as probation over prison where appropriate, diminishing penalties for minor infractions such as marijuana possession, and juvenile-justice reform, these reforms are also fair and just. And given that the United States is in an environment of economic duress and relatively low violent-crime rates, the moment is perfectly suited for reform. There are three broader points that need to made: First, if knee-jerk reactions and partisan preferences keep us from looking at a politician's record in detail, the loss is really to us all rather than just them. Second, if you're trying to get something done, then it is very nice to have a solid an economic argument about it; in many cases, perhaps including this one, the economic rationale may be sufficient on its own, regardless of whatever net social benefits you may be after. The third is that this Right on Crime initiative is an example of the phenomenon that sometimes the most influential political moves can come from the party that does not "own" the issue - the Conservatives might achieve some real penal reform, an activity that the Liberals failed so miserably at in the 70s.

Age and Aging

What is Longevity?
It is important to be clear about the distinction between longevity and aging. Longevity is the life span of an organism. Longevity is based on two major factors, genetics and lifestyle choices. The upper range of the human life span seems to be about 115 years for men, 120 years for women. Jeanne Calment (18751997, 122 years, 164 days) was the oldest person in history whose age had been verified by modern documentation. How long one can live is based both on the genes that come from one parents, and also on the lifestyle choices one makes. However social determinants can limit the available lifestyle choices. Few of us can expect to live to be a 100 plus though that number is increasing. In Classical Rome, life expectancy was only 28, but if a person survived until age 15, then the life expectancy could increase an additional 37 years resulting in a total life span of 52 years. Julius Caesar had a long life for a Roman, he was 55 when he was assassinated March 15, 44 B.C.E 14

The current world average life expectancy is now up to 67.2 years which is about half of the potential life human span of 115 to 120 years.

What is Aging?
If the potential human lifespan is over 100 years, then what is aging? When does it start? The Encyclopdia Britannica article on aging states that Aging is the sequential or progressive change in an organism that leads to an increased risk of debility, disease, and death; senescence consists of these manifestations of the aging process. To put it very simply, aging is the process that increases the probability of debility, disease, and death. Aging takes place in a cell, an organ, or the total organism with the passage of time. It is a process that goes on over the entire adult life span of any living thing. Gerontology, the study of the aging process, is devoted to the understanding and control of all factors contributing to the finitude of individual life. It is not concerned exclusively with debility, which looms so large in human experience, but deals with a much wider range of phenomena. Every species has a life history in which the individual life span has an appropriate relationship to the reproductive life span and to the mechanism of reproduction and the course of development. How these relationships evolved is as germane to gerontology as it is to evolutionary biology. It is also important to distinguish between the purely physicochemical processes of aging and the accidental organismic processes of disease and injury that lead to death. Gerontology, therefore, can be defined as the science of the finitude of life as expressed in the three aspects of longevity, aging, and death, examined in both evolutionary and individual (ontogenetic) perspective. In the Encyclopdia Britannica article on human aging, it is defined as the physiological changes that take place in the human body leading to senescence, the decline of biological functions and of the ability to adapt to metabolic stress. In humans the physiological developments are normally accompanied by psychological and behavioural changes, and other changes, involving social and economic factors, also occur. Aging begins as soon as adulthood is reached and is as much a part of human life as are infancy, childhood, and adolescence. All living things will age, all living things will die. The key question for us all is going to the individuals quality of life and the potential of resilence to the aging process.

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Seven Ages: Shakespeares Worst Case Scenario

A common understanding of the aging process is that it is must be a period of decline. William Shakespeare conveyed that sense of decline in his As You Like It with a monologue that starts thus: All the world's a stage, And all the men and women merely players, They have their exits and entrances, And one man in his time plays many parts, His acts being seven ages. These early ages are the infant, the whining schoolboy, the lover (adolescent), the soldier (adult), the justice in fair round belly (mature adult) which are then followed by the ages of decline and death. The sixth age shifts Into the lean and slipper'd pantaloon, With spectacles on nose, and pouch on side, His youthful hose well sav'd, a world too wide, For his shrunk shank, and his big manly voice, Turning again towards childish treble, pipes And whistles in his sound. Last scene of all, That ends this strange eventful history, Is second childishness and mere oblivion, Sans teeth, sans eyes, sans taste, sans everything Basically William Shakespeare's seven ages make up a total of 60 to 70 years at best with the last two decades being one of limits (a world too wide. For his shrunk shank), loss. dementia and finally death. Life expectancy in Elizabethan England was only a little better than Ancient Rome. Infant and early childhood death rate contributed to a low average life expectancy. However barring plague, war, accident, crime, and childbed, if one managed to live to be 12 years old, then one might live to be 60- 70. Shakespeares son Hamnet was only 11 when he died in 1596. Shakespeare retired when he was 49. In Elizabthan England, men only started describing themselves as being old at about age 50. Sadly Shakespeare was the same age as Caesar, age 52, when he died of an unknown cause. Elizabeth the 1st lived until the age of 70.

What happens as the person ages?

The aging literature makes a critical distinction between body systems and the psychological aspects. Basically with ageing many body systems do not work as well. However the process of ageing is slow and most people can adapt to the decline. The following comments were taken from the longer Encyclopdia Britannica article on human aging. At first it seems to be a rather depressing list but it is important to make a distinction between aging and disease. Many diseases that people associate with aging have 16

little or nothing to do with the process of aging in the same way as the diseases that tended to kill the young had little to do with being young. Human lifespan change is one thing, diseases are another thing.

Physical Aspects of aging

The normal physical aspects of aging , that we can all expect to experience, include the following:

Cardiovascular system
Diseases of the heart are the single largest cause of death after age 65. Thus, with increasing age the heart becomes more vulnerable to disease. Even in the absence of detectable disease, the heart undergoes deleterious changes with advancing age. ...The heart also shows a gradual reduction in performance with advancing age. The amount of blood pumped by the heart diminishes by about 50 percent between the ages of 20 and 90 years. There are marked individual differences in the effects of age. For example, some 80-year-old individuals may have cardiac function that is as good as that of the average 40-year-old individual.

Digestive system
Loss of teeth, which is often seen in elderly people, is more apt to be the result of long-term neglect than a result of aging itself. ...While it is true that the secretion by the stomach of hydrochloric acid, as well as other digestive enzymes, decreases with age, the overall process of digestion is not significantly impaired in the elderly.... There is no evidence that the intake of any nutrient, such as vitamins and minerals, need be increased in the elderly because of impaired absorption. Nutritional deficiencies can be avoided as long as the diet is varied to assure adequate intake of all nutritional elements. Deficiencies are most likely to develop from poor eating habits, such as excessive intake of carbohydrate with a reduction in protein. In the elderly these deficiencies are most apt to be in the intake of protein, calcium, iron, vitamin A, and thiamine (also called vitamin B1).

Nervous system
Changes in the structures of the brain due to normal aging are not striking. It is true that with advancing age there is a slight loss of neurons (nerve cells) in the brain. ... Since the physiological basis of memory is still unknown, it cannot be assumed that the loss of memory observed in elderly people is caused by the loss of neurons in the brain. There are probably functional changes in the brain that account for the slowing of responses and for the memory defects that are often seen in the elderly; and even small changes in the connections between cells of the brain could serve as the basis for marked behavioral changes, but, until more is known about how the brain works, behavioral changes cannot be related to physiological or structural changes. It is known that, because of the slow course of aging, the nervous system can compensate and maintain adequate function even in centenarians (all emphasis added). 17

The incidence of gross sensory impairments, of which many are the result of disease processes, increases with age. One survey conducted in the United States classified 25.9 per 1,000 persons aged 6574 as blind, in contrast to 1.3 per 1,000 aged 2044 years. In the age group 6574, 54.7 per 1,000 persons were classified as functionally deaf, compared with 5.0 per 1,000 in the age range 2534 years.

Vision.
Visual acuity (ability to discriminate fine detail) is relatively poor in young children and improves up to young adulthood. From about the middle 20s to the 50s there is a slight decline in visual acuity, and there is a somewhat accelerated decline thereafter. This decline is readily compensated for by the use of eyeglasses. There is also reduction in the size of the pupil with age. Consequently, vision in older people can be significantly improved by an increase in the level of illumination. Aging also brings about a reduction in the ability to change the focus of the eye for viewing near and far objects (presbyopia), so that distant objects can ordinarily be seen more clearly than those close at hand. This change in vision is related to a gradual increase in rigidity of the lens of the eye that takes place primarily between the ages of 10 and 55 years. After age 55 there is little further change. Many people in their 50s adopt bifocal glasses to compensate for this physiological change. The sensitivity of the eye under conditions of low illumination is less in the old than in the young; that is, night vision is reduced. Sensitivity to glare is also greater in the old than in the young. The incidence of diseases of the eye, such as glaucoma and cataracts (characterized, respectively, by increased intra-ocular pressure and opaque lenses), increases with age, but recent advances in surgery and the development of contact lenses have made it possible to remove cataracts and restore vision to many individuals.

Hearing
Hearing does not change much with age for tones of frequencies usually encountered in daily life. Above the age of 50, however, there is a gradual reduction in the ability to perceive tones at higher frequencies. Few persons over the age of 65 can hear tones with a frequency of 10,000 cycles per second. .... Listening habits and intellectual level play an important role in determining the ability to understand speech, so that there is often a disparity between measurements of pure tone thresholds and ability to perceive speech.

Other sensory impairment

After the age of 70 other sense organs may show a reduction in sensitivity. Reduced taste sensitivity is associated with atrophy and loss of taste buds from the tongue in the elderly. The effect of aging on the sense of smell has not been precisely determined because this sense is extremely difficult to assess quantitatively

18

Sensitivity to pain is difficult to evaluate quantitatively under controlled laboratory conditions. There is some evidence that it diminishes slightly after the age of 70. There is a general slowing of responses in the elderly. Reflexes become slightly more sluggish and the speed of conduction of impulses in nerves is slightly slowed. Old people require more time to respond to the appearance of a light than do young. The slowing with age is greater in situations where a decision must be made.

Skin
The primary age change in the skin is a gradual loss of elasticity. Although this basic change plays a role, other factors, such as exposure to the weather and familial traits, also contribute to the development of wrinkles and the pigmentation associated with senescence.

Endocrine system
Because of the importance of hormones in the regulation of many physiological systems, impairments in endocrine (ductless) glands have traditionally been cited as important determinants in aging. Since aging is associated with reduced ability to adjust to stresses, and since the adrenal cortex (the outer part of the adrenal gland) plays a role in many of these adjustments, numerous attempts have been made to assess senescent changes in the function of the adrenal cortex. Although after the age of 50 there is a reduction in blood levels of the hormones secreted by the adrenal cortex, the ability of the gland to produce hormones when stimulated by the experimental administration of adrenocorticotrophic hormone (ACTH), the pituitary hormone that regulates the activity of the adrenal cortex, has been shown to be as good in the old as in the young. The pituitary gland is often referred to as the master gland of the body, since it produces hormones that stimulate the activities of other endocrine glands, such as the adrenal, the thyroid, and the ovary. It was therefore once assumed that reduction in the function of these glands associated with aging is due to lack of proper stimulation from the pituitary gland. The pancreas secretes insulin, the hormone that regulates the utilization of sugar and other nutrients in the body. When the pancreas fails to produce adequate amounts of insulin, diabetes occurs. One test for diabetes involves measuring the rate of removal of sugar from the blood, that is, the glucose-tolerance test. One characteristic of aging is a reduction in the rate of removal of excess sugar from the blood. At present it is not known whether this represents the early stages of diabetes or whether it is a normal age change. It does appear in aged individuals who do not show any of the other symptoms of diabetes. It has long been known that the excretion of both male and female sex hormones diminishes with age. In the female, the excretion of estrogens (female sex hormones) falls markedly at the menopause. In the male, the excretion of androgens (male sex hormones and their degradation products) falls gradually over the age span 5090, so that the existence of a male climacteric is highly improbable. 19

Sexual activity, as reported in interview studies, diminishes progressively between the ages of 20 and 60 in both males and females. In males the frequency of marital intercourse falls from an average of four per week in 20-year-olds to one per week in 60-year-olds. Practically all males aged 2045 reported some level of sexual activity. Between the ages of 45 and 60 only about 5 percent of males reported loss of sexual activity.

Skeletal system
With aging, the bones gradually lose calcium. As a result they become more fragile and are more likely to break, even with minor falls. Healing of fractures is also slower in the old than in the young. Recent advances in orthopedic surgery, with the replacement of parts of a broken bone or joint with new structures or the introduction of metallic pegs to hold broken parts together, have been of great value to elderly people.... The mobility of joints diminishes with age and the incidence of arthritis increases.

Respiratory system
Vital capacity, or the total amount of air that can be expelled from the lung after a maximum inspiration, diminishes with age, as does the total volume of air that can be contained in the lungs. In contrast, the amount of air that cannot be expelled from the lung increases. These changes in respiratory mechanisms are primarily a reflection of the increased stiffness of the bony cage of the chest and decreased strength of the muscles that move the chest during respiration. The lung also contains elastin and collagen to give it elastic properties ... the formation of cross-links in elastin and collagen that takes place with aging reduces the elastic properties of the lung. The transfer of oxygen and carbon dioxide from the air in the lungs to the blood is influenced by the amount of blood flowing through the lungs as well as by the amount of air moved in and out. The characteristics of the membranes that separate blood and air in the lungs are also important in maintaining an adequate supply of oxygen to the body. Although with age there is a slight reduction in the amount of oxygen that can be moved from the air to the blood in the lungs, the reduction becomes apparent only when large amounts of oxygen are required, as during strenuous exercise. It is believed that a primary factor in the impairment of oxygen transfer in the lungs of elderly subjects is the lack of appropriate adjustment of the blood flow to the air sacs in the lung.

Kidney
The kidney removes wastes from the body by separating them from the blood and forming urine. In this process many substances are accumulated in the urine at a higher concentration than in the blood. With advancing age the concentrating ability of the kidney falls, so that a greater volume of water is required to excrete the same amount of waste material

Regulatory mechanisms
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Some physiological characteristics, such as the mechanisms that regulate the acidity of the blood or its sugar level, are adequate to maintain normal levels under resting conditions even in very old people; however, the aged require more time than the young to reestablish normal levels when changes from the normal occur. The body's physiological mechanisms for adjusting to changes in environmental temperature are less adequate in the old than in the young. Consequently older people may prefer more uniform and slightly higher temperatures than the young. High temperatures are also more hazardous to the elderly. The incidence of heat prostration in hot weather increases with age. Exercise is one of the physiological stresses of daily living. In reasonable amounts it is a valuable stimulus to maintain physiological vigour. A number of studies have indicated a lower incidence of cardiovascular disease among adults who indulge in physical activity than in those who do not. The capacity to perform muscular work diminishes progressively in the elderly. Muscle strength diminishes; however, the reduction in strength is less in muscles that continue to be used throughout adult life than in those that are not. Thus a part of the reduction in muscle strength may be an atrophy of disuse. With less than maximum exercise, there is a greater increase in blood pressure, heart rate, and respiration in the old than in the young; that is, a given work load induces a greater physiological stress in the old than in the young. Furthermore, recovery of blood pressure, heart rate, and respiration to resting values takes longer in the old. Comment: The most interesting thing about this Encyclopedia Britannica list is how much these normal physical aspects of aging can be moderated by lifestyle decisions, especially nutrition and exercise. Biomedical research has demonstrated how much can be done through evidence-based lifestyle decisions. Reports such as The Surgeon General's Report on Nutrition and Health (1988) and The Surgeon Generals Report on Physical Activity and Health (1996) as well as similar WHO reports have made the evidence readily available. Medical researcher such Dean Ornish and Caldwell B. Esselstyn have shown that Cardiovascular Disease can be treated by diet, exercise and stress management. President Bill Clinton has reviewed this evidence and now lives on a vegan diet. It is beyond the scope of this essay to go into this nutritional and exercise research, but it should be part of the planning in any prison - especially since so many prisoners have a long history of nutritional neglect and substance abuse.

Psychological aspects of aging

The most outstanding psychological features of aging are the impairment in short-term memory and the lengthening of response time (emphasis added). Both of these factors contribute to lower scores of the elderly on standard tests of intelligence. When the aged are given all the time that they wish on tests that are not heavily dependent on school skills, their performance is only slightly poorer than that of young adults. Age decrements are negligible on tests that depend on vocabulary, general information, and well-practiced activities.

21

Experimental studies on learning show that, although the elderly learn more slowly than the young, they can acquire new material and can remember it as well as the young. Age differences in learning increase with the difficulty of the material to be learned. Aged people tend to become more cautious and rigid in their behaviour and to withdraw from social contacts. These behaviour patterns may be the result of social institutions and expectancies rather than an intrinsic phenomenon of aging. Many persons who age successfully make conscious efforts to maintain mental alertness by continued learning and by expansion of social contacts with individuals in a younger age group (emphasis added). There is growing evidence that it is probably possible to maintain brain fitness even as ones age increases (Alvaro & Goldberg, 2009). There is moderate clinical validation that targeted brain workout products such as Posit Sciences computer programs can help with auditory processing, working memory and visual processing . These brain workouts act as cognitive reserves so that impact of aging and even disease is minimized. It is also true that many claims about brain training, like those being made in diets and nutrition, are not based on evidence .

Aging is not about Age

Since aging begins as soon as adulthood is reached, perhaps a person in their mid-20s could be described as being aged. American soldiers in Vietnam had evidence of heart disease that was supposed to be more typical of a person aged 50 plus. Being aged or elderly is usually associated either with an evaluation that there is a significant level of decline and/or a person is ready to retire. Perhaps a person who is 90 years old , but who is active and in reasonably good health, should be considered to be less aged than a person who is decades younger in years but who is inactive and in bad health. It is important to assess the overall quality of life and the individuals resilience. We will all age, we will all die in the end, and the real question is how we live during that process. The reality is that most of us usually adapt and cope quite well. Resilent aging is becoming the norm for the rapidly growing older population. Winston Churchill once stated that Democracy is the worst form of government except for all those other forms that have been tried from time to time. The same could be said of old age. As Maurice Chevalier put it when reflecting on his own process of aging, " Old age isn't so bad when you consider the alternative.

Aging Europe, Aging World

In many ways the increase in average life expectancy is the result of our success in the promotion of public health in the late 1890s and the start of the 20th century along with biomedical advances in the last part of the 20th century . Overall in the past decade there has continued to been a steady increase in life expecancy in the EU (despite fears of the negative impact of an increase in the levels of obesity). In Finland a mans life expectancy was 73.8 in 1999, and by 2010 it was 76.9. In Estonia a mans life expectancy was 65.7 in 1999, and by 2010 it was 70.6. Russias average life expectancy had suffered a catastrophic crash following the collapse of the Soviet Union, plunging to 56 years 22

for men during the early 1990s. Life expectancy in Russia has now been increasing, and the total population grew for the first time in 15 years in 2009. The population of the 25-member European Union (EU) in the coming decades is set to become slightly smallerbut much olderposing significant risks to potential economic growth and putting substantial upward pressure on public spending. The overall aging of the EU population has been caused by a decrease in fertility, a decrease in mortality rate, and a higher life expectancy among Europeans. In the IMFs Finance and Development quarterly, Giuseppe Carone and Declan Costello asked Can Europe Afford to Grow Old? They state that the problem is that The population of the 25-member European Union (EU) in the coming decades is set to become slightly smallerbut much olderposing significant risks to potential economic growth and putting substantial upward pressure on public spending. The region's old-age dependency ratio (the number of people 65 and over relative to those between 15 and 64) is projected to double to 54 percent by 2050, meaning that the EU will move from having four persons of working age for every elderly citizen to only two. In addition, upward pressure on spending has fueled concerns that unsustainable public finances could jeopardize the smooth functioning of the single currency, the euro. Population aging in Europe is occurring because of the interaction of four demographic developments. First, fertility rates in all EU countries are, and are projected to remain, below the natural population replacement rate. Second, the recent decline in fertility rates followed the postwar baby boom, and the impending retirement of these cohorts will lead to a transitory increase (albeit lasting several decades) in the old-age dependency ratio. Third, life expectancy at birth, having increased by eight years since 1960, is projected to rise by a further six years for males and five years for females by 2050, with most gains resulting from longer life spans. Fourth, large net migration inflows are projected up to 2050: although cumulating to close to 40 million people, they will not offset low fertility and growing life expectancy. The latest World Population Prospects1 (2010) still shows a lower life expectancy in Eastern Europe and Russia when compared with the rest of the EU. Country Finland Hungary Estonia Latvia Lithuania Belarus (2009) Russia (2009) Life Expectancy at birth 2010 (male/ female) 76.9/ 83.5 70.7/ 78.6 70.6/80.8 68.6/78.4 68.0/ 78.9 64.7/76.5 61.8/74.2

http://www.stat.ee and World Bank (2009 data)

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Most EU countries are now facing the challenge of a combination of fewer persons of working age plus the demand for increased spending to meet the health and social care needs of the aging population. The key question: Where will the state find the fiscal resources? EU governments are starting to respond to this threat by increasing the retirement age so people will remain in the work force for a longer period of time, by changing when people can be able to receive a pension, as well as reducing the amount of pensions that people can expect to receive, and putting limits on public spending for health and social care. The state will be able to do much less, and people will be expected to take more care of themselves by investing in personal pension plans or suffer the consequences of a lack of preparation. Aging is an issue world-wide. In Japan, the prison systems are already dealing with a population of very old prisoners with physical and mental health needs. The Japanese experience may well be the future of prisons in the European Union.

Age, Disease and the Aging Prisoner

This essay is organized around a consideration of three interwined areas: Age, Disease and the Aging Prisoner Health and Well-Being Penal Policy and Practices

When the literature is talking about the physical and mental health needs of the aging prisoner, the discussion is really about disease. Most healthcare in prison is about the prevention and treatment of disease, not about health or health promotion. The UNDOC put it best the focus is on chronic health problems, unhealthy lifestyles, alcohol and substance abuse, as well as the stress and harmful effects of imprisonment itself. The Venn diagram in Figure 1 shows how the three areas interact around the themes of resillence, salutogenesis, and the healthy prison.

24

The Quality of Care and the Quality of Prison Life for the Aging Prisoner

Health & Well-being

Salutogenesis Resilience

Age, Disease and the Aging Prisoner

Penal Policy & Practices

Healthy Prison Figure 1: The Quality of Prison Life for the Aging Prisoner (Q)

The Older Prisoner (UNDOC)

In its Handbook on Prisoners with special needs, the UNODC tried to define the older prisoner. The UNODC wrote that In demographic analysis, age 60 is typically taken as the dividing line between older and younger cohorts of the population. On the other hand, many people, especially in the developed countries, think of 65 as the cut-off point because it is at this age that many people become eligible for full pension and social security benefits for older persons; but such a cut-off point does not apply everywhere else. Old age, therefore, cannot be defined exactly because the concept does not have the same meaning in all societies. Nor, with the steady expansion of life expectancy, does it correspond to a specifi c time span. Similarly the age at which a prisoner is defined as elderly or older is arbitrary and varies between countries and studies. For example, in the United States and Australia, prisoners above the age of 50 are generally considered as elderly. In the United Kingdom those above 60 or 65 are considered to fall within this category, according to different studies. In Canada older prisoners are defined as those between 50 to 64 years of age, elderly prisoners as those who are 65 or older, though the term older is used to cover both these categories. The low threshold is said to be justified by the likelihood that prisoners have an individual age 10 years in advance of their counterparts in the community, due to chronic health problems, unhealthy lifestyles, alcohol and substance abuse, as 25

well as the stress and harmful effects of imprisonment itself ( n.d.: 123. Emphasis added)

The Older Prisoner (United States)

The American experiment in mass incarceration over the past 30+ years has resulted in a lot more research on both the health needs of the older prisoner as well as the dynamics of the reentry process. This is probably the one clear benefit. Ronald H. Aday is a Gerontologist who has been writing about aging prisoners since the mid90s including his classic Aging Prisoners: Crisis in American Corrections (2003). His most recent work (with J.J.Krabill) looks at Women Aging in Prison: A Neglected Population in the Correctional System (2011). In 2004 he wrote about the problem of DEFINING THE OLDER OFFENDER The lack of consensus on what constitutes an elderlyoffender is one of the most bothersome aspects of comparing research outcomes (Fattah & Sacco,1989; Forsyth & Gramling, 1988). A review of the literature finds that previous researchers have used a variety of age cutoffs when collecting and analyzing data. For example, Forsyth and Gramling (1988) defined elder inmates as those 65 years of age or older; other researchers reported findings using age 60 (Aday, 2003; Douglass, 1991; Kratcoski, 1990); in yet other research projects, the ages of 50 and over were used (Aday & Nation, 1999; Falter, 1999; Colsher, Wallace, Loeffelholz, & Sales, 1992; Wahidin, 2004). Whereas governmental programs typically recognize age 65 as the demarcation into old age, correctional officials usually consider 50 and over as old (Aday, 1999). Correctional officials commonly agree that the typical inmate in his 50s has the physical appearance and ccompanying health problems of someone at least 10 years older. House (1990, p. 398) supports this view of early aging when he states that the lowest socioeconomic stratum manifests a prevalence of chronic conditions at ages 4555 that is not seen in the highest socioeconomic stratum until after age 75. Morton (1992) also stresses that age 50 is the ideal age to initiate preventive health care and the taking of other appropriate measures to reduce long-term medical costs for older inmates. Of course, although the declining health of many inmates substantiates the phrase old before their time, other inmates may remain in reasonably good health into their 60s and 70s. Although 50 and over are the ages used in this chapter, caution should be used when using chronological age exclusively to define the onset of old age. In 2001 he did a study for the Tennessee Department of Correction. Tennessee defines an elderly prisoner as 55 plus. Aday found the following special health care needs in the 318 prisoners over age 60 (2004).

Special Needs Requires ground-level housing 26

Percent 60.2

Requires lower bunk for easy access Has difficulty walking long distances Has difficulty standing up for 15 minutes Independent but exhibits slow mobility Requires special equipment for mobility Incapable of ascending/descending stairs Frail, brittle, unstable, or physically weak High risk of victimization by other inmates Possesses some vision problems Possesses some hearing problems Considered legally blind Judged to have unstable chronic condition Exhibits symptoms of confusion

68.9 48.6 37.5 55.0 19.7 51.4 43.3 44.2 39.3 72.9 12.9 33.0 10.5

Table 1. TDOC Inmates Over Age 60 With Special Health Care Needs
The key consideration is whether or not the prisoner needs asssitance in daily living (ADL). The majority of the Tennessee prisoners over age 60 did need assistance. Aday now uses 50+ age as his baseline for his research on aging prisoners. A National Survey of Older Prisoner Health, Mental Health and Programming (Sterns, Lax, Sed, Keohane and Sterns, 2008) found there a wide range of age was being used by the differnt States to define what is an older prisoner.

Age
50+ 55+ 60+ 65+ 70% Total

N
15 5 4 2 1 27

Percent
56% 18% 15% 7% 4% 100%

Table 2.Age States Use to Define Older Prisoners

The report did find evidence of dramatic physical health changes in older prisoners: In the noninstitutionalized U.S. population, one in 10 adults has a chronic disease leading to major limitations in activity and so does about one in four people older than 65. Prisoners are considerably less healthy. Of prisoners 50 years of age and older in the survey, nearly 45 percent were reported as having a chronic physical problem. More alarming is that 82 percent of prisoners 65 and older have a chronic physical problem..... it can be concluded that not only will the number of older prisoners increase by as much as tenfold, the medical resources to maintain current services will need to increase by double that

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Survey Count

State Average Average

Average Number With Chronic Physical Problem

Percent with Chronic Physical Problem

AverageNumber With Chronic Mental Health Problem

Percent With Chronic Mental Health Problem

Total Male Prisoners Total Female Prisoners Males 50+ Males 65+ Males 75+ Females 50+ Females 65+ Females 75+

1,168,906 121,549 117,337 11,055 1,621 7,541 439 46 2,414.6 226.3 36 154.7 7.6 0.9 1,102.7 185.4 30 64.9 5.6 1.2 46% 82% 83% 42% 74% 133% 397.4 29.5 5 46.4 5 0 16% 13% 14% 30% 66% 0%

Table 3. Older Prisoner Population, Chronic and Mental Health Problem Totals
*Note: State averages are determined by totaling the number of prisoners for those states responding and dividing by the number of states responding. Chronic physical problems were reported by 21 states; mental health problems were reported by 19 states. All others indicated the information was not available.

The most comprehensive report ever completed is probably The Health Status of Soon-ToBe-Released Inmates: A Report to Congress (2002) This report was prepared for the US Congress because a number of studies had found a higher prevalence of certain infectious diseases, chronic diseases, and mental illness among prison and jail inmates. The potential that ex-offenders may be contributing to the spread of infectious disease in the community had become an increasing concern. Therefore in 1997, the Congress instructed the U.S. Department of Justice to determine whether these concerns were well founded and, if so, to recommend solutions. The National Institute of Justice (NIJ), the research arm of the Department of Justice, entered into a cooperative agreement with the National Commission on Correctional Health Care (NCCHC) to study the problem. The research clearly documented that thousands of inmates are being released into the community every year with undiagnosed or untreated communicable disease, chronic disease, and mental illness. Another set of commissioned papers clearly shows that it not only would be cost effective to treat several of these diseases, but in several instances, it would even save money in the long run (2002, Vol1: iii). The report made several policy recommendations designed to improve disease prevention, screening, and treatment programs in prisons and jails. It was noted that 28

Prisons and jails offer a unique opportunity to establish better disease control in the community by providing improved health care and disease prevention to inmates before they are released. Implementing the recommendations in this carefully researched report will go a long way toward taking advantage of this opportunity and contribute significantly to improving the health of both inmates and the larger community (2002, Vol1: iii). Of course the cnverse is also true. If these men and women are not provided with the necessary health care and disease prevention, then on their release, they are a significant health risk to themselves and the larger community. This report provides the most detailed information available on the US prison and jail population. It is worrying data since these inmates in the survey were soon-to-be-released. The summary data is as follows: Communicable diseaseprevalence The approximate number of inmates with selected communicable diseases in 1997 was calculated by applying national prevalence estimates for each condition to the total number of inmates in U.S. prisons and jails on June 30, 1997. The approximate number of releasees with these conditions was obtained by applying the same prevalence percentages to the total unduplicated number of persons released from prisons and jails during 1996 (the most recent data available at the time the estimates were done). Because the estimates for releasees are based on total numbers of persons released during a full year, an especially high figure for jails, they are much higher than the estimates for inmates, which are based on the correctional population on a given day. Statistics on total number of individuals incarcerated during a full year are not available. The estimated prevalence of selected communicable diseases in prisons and jails is as follows: An estimated 34,800 to 46,000 inmates in 1997 were infected with HIV. An estimated 98,500 to 145,500 HIV-positive inmates were released from prisons and jails in 1996. Included among the HIV-positive inmates in 1997 were an estimated 8,900 inmates with AIDS. An estimated 38,500 inmates with AIDS were released from prisons and jails in 1996. There were an estimated 107,000 to 137,000 cases of STDs among inmates in 1997 and at least 465,000 STD cases among releasees: 36,000 inmates in 1997 and 155,000 releasees in 1996 had current or chronic hepatitis B infection; between 303,000 and 332,000 prison and jail inmates were infected with hepatitis C in 1997; and between 1.3 and 1.4 million inmates released from prison or jail in 1996 were infected with hepatitis C. About 12,000 people who had active TB disease during 1996 served time in a correctional facility during that year. More than 130,000 inmates tested positive for latent TB infection in 1997. An estimated 566,000 inmates with latent TB infection were released in 1996. Thus, a highly disproportionate number of inmates suffer from infectious disease compared with the rest of the Nations population. During 1996, about 3 percent

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of the U.S. population spent time in a prison or jail; however, between 12 and 35 percent of the total number of people with selected communicable diseases in the Nation passed through a correctional facility during that same year. Seventeen percent of the estimated 229,000 persons living with AIDS in the United States in 1996 passed through a correctional facility that year. The prevalence of AIDS among inmates is five times higher than among the general U.S. population. The estimated 98,000 to more than 145,000 prison and jail releasees with HIV infection in 1997 represented 13 to 19 percent of all HIV positive individuals in the United States. The estimated 155,000 releasees with current or chronic hepatitis B infection in 1996 indicate that between 12 and 15 percent of all individuals in the United States with chronic or current hepatitis B infection in 1996 spent time in a correctional facility that year. The estimated 1.31.4 million releasees infected with hepatitis C in 1996 suggest that an extremely high 2932 percent of the estimated 4.5 million people infected with hepatitis C in the United States12 served time in a correctional facility that year. The 17.018.6 percent prevalence range of hepatitis C among inmatesprobably an underestimateis 910 times higher than the estimated hepatitis C prevalence in the Nations population as a whole. Of all people in the Nation with active TB disease in 1996, an estimated 35 percent (12,200) served time in a correctional facility that year. The prevalence of active TB among inmates is between 4 and 17 times greater than among the total U.S. population. Chronic diseaseprevalence The prevalence of asthma among Federal, State, and local inmates in 1995 is estimated to be between 8 and 9 percent, for a total of more than 140,000 cases nationwide. Prevalence rates for asthma are higher among inmates than among the total U.S. population. The prevalence of diabetes in inmates is estimated to be about 5 percent, for a total of nearly 74,000. More than 18 percent of inmates are estimated to have hypertension, for a total of more than 283,000 inmates. Mental illnessprevalence The estimated prevalence of mental illness among jail inmates is as follows: An estimated 1 percent have schizophrenia or another psychotic disorder. About 815 percent have major depression. Between 1 and 3 percent have bipolar disorder. Between nearly 2 and less than 5 percent of jail inmates are estimated to have dysthymia (less severe but longer-term depression). Between 14 and 20 percent have some type of anxiety disorder. Another 4 to less than 9 percent suffer from post-traumatic stress disorder. The estimated prevalence of mental disorders among State prison inmates is as follows: 30

 An estimated 24 percent have schizophrenia or another psychotic disorder. Between 13 and less than 19 percent have major depression. Between 2 and less than 5 percent have bipolar disorder. Between 8 and less than 14 percent have dysthymia. Between 22 and 30 percent have an anxiety disorder. Between 6 and 12 percent have post-traumatic stress disorder. The research done for this report is probably the best picture of the health needs of a prison population. The data from other countries does show a similar picture. Not only do the poor tend to get prison more than the rich (Reiman & Leighton, 2010) but they also tend to be in bad health. These US findings are not unexpected,but the range and severity of illness is striking. Two questions: Do prisoners come to prison with more health needs (importation thesis), or does their health suffer as a result of being in prison (the deprivation thesis), or is it a combination of both (De Viggiani, 2007) ? What can be done by prison management to best promote prisoner health?

Satellite/Internet Broadcast
On March 11th, 2010 the National Institute of Corrections, U.S. Department of Justice, held a Satellite/Internet Broadcast training session on Effective Managing Aging and Geriatric Offenders. In the broadcast, the NIC used a definition based on the combination of two factors: Prisoners identifed as needing assistance with daily living (ADL) + Prisoners who are 50 years plus The NIC panel in the broadcast emphasized the importation thesis - that many prisoners entered the prison with significant,chronic health problems due to social determinants and lifestyle choices. The panel emphasized the need for a proper assessment and staff training. Though 50 years was the agreed upon age criteria, it was noted that even younger prisoners could have problems with daily living. It is clear that in the U.S. Federal prison system has the legal responsibility to provide adequate health and social care because of the requirements of the Americans with Disabilities Act (1990). There are also court decisions such as the decision (May 23rd,2011) by the U.S. Supreme Court that California must drastically reduce its prison population to relieve severe overcrowding that has exposed inmates to increased violence, disease and death. The high courts 5-4 decision called on California to cut the prison population to no more than 110,000 inmates. To do this, state ofcials have two years to either transfer some 33,000 inmates to other jails or release them. Adequate health and social care for prisoners is a fundamental human right. However the 31

the annual cost of incarcerating this population has risen dramatically to an average of $60,000 to $70,000 for each elderly inmate compared with about $27,000 for others in the general population (Correctional Health Care, 2004:11).

Older Offender (Canada)

Canada had a moderate rate of incarceration for the past three decades despite being next door to the United States with its politics of penal populism. Its present prison population is 38,132 with a rate of incarceration at 117 based on an estimated national population of 33.4 million ( as of 30.9.2008 from Statistics Canada figures). This will change radically with the new Bill C-10 the Safe Streets and Communities Act. It has passed a Commons vote and is now at the Senate. It should be in force in early March 2012. Because of the radical change in penal policy the comments on Canada are divided into two sections- Before Bill C10 and After Bill C10. In the past 40 years Canada has been a leader in programs for the older prisoners including an innovative program for lifers. With the change in penal policy and the projected signifcant increase in the number of prisoners in the provincial and federal systems, it is very uncertain that older prisoners will still receive the required health care. The need for prison health care has been well documented.

Before Bill C10

The age classification system developed in Managing Older Offenders:Where Do We Stand? (Uzoaba,1998) has proven to be very useful. Uzoaba divided the population into Older Offenders: Offenders who are 50 to 64 years of age. It covers such age categories as 50 to 54, 55 to 59, and 60 to 64. Elderly Offenders: Offenders who are 65 years of age and older. Older Offenders: The term older offenders is applied broadly to include both old offenders (50-64) and elderly offenders (65+). Generally, this term describes the various physical, social and biological changes that individuals undergo with the passage of time that render them less viable for activities requiring a great deal of physical strength. Geriatric Offenders: Offenders who are 70 years of age and older. In 2004 a study of The Health Care Needs Assessment of Federal Inmates Report was published in the March/April 2004 issue of the Canadian Journal of Public Health The report illustrates the differences between the health status of the general Canadian population and the inmate population in federal penitentiaries. From a health perspective, inmates represent a high risk, high needs population and their health status indicators are influenced by many social and economic factors (emphasis added).

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CSC must fulfill its legal obligation to provide quality health services and care for inmates that take into account specific health needs of this population. CSC provides health care services that are consistent to professionally accepted standards. MAIN FINDINGS Inmate Population

The report indicates that federal inmates have a poorer health status compared to the general Canadian population. There are many socio-economic factors that negatively influence health in the inmate population, such as lower levels of formal education, a history of unemployment, previous unstable accommodation and lack of social support networks.

The provision of health services to inmates is an extremely challenging undertaking. Inmates constitute a highly mobile, high needs population with substantial rates of unhealthy behaviours, infectious diseases, injuries, chronic diseases, mental disorders and premature deaths.

Male inmates account for 97% of all inmates with the majority of inmates being less than 40 years of age. The number of women inmates admitted to federal penitentiaries has been increasing. Aboriginal inmates are over-represented, comprising 17% of the federal prison population. The population of older inmates has also been steadily increasing, doubling in the past 10 years (emphasis added).

Physical Health 1. Information on health behaviours indicates that inmates are more than twice as likely to smoke and more likely to have alcohol or substance abuse disorders. 2. The rate of several chronic diseases is higher in the inmate population, including: Diabetes - 40% more likely to be treated for diabetes in males and three times more likely in females; Cardiovascular conditions - 68% more likely to be treated for cardiovascular conditions in males and over two times more likely in females; and Asthma - 43% more likely to be treated for asthma in males and almost three times more likely in females.

Infectious Diseases

Prison inmates experience higher rates of infectious diseases than the general population. They often possess a history of high-risk behaviours, such as injection drug use, trade sex and unprotected sex with high-risk partners, which place them at risk of infection prior to their incarceration.

Current data is based on self-selected testing of inmates. Neither the actual prevalence of infection nor the rates of transmission within prisons are known.

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Inmates have high rates of injection drug use prior to and during incarceration. They are: o more than twice as likely to have been infected with Hepatitis B; o more than twenty times more likely to have been infected with Hepatitis C; o more than ten times more likely to have been infected with HIV; and o much more likely to be infected with Tuberculosis. Mental Health

Promoting mental health in a correctional setting represents a challenge since a prison is a difficult environment. Overall, 38% of inmates reported stressful incidents, with maximum security inmates (44%) more likely to feel depressed than inmates in minimum security (25%). The intake assessment indicates that a substantial proportion of inmates have mental health disorders that co-exist with substance abuse needs. Inmates are more than twice as likely to have had any mental disorder. Males are three times more likely to have schizophrenia and females are 20 times more likely. Inmates are also four times more likely to have a mood disorder. Inmate suicide rate is almost four times higher than comparably aged Canadians.

The Health Care Needs Assessment of Federal Inmates Report (2004) made it very clear that the prison population needed health care at a level far greater than the general population. In response to the identified needs, CSC developed a Public Health Strategy for Offenders. It is an excellent public health strategy that could be easily adapted to other prison systems. Here are some selected parts of the strategy, the full strategy is available from Correctional Service Canada (CSC). THE PURPOSE OF A PUBLIC HEALTH STRATEGY FOR CORRECTIONS The penitentiary environment inherently presents the potential for the transmission of diseases, given the high number of persons in close confinement and the daily movement of staff, visitors and others from the community in and out of the penitentiary. The potential for transmission of air-borne, sexually transmitted and blood-borne pathogens is heightened by the generally poorer levels of health among inmates, many of whom also have a history of high-risk behaviours such as injection drug use, sex work, and unprotected sex with high-risk partners, and by the compromised health of those with chronic diseases. For example, in the area of infectious disease, at year-end 2008, 219 inmates or 1.69% of the total inmate population were known to be living with HIV and 3,903 or 30.2% of the total inmate population were known to be Hepatitis C Virus positive..... The plan was for the Public Health Strategy for CSC will be implemented across five years, beginning in fiscal year 2010-2011. Given the massive changes in CSC required by the new Bill C10 that plan is probably not going to be realistic.

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LEGISLATIVE CONTEXT Section 86(1) of the Corrections and Conditional Release Act (CCRA) requires that every inmate be provided with essential health care as well as reasonable access to non-essential mental health care that will contribute to successful rehabilitation and reintegration into the community. Section 86 (2) states that the provision of health care under subsection (1) shall conform to professionally accepted standards. In addition, section 70 requires that CSC take all reasonable steps to ensure that the penitentiary environment and the living and working conditions of inmates are safe and healthy (emphasis added).. Section 4 (h) of the CCRA sets out the principle that corrections policies, programs and practices [shall] respect gender, ethnic, cultural and linguistic differences and be responsive to the special needs of women and Aboriginal peoples, and the needs of other groups of offenders with special requirements. Accordingly, public health activities must be tailored to achieve the most appropriate, meaningful and most likely to succeed approaches for those groups. This is the legal framework within which CSC provides public health services to offenders. GUIDING PRINCIPLES The way forward in implementing the Strategy is illuminated by a set of Guiding Principles for the delivery of public health services in CSC.

Offender responsibility: Offenders must be involved both in taking responsibility for behaviours that affect their health and in being proactive in order to safeguard their health. Long-term public health perspective: The provision of public health services to offenders has the potential to lessen the burden of health care on society as a whole. Continuous Quality Improvement: CSC is committed to ongoing improvement in the quality and delivery of health services to offenders. Public health services must meet or exceed national accreditation standards. Partnerships: Public health activities will be strengthened through internal and external partnerships. Holistic health approaches: Holistic approaches to meeting the public health needs of offenders will be developed and implemented over time, as resources permit. Emergency response preparedness: Public Health staff will work collaboratively with all sectors to develop contingency plans and protocols for timely, effective and efficient responses to infectious disease outbreaks and other health challenges in CSC institutions. THE PUBLIC HEALTH STRATEGY FRAMEWORK Seven strategic areas along with corresponding goals provide the framework for the Strategy and its implementation through annual work plans. Strategic Area #1: Infectious disease prevention, control and management

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Management measures include community standard treatments for infectious diseases such as HIV, Hepatitis B/C, sexually transmitted infections, influenza A and Tuberculosis. CSC currently offers a range of prevention, control and management measures including: screening and testing at reception; immunizations; counselling and education on infectious diseases and how to prevent their acquisition and/or transmission; discreet access to harm reduction devices and information (bleach, condoms, dental dams, instructions on cleaning syringes and tattooing materials); discharge planning to ensure continuity of care upon return to the community; and planning for outbreaks of disease such as Influenza A. Strategic Area #2: Health promotion and health education The goal is to ensure dissemination of health promotion materials to all offenders; and to broaden their content to include healthy lifestyle behaviours, risk factors for chronic diseases, and health needs specific to certain groups. Public health program managers are leading on the development of material and information reflecting best practice in health promotion, and regional health promotion nurse positions have been established to oversee and facilitate institutional program delivery. The content of current health promotion materials is being expanded to include healthy lifestyle choices and prevention of chronic diseases such as Type 2 diabetes, heart disease and obesity. In addition, health promotion materials are being developed for specific groups or situations, e.g. offenders with mental health needs; private family visits that include children. Offenders generally rely on health care staff to direct their health-related behaviours and maintain their health. A key element of this strategic direction is the encouragement of offenders to take responsibility for adopting healthy behaviours and to support their efforts through health education programs. Strategic Area #3: Surveillance and knowledge sharing CSC currently has an effective infectious diseases web-based surveillance system which enables us to understand the prevalence of specific diseases in the offender population and leads to the identification of groups at risk as well as to emerging areas of risk such as local outbreaks. The goal is to inform the development of evidence-based measures in the prevention, control and management of infectious diseases and other risks to offender health, through enhanced, co-ordinated surveillance efforts and knowledge sharing In order to monitor public health issues within the overall offender population, the focus and scope of surveillance activities should be broad and data collection, analysis and evaluation inclusive of all offender groups including women, Aboriginal peoples, ageing offenders and offenders with chronic and other diseases. Information should also be gathered about co-morbidities within the offender population. An expanded surveillance system, which would require additional resources, would assist health professionals to understand the diverse health characteristics of the offender population and to target appropriate interventions.

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Strategic Area #4: Aboriginal and women offender health The goal is to ensure sustained emphasis on addressing the public health issues affecting Aboriginal and women offenders. Two separate strategies have been developed to address the needs of Aboriginal and women offenders, many of whom, having been disadvantaged according to the social determinants of health, are at increased risk of compromised health. Strategic Area #5: Healthy Environments The goal is to ensure that public health activities contribute to and support healthy environments. In the future, the Public Health Program could play an advisory role in areas related to infrastructure, water and air quality, cleanliness, physical activities and nutrition for inmates. Strategic Area #6: Public Health competencies The goal is to ensure that staff has the requisite public health skills and knowledge. The Public Health Agency of Canada has identified 36 core competencies (essential knowledge, skills and attitudes) necessary for the practice of public health which can be used as a baseline for CSC public health staff. Strategic Area #7: Visibility and accountability The three goals are (1) to secure collaboration from internal and external partners and stakeholders; (2) to broadly communicate the Strategy and the results of its implementation; and (3) to have in place updated performance measurement indicators and an evaluation framework It is essential that all branches of Health Services - clinical, mental health, public health, and policy, planning and quality improvement -- work in collaboration. Reinforcing the close relationship with our colleagues in clinical services and mental health services will help weave health promotion and health education into their activities. Quality improvement and accreditation partners will assist in ensuring that the quality of public health services meets or exceeds national accreditation standards. This collaboration must take place at all levels of CSC: national, regional, and institutional. Second, it is imperative that public health activities have strong horizontal linkages, where appropriate, to other sectors of CSC such as Policy, Security, Corporate Services, Human Resources, Correctional Operations and Programs, Aboriginal Initiatives and the Women's Sector. These linkages must be both strategic and practical, i.e. serve to improve the effectiveness of public health services in the institutions. The Public Health Branch at National Headquarters has existing external partnerships with federal departments such as the Public Health Agency of Canada (PHAC), Health Canada (particularly the First Nations and Inuit Health Branch), and Public Safety 37

Canada. A Memorandum of Agreement with PHAC for the provision of expert advice and technical support with respect to the prevention, control and management of infectious diseases has been in place since 2003. This MOU will be replaced in 2010 by an Interdepartmental Letter of Agreement that enables the expansion of collaborative activities of mutual interest, reflecting CSC's increasing public health competence and capacity. The evaluation of the Public Health Program is targeted for 2014. CONCLUSION It is intended that the Public Health Strategy for CSC will have a positive impact on the public health program. It is expected to contribute to more effective and efficient public health services and, in the long term, to the reduction of health costs for offenders, healthier communities, and better public safety. It is a collaborative approach to providing public health services to offenders from the date of admission to penitentiary through to their release to the community that will draw upon the expertise of a national network of internal and external partners and stakeholders. Annual Report of The Office of the Correctional Investigator 2010-2011 Howard Sapers , the Correctional Investigator, has been concerned for a long time about the mental health of offenders and also the steady increase in older prisoners . The 38th Annual report notes: In general, prison victimization research confirms four key findings: 1. Older offenders are victimized by younger inmates. 2. They feel vulnerable to attack by younger offenders. 3. They prefer to live with inmates in their own age bracket. 4. They may live in age-segregated protective-custody units. The Canadian situation is not that much different than the American review. Close to 20% of the federal incarcerated population is aged 50 and over, while 30% of offenders in the community are aged 50 and over. In the past decade, there has been more than a 50% increase in the number of older offenders under federal sentence. The average age of Canadas federal prison estate is 47 years. In fact, several penitentiaries are designated heritage buildings and five were built between 1835 and 1900. The penitentiaries in operation today were designed for young men and they are not typically very accessible to the mobility or sight-impaired. Physical ambulation and accessibility; independent care and living; palliative care; employment assistance; and vocational programming are some of the issues that older offenders face with respect to the physical conditions and limitations of prison confinement. Elderly offenders use a disproportionate share of prison health-care services. The physical and mental impacts of aging are hard on the human body. Older inmates have higher rates of both mild and serious health conditions. United States data suggests that older prisoners are, on average, afflicted with three chronic health conditions at any given time. The most commonly reported health 38

problems among older offenders include arthritis, back problems, cardiovascular diseases, endocrine disorders, respiratory diseases, sensory deficits (hearing and vision impairments) and substance abuse problems. Some older offenders find it difficult to maintain normal everyday routines (eating, dressing, hygiene) as a result of ongoing physical impairment. Mental health concerns impact an older offenders ability to live normally in a prison setting, including their participation in daily institutional routines as well as their ability to live independently and with dignity eating, dressing and maintaining a regular regimen of personal self-care and hygiene. The most common mental health disorders among elderly offenders are depression, Alzheimers disease, anxiety and late life schizophrenia and dementia. Offenders that may be suffering from age-related degenerative diseases characterized by memory loss or distorted thinking, such as dementia and/or Alzheimers, often exhibit behaviours that are considered maladaptive in the correctional setting. symptoms may include disruptive or difficult behaviour, anxiety, paranoia, major depression, self-injury and/or the refusal/inability to follow prison rules and routines

In a conference in November 2011, Sapers told the press that Some aging offenders find it difficult to maintain everyday essential routines such as eating, bathing dressing and meeting their hygiene requirements. Unable to take part in prison work or programs, some older offenders report feeling isolated, marginalized, abandoned. Sapers also has are significant concerns associated with mixing vulnerable older inmates with younger, more aggressive convicts. He told reporters that aging offenders in an Ontario prison told him they live in fear of these younger inmates. Intimidation and muscling are pervasive concerns amongst older offenders. I heard instances of physically challenged offenders being bullied to the top bunk by the cell mates, while others reported having to give up their prescription medications or meals to younger offenders, he said, adding that these instances are rarely reported. In summary the report states that There is little doubt that the combined effects of an inadequate prison infrastructure and increased impairment of older offenders will be an area of growing concern in federal corrections. The challenge is to make existing policies and practices more effective and to identify and assess new approaches to managing a population that is expected to grow in federal prisons. There appears little point in providing vocational training and employability skills that may have no relevance to an older offender who is already past retirement age, Sapers said. The Correctional Services must act quickly to address needs of this growing segment of the population. Our prisons were never meant to be hospitals, nursing homes or geriatric facilities, he said. Correctional Service of Canada made a response to the Correctional Investigator s recommendations in the Annual Report including the section on PHYSICAL HEALTH CARE - SPECIAL FOCUS ON ELDERLY OFFENDERS

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Recommendation 6: I recommend that the Service develop a more appropriate range of programming and activities tailored to the older offender, including physical fitness and exercise regimes, as well as other interventions that are responsive to the unique mobility, learning, assistive and independent living needs of the elderly inmate. CSC Response: Upon admission, all older offenders and those with self care needs undergo a functional assessment, which measures their ability to perform daily living activities. Results of this assessment influence further health related consultations as well as special needs for accommodation and services. Throughout the inmate's sentence he/she is assessed in terms of their ability to function in their environment. In addition to the above, CSC is currently conducting research on male and female older offenders that will help inform future strategies and initiatives. Recommendation 7: I recommend where necessary, CSC hire more staff with training and experience in palliative care and gerontology. Sensitivity and awareness training regarding issues affecting older offenders should be added to the training and refresher curriculums of both new and experienced staff. CSC Response: In 2009, CSC updated the national Hospice Palliative Care (HPC) Guidelines to provide direction and tools necessary for a consistent approach to the provision of care to terminally ill inmates within CSC. Consistent with professional practice standards, CSC uses a patient- and family-centred HPC approach that seeks to address the physical, psychological, social, and spiritual needs and expectations of the offender in collaboration with their close relations. The updated guidelines were followed by the development of a pilot Palliative Care Training Module in November 2010 and the launch of the training sessions in March 2011. Similarly, in November 2010, CSC launched the "Older Offender Training Module" for CSC nurses with the opportunity for other members of the interdisciplinary team to participate. The two day training provides education in a number of areas such as normal aging, diseases associated with aging, performing a comprehensive geriatric assessment, and behaviour issues (bullying, depression, suicide, and delirium). Recommendation 8: I recommend where new construction is planned, age-related physical and mental impairments should be part of the infrastructure design, and include plans and space for sufficient number of accessible living arrangements.

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CSC Response: The new units that are being constructed include cells and rooms that are accessible. In conjunction with the new units being built, we are also continuously modifying some of our facilities as the needs of the inmate population change. As part of the development of its Long Term Accommodation Strategy, CSC will continue to take every opportunity to ensure the needs of the inmate population are considered. Recommendation 9: I recommend that the Service prepare a national older offender strategy for 201112 that includes a geriatric release component as well as enhanced post-release supports. CSC Response: CSC recognizes that a comprehensive discharge plan that addresses the physical, mental, emotional, social and spiritual needs of individuals, best ensures postrelease access to health care and other community services to facilitate continuity of care after a period of incarceration. CSC will continue to implement the framework that is already in place to ensure appropriate release planning of offenders, including geriatric offenders. As part of the planning process, when indicated, a functional assessment is completed by health care services and identified areas of concern are taken into consideration in the development of an individualized release plan. For example, a functional assessment might suggest the need for a certain type of accommodation. As well as part of the pre-release decision process, a community strategy is developed that outlines the way in which the various dynamic factors will continue to be addressed in the community, the way in which the offender will be monitored and determines the level of intervention to be applied upon the offender's release to the community. The identification of the offenders' functional needs and required resources are included in the plan. Continuity of care is directed by health services and institutional/community reintegration policies, discharge planning guidelines for both physical and mental health needs, and affiliated official forms to be completed for all types of transfers and a release to the community. CSC Regional Discharge Planners continue to develop a network of community resources through education, networking, and partnerships Thus CSC agreed with the assessment of the Correctional Investigator and is planning appropriate action. The CSC did note The introduction of new legislation such as the abolition of Accelerated Parole Review, as well as legislation such as the Truth in Sentencing Act and the Tackling Violent Crime Act is expected to result in increased numbers of federal offenders with a wider 41

range of needs, underscoring the requirement for both short and long-term capital planning and for adjustments to correctional programming and population management strategies. The demands of Bill C10 will impact on CSCs ability to response to the physical and mental needs of the older prisoners especially since as the Correctional Investigator had noted: In general, older prisoners pose limited control problems for correctional authorities indeed, most research suggests that longer serving older offenders are easier to manage because they are less likely to violate rules or require disciplinary measures. Only time will tell if the needs of older prisoners can remain a priority for CSC.

After Bill-C10: Politics not Evidence-based Policy

Radical change. The American experiment in mass imprisonment was not planned . The Canadian experiment in mass incarceration is planned. Bill C-10 includes almost every penal policy and practice developed by the Americans in their 30 year war on drugs and hard-on-crime approach. Bill C-10 combined nine previous pieces of legislation and was passed in the House of Commons in December 2011. The Bill is now at the Senate level and will probably become law in spring 2012. The present Canadian government won the last Federal election using a strategy of penal populism. The Conservative government secured a majority so it can now ram laws through Parliament. The Conservatives are committed to a much more punitive policy and a massive increase in prison capacity at the Provincial and Federal level. In Canadas provinces and territories, 23 new prisons and 16 additions to existing facilities are at various stages of planning and completion. At the Federal level a total of 34 new units to be built on the grounds of existing penitentiaries have been announced to date. These radical changes are being made at the same time that Canada's crime rate is the lowest it has been in nearly 40 years, according to Statistics Canada, as the volume of crime dropped five per cent in 2010 from the year before. "The national crime rate has been falling steadily for the past 20 years and is now at its lowest level since 1973," Statistics Canada reported. The Conservative strategy is a radical solution to a non- problem. Cost is unknown The government is cutting back on funding in several other important areas but still planning to spend $478.8 million over five years to begin the implementation of its new vision. CSC's annual budget has already been increased 86.7 percent from the $1.597 billion in 2005-2006. By 2012-2013, expenditures in this area are projected to rise to $3.178 billion before it modestly declines to $3.147 billion in 2013-2014. According to the limited information

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provided to Canadians thus far, these projects will add a total of 2,552 new prisoner beds at a construction cost of $601 million, or an average of $235,305.64 per prisoner bed. The Conservative government has so far refused to provide a full costing of Bill C-10. Since the Bill combines nine previous pieces of legislation, there are several different budget lines. In December 2011 the Quebec Institute for Socio-economic Research and Information (IRIS) released its study which states that it will cost Canadians some $19 billion to build the new prisons. The report also notes the provinces are expected to shoulder the majority of the extra costs associated with the legislation, which it estimates at $14 billion. The Provinces of Quebec and Ontario have already said they won't pay for the added cost of locking up more people, which requires building more jails. IRIS stated that, using ``the most conservative estimates,'' it pegs the costs of the plan to end the practice of judges handing offenders time credits - on a two-for-one basis, to compensate for time spent in pre-sentence custody - at $16.5 billion for the country as a whole, with the provinces footing $12.6 billion. The costs associated with providing for mandatory prison sentences for drug-related crimes and child sex offenders are estimated by the researchers to be another $2.3 billion. On top of that, the study argues annual maintenance and operation costs for prisons will reach $1.6 billion for the federal government and $2.2 billion for the provinces. The IRIS report draws on academic studies, Statistics Canada numbers, Public Security and Correctional Service Canada budget estimates and a report by the parliamentary budget officer that said it will cost $1 billion a year for five years to implement C-25, which came into effect last year. The federal government has disputed that figure and has pegged the cost at closer to $2 billion total. The Government has pegged the cost of C-10 for the federal government at $78.6 million over five years. The Quebec study puts a $924-million price tag to that bill for the federal government. The Provincial costs will be additional expense. In October, Parliamentary Budget Officer Kevin Page said his office would look at C-10 at the request of the NDP and the Liberals, to provide an ``independent costing'' of the legislation. The Quebec study also criticizes the federal government for favouring incarceration over rehabilitation and reintegration. ``The changes introduced with the bills C-25 and C-10 are likely to have no effect on Canada's criminality rate,'' wrote study authors Jean-Mikael Michaud and Guillaume Hebert. ``And on top of being inefficient, the measures put forward by the government carry a very heavy price for taxpayers,'' they added. Strong opposition The Canadian government is moving ahead on its plans despite strong opposition from most Canadian criminologists and the different NGOs working in the area of criminal justice, along

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with several warnings from American experts to not make the same mistakes as the Americans. The Canadian governments tactics are a classic example of penal populism. A critical article in Macleans ( November 9, 2009) quoted a speech by Ian Brodie who served as Prime Minister Stephen Harpers chief of staff from 2006 to 2008. In an unusually candid talk on Conservative strategy Brodie said that Every time we proposed amendments to the Criminal Code, sociologists, criminologists, defence lawyers and Liberals attacked us for proposing measures that the evidence apparently showed did not work, Brodie said. That was a good thing for us politically, in that sociologists, criminologists and defence lawyers were and are all held in lower repute than Conservative politicians by the voting public. Politically it helped us tremendously to be attacked by this coalition of university types. Thus the federal government of Canada is set to institute the broadest, most regressive, costly, and probably one of the most ineffective criminal justice policies in Canadian history. One Canadian colleague stated that Forty years of progress are being destroyed by one Bill. It is an excellent example of government through (the fear of) crime, rather then evidence based policy. It is very different than the Finnish transformation of its criminal justice system in the 1970s. That was made possible because of a shared political consensus, support from the police and other justice stakeholders, but most importantly, because of a trust in, and the utilization of, expert opinion. In Canada the opinion of most criminologists and the different NGOS has just been ignored, devalued, and combined with personal attacks on critics. It has been a very ugly process. The government of Canada may claim that it is concerned about crime victims, but the National Associations Active in Criminal Justice (NAACJ) and The Church Council on Justice and Correctuons (CCJC) argue that the limited funds allocated for crime prevention and victim services will be reduced even further because of these changes. The best example of the growing professional resistance to the new government policy is a remarkable letter in the Globe & Mail (Jan. 05, 2012). The letter was from John Edwards , former commissioner of Correctional Service Canada; Willie Gibbs, former chair of the Parole Board of Canada; and Ed McIsaac, former executive director of the Office of the Correctional Investigator. These three men state that Collectively, we have nearly 10 decades of experience in the area of corrections and conditional release. There are many issues we have disagreed over, but we are united in our concerns with the direction of the Harper governments tough on crime agenda. These critics are not Brodies coalition of university types. They were extremely high-level civil servants. They would not have decided upon this letter without serious discusion with colleagues within government, and then only with significant support for their actions. They make the following points: At both the federal and provincial levels, Canadian jails are overcrowded....The overcrowding limits access to already scarce rehabilitative programming and increases the incidence of institutional violence. The fastest-growing portions of the inmate 44

population continue to be those most marginalized within our society: the mentally ill, women and aboriginals. Decades of reports have detailed our correctional systems failure to reasonably address the needs of these offenders and limit their numbers. Bill C-10, the Safe Streets and Communities Act, which is before the Senate, will significantly increase the prison population. The Canadian Bar Association, summarizing its testimony before the House of Commons standing committee on justice and human rights, stated that the bill will require new prisons; mandate incarceration for minor, non-violent offences; justify poor treatment of inmates and make their reintegration into society more difficult. These results are inconsistent with our collective concepts of fairness, compassion and equality. In addition, no evidence is provided to support the bills objectives. ............. Our collective experience and decades of research tell us that increased rates of incarceration neither decrease crime nor act as a deterrent to it. Safer communities and effective crime prevention are achieved through the development of integrated systems with both the flexibility and resources required to respond to individuals in a timely fashion. As a society, we must be prepared to actively support and finance early intervention strategies for youth; a judicial process with options to ensure that incarceration is a last resort; a community mental-health system that keeps the ill out of jail; a prison service that addresses individual offenders problems rather than acting as a human warehouse; and conditional-release programming that supports timely, safe community reintegration. Our focus and our resources should be directed toward keeping people out of jail, not in it. The financial cost of implementing effective, integrated systems pales in comparison to the billions it costs to build and operate new prisons. Criminal justice legislation that increases prison populations while draining resources from community programs in mental health, education, child poverty and social services makes absolutely no sense. After this damning criticism, they then call on the Senate to stop this ill-considered Bill C-10. The fiscal and human costs of the path we are on, in pursuit of safer communities, are far too high and will not be easily reversed. Sober second thought is desperately needed. We call on the Senate to ensure that our justice policies promote a fair and effective corrections and conditional-release system that will actually make Canada safer. Pyrrhic victory? Bill C-10 will probably pass the Senate and become law. Prime Minister Stephen Harper will maintain control of his party, and the oppostion parties will not act together. The opposition from criminologists, the Canadian Bar Association, and NGOs such as the National Associations Active in Criminal Justice (NAACJ) and The Church Council on Justice and Corrections (CCJC) as well as resistance from some civil servants will continue. It is also probable that the worst case scenarios similar to what happened in the Unites States will also happen in Canada. The experiment in mass incarceration will be as great a failure as it was in the United States. The collatoral damage will be as great, as well as the need for justice reinvestment. 45

Canadas reputation as a world-leader in evidence-based, humane and effective offender rehabilitation will be destroyed. There will be no significant impact on crime. The fiscal costs will probably be as great as feared by the Quebec Institute for Socio-economic Research and Information (IRIS) and the Parliamentary Budget Officer. The investment in human resources and prisons will make it very difficult to change the system. For the Conservatives, it could easily be a Pyrrhic victory.

The Older Offender (Australia)

Who are the older prisoners? A research team prepared Growing old in prison? A review of national and international research on Ageing Offenders (Baidawi, Turner, Trotter, Browning, Collier, OConnor and Sheehan, 2010) for the Department of Justice, State of Victoria, Australia .The report looked critically at the issue of who are the older offenders: Despite the variability of definition, most writers and researchers agree that older offenders are at least 50 years of age ..This tends to vary considerably from the definitions of old age used to refer to people in society generally, where the cut-off age is typically related to the age of retirement from the work-force and eligibility for financial support. In most Western countries, including Australia, old age is considered to start around the age of 60 - 65 years ... Many writers suggest that 50 years is used as an appropriate gauge for old age in prison because it is based on research findings that the ageing process is accelerated by approximately 10 years in prison, as the majority of people who end up in prison are already in poor health, due to leading lives involving malnutrition, lack of medical care and substance misuse, and because prison environments escalate age-related illnesses and other .. Likewise, most Australian researchers appear to prefer to limit the definition of older offenders to those aged 50 years and over, in order to accommodate research, which has identified an apparent 10-year differential between the overall health of prisoners and that of the general population (Grant 1999). In a later report, the Victoria team also prepared Older prisoners - A challenge for Australian corrections (2011) as part of the Australian Institute of Criminologys Trends & Issues in crime and criminal justice (No. 426). The team is now working with the other Australian States. The rationale for using a functional definition of older prisoners as being those who are 50 years of age and over (Kerbs & Jolley 2007; Stojkovic 2007). The utilisation of 50 years and older as an appropriate gauge for old age in prison is based on research findings that identified an apparent 10-year differential between the overall health of prisoners and that of the general population (Grant 1999: 1). The acceleration of the ageing process among prisoners is generally attributed to a

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combination of the lifestyle of offenders prior to entering prison (including poor nutrition, substance misuse and a lack of medical care) and the understanding that prison environments may escalate age-related illnesses and conditions (Carlisle 2006; HMIP 2004; Stojkovic 2007; UNODC 2009). The Trends review notes that A further advantage of adopting this definition of ageing in the Australian context is that it allows for the inclusion of data concerning both female and Indigenous prisoners two groups of offenders who are generally younger than the mainstream prison population (ABS 2010b). This is the same rationale for using age 50 for women in the UK research since if 65 is used then there were no data for inclusion. Increase in Number of Older Inmates Age (yrs) 5054 5559 6064 65+ Total prison population Australian prisoners in 2000 848 459 281 218 21,714 Australian prisoners in 2010 1,445 825 529 527 29,696 Increase, 20002010 (%) 70.4 % 79.7 % 81.8% 141.7% 36.8%

Table 4 Prisoners in Australia by age and year Prisoners aged 50 years and over in 2001 Prisoners aged 50 years and over in 2010 64 218

Table 5 Female Prisoners aged 50 years and over There has been a dramatic increase in the number of older inmates in the Australian system. The Trends report noted on the global data showing that there was Considerable evidence to indicate that older prisoners are increasing in number across the United States, United Kingdom and New Zealand. In England and Wales, there was a 149 percent increase in the number of sentenced prisoners aged 60 years and over between 1996 and 2006. It appears to be the fastest growing age group among prisoners in the United Kingdom. In the United States, between 2000 and 2009, the number of prisoners aged 55 years and older increased from 42,300 to 75,300 and the proportion of all prisoners aged 55 years and over rose from 3.4 percent to 5.2 percent & West 2010). It is predicted that by 2030, one-third of all prisoners in the United States will be over the age of 55 years. 47

New Zealand experienced a 94 percent increase in the number of prisoners aged 50 years and over from 200009.

The incease in the number of prisoner aged 50 + cannot be explained just in terms of aging of the general population. The numbers of Australians aged 50 years and over increased by 31 percent over the period 200010, which is a lot smaller than the 84 percent increase in the older prisoner population over the same period. It has been suggested that older prisoners are now being sentenced to offences with long sentence periods (in particular, sex offences, homicide and drug-related offences). There may be both more older offenders and also a change in sentencing patterns. What is clear is the increase in the number of older prisoners is greater than the increase in the population of older individuals. Global research has identified four main groups of older prisoners based on offending history: first-time prisoners, incarcerated at an older age; ageing recidivist offenders who enter and exit prison throughout their lifetime and return to prison at an older age; prisoners serving a long sentence who grow old while incarcerated; and prisoners sentenced to shorter periods of incarceration late in life.

The prison experience will be very different for these four groups.

Health concerns
As with older people in general, the most immediate and apparent issues facing older prisoners are those related to ageing and associated declines in mental and physical health. Furthermore, considering the accelerated biological ageing process, a prisoner who is chronologically 50 years of age is generally expected to display the onset of age-related health concerns of a 60 year old in the general population. Such concerns include coping with chronic disease and/or terminal illness, fear of dying, pain management, reduced levels of mobility, disability, loss of independence and cognitive impairments The rising numbers of older prisoners has specific implications for prison health services (eg in screening, preventative healthcare and chronic disease management) as well as custodial management of older prisoners (in terms of accommodation needs and program delivery, for instance).

Mental health and adjustment

Research suggests that although older prisoners are generally less disruptive than younger prisoners, a considerable number experience depression and other psychological problems, suggestive of institutional adjustment difficulties. Historically, it seems that little attention has been paid to issues relating to older prisoners, partly due to the perception of prison staff that older prisoners are compliant and therefore, not (overtly) a 48

This is reflected in national and international research concerning mental health among older prisoners, of which there is strikingly little International research indicates that up to 40 or 50 percent of ageing prisoners experience mental health issues, including a high prevalence of depression. Further, research has also identified that prevalence rates of mental illness among prisoners are likely to be higher than estimates which rely on prison records due to a number of reasons. First, mental illness may develop during the course of incarceration after initial screenings have been completed and second, prisoners may also not disclose symptoms of mental illness due to fear of consequences, such as eligibility for parole and fear of judgment. This may have implications for older prisoners upon release, particularly those with unidentified mental health needs, as they may be unable to access various health and social services, leaving them vulnerable and at risk of reoffendng. Since both the Growing old in prison? A review of national and international research on Ageing Offenders (2010) and also their later report Older prisoners - A challenge for Australian corrections (2011) integrate the national and international research at least the US, UK and Australian findings - most of their analysis has already been covered in the earlier sections and need not be repeated here. The additional Australian data on the rapid increase in their number of aging prisoners is important. Though there is no firm consensus on the age when a prisoner should be considered older, it is clear that much experts in the US, Canada, Australia and New Zealand do place the cut- off around 50 +/- 5 years. In the Greying Prisoner research project, 50 and older was also selected by the research team. It is important that there is an international agreement that the prison population tends to have the health needs of the non-population that is about 10 years older- whether this is because of life style (importation), or the prison environment (deprivation), or both is a subject for further debate and research. . The Australian researchers were quite good in their use of international criminological research, especially from the United Kingdom and the United States of America. The Australian team do not reference the report The Health Status of Soon-To-Be-Released Inmates (2002) that was prepared for the US Congress by the National Institute of Justice (NIJ), the research arm of the Department of Justice, working with the National Commission on Correctional Health Care (NCCHC). This report does provide detailed and comprehensive information about the health needs of soon- to- be - released prisoners. It has also been sadly neglected by the criminal justice research community. Of more interest is the omission of the work being done by the Australian Institute of Health and Welfare.

The health of Australias prisoners 2010

The Australian Institute of Health and Welfare has started to collect information on the health of Australias prisoners. The first report was published in 2009. The health of Australias prisoners 2010 is the second report using the National Prisoner Health Indicators, which were developed to help monitor the health of prisoners, and to inform and evaluate the planning, 49

delivery and quality of prisoner health services. It is a large report complete with excellent graphics. Some of its key findings include:

Overall prisoner health

Mental health issues Prisoners in Australia have high rates of mental health related issues. In 2010, 31% of prison entrants reported having ever been told that they had a mental health illness and 16% of prison entrants reported that they were currently taking mental health related medication. On entry to prison, almost one-fifth of prison entrants were referred to the prison mental health services for observation and further assessment following the reception assessment. Almost 1 in 10 prisoners in custody visited the clinic for a psychological or mental health issue, and 1 in 5 prisoners in custody was taking mental health related medication. When looking at the type of medication, 18% of all repeat medication was for depression/mood stabilisers, 9% for antipsychotics, 2% for antianxiety medication and 1% for sleep disturbance. Risky health behaviours Prison entrants in Australia reported previously engaging in various risky health behaviours, such as smoking tobacco, drinking alcohol at extreme levels and using illicit drugs. Four in five prison entrants reported being a current smoker, and three in four reported being a daily smoker. More than half of prison entrants reported drinking alcohol at levels that placed them at risk of alcohol-related harm, while less than twenty per cent reported that they did not drink. Further, two-thirds of prison entrants reported illicit drug use in the previous 12 months. These rates are all substantially higher than in the general community. Aboriginal and Torres Strait Islander prisoners Aboriginal and Torres Strait Islander prison entrants were significantly over-represented in the entrants sample, with 43% being Indigenous, compared with 2.5% of the general population. Indigenous prison entrants reported poorer health behaviours than nonIndigenous prison entrants, and were more likely to be current smokers (89% compared with 79%) and to have consumed alcohol at levels considered to place them at risk of alcohol-related harm (73% compared with 48%) in the previous 12 months. However, Indigenous prison entrants reported lower level of mental health related issues (23% compared with 38%), use of mental health medication upon entry to prison (12% compared with 19%), and chronic conditions.

Prisoners Aged 45 and older

When looking at the data to compare issues of gender, age, and indigenous or non indigenous, the older prisoners had some clear differences from the younger prisoners positive and negative (all emphasis added). Head injuries causing loss of consciousness

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In 2010, it was slightly more common for female (41%) than male (38%) entrants to report having ever had a head injury leading to a loss of consciousness (Table 3.9).There was no particular pattern of head injury by age. The proportion of entrants with a head injury was highest for those aged 3544 years (45%) and lowest for those aged 45 years or older (30%). A higher proportion of nonIndigenous (43%) than Indigenous (33%) entrants reported a blow to the head resulting in a loss of consciousness. Asthma A higher proportion of female prison entrants (25%) than males (20%) reported ever having been told they had asthma, which is consistent with reporting in the general population. Younger prison entrants were most likely to report ever having been told they had asthma26% of entrants aged 1824 years, compared with 16% of entrants aged 35 years and over. This observed difference may be partly due to changes in diagnostic practice for asthma over time. In the 2010 Census, Indigenous entrants were less than half as likely as non-Indigenous entrants to report having a history of asthma (13% and 27%, respectively). Arthritis Of prison entrants, 57 (9%) reported ever having been told they have arthritis . The majority of these (51 or 8% of all entrants) reported that they still had the condition A slightly higher proportion of female (11%) than male (9%) entrants reported a history of arthritis . As may be expected for a condition affecting joints, much higher proportions of entrants reporting having arthritis were found in the older age groups. One-quarter of entrants aged 45 years and over reported ever having been told they have arthritis, compared with less than 4% of those aged less than 35 years. Non-Indigenous entrants (13%) were more than twice as likely as Indigenous entrants (5%) to report having ever been told they have arthritis. Cardiovascular Disease Of the 610 prison entrants in the Census period, 46 (8%) reported ever having been told they have cardiovascular disease, and most reported still having the condition (33 or 5% of all entrants) Proportionally, twice as many male (8%) as female (4%) entrants reported ever having been told they had cardiovascular disease. Cardiovascular disease was also much more common among older than younger prison entrants, with 22% of entrants aged 45 years and over having been told they had cardiovascular disease, compared with less than 5% of those aged less than 35 years. Indigenous entrants were slightly more likely than non-Indigenous entrants to report a history of cardiovascular disease (9% and 7%, respectively). Diabetes

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Of the 610 prison entrants in the Census period, 30 reported ever having been told they had diabetes, and 27 (4% of all entrants) still had the condition at the time of reception assessment . There was little difference between male and female entrants in reporting a history of diabetes. Consistent with the increasing prevalence of diabetes with age, diabetes was reported by 9% of entrants aged 45 years and over, compared with 1% of those aged 1824 years. Diabetes was also more common among Indigenous than nonIndigenous entrants. Risky Alcohol consumption A higher proportion of male (59%) than female (54%) prison entrants reported consuming alcohol at hazardous levels. The risk of alcohol-related harm generally decreased with age of entrants. About twothirds (66%) of entrants aged under 35 years were at risk, compared with just under half (48%) of their older counterparts. Consumption of alcohol at levels considered to place a person at risk of alcohol-related harm was found in almost three-quarters (73%) of Indigenous entrants, compared with just under half (48%) of non-Indigenous entrants. High alcohol risk was more common in Indigenous male and female entrants. A total of 73% of Indigenous males and 74% of Indigenous females consumed alcohol at levels considered to place a person at risk of alcohol-related harm, compared with 50% of non-Indigenous males and 35% of non-Indigenous females. Illicit Drug Use As in the general population, recent illicit drug use was found most often in the younger age groups of prison entrants.. The highest proportion of illicit drug use in the previous 12 months was by prison entrants aged 2534 years (74%), and the lowest by entrants aged 45 years and over (38%).The proportion of Indigenous and non-Indigenous prison entrants who had used illicit drugs in the previous 12 months was similar (68% and 65%, respectively)..... The most commonly used drugs were similar for male and female prison entrants . Cannabis/marijuana was the most common drug, used by about half of both male (52%) and female (49%) prison entrants, followed by meth/amphetamines, used by 28% and 40% respectively. Analgesics/pain killers were used by proportionally 3 times as many female (36%) as male (13%) entrants. Of the most commonly used illicit drugs, the types used by prison entrants also differed by the age of the entrant. In each age group, cannabis/marijuana was the most commonly used drug, followed by meth/amphetamines. Cannabis/marijuana had been used by 60% of entrants aged 1824 years, but only by 28% of entrants aged 45 years or older. Meth/amphetamines were used by 34% of entrants aged 3544 years, 33% of entrants aged 2534 years and 32% of entrants aged 1824 years. For entrants aged 1824 years analgesics/ pain killers was the next most commonly used drug (17%) followed by ecstasy (16%). The age group with the highest proportion reporting illicit use of tranquilisers/sleeping pills was those aged 2534 years (15%). 52

Use of Health Services All female entrants who had been in prison in the previous 12 months had consulted a health professional while there, compared with 73% of male entrants. A difference was seen for consultations with mental health professionals. In the community, similar proportions of males and females saw a psychologist or psychiatrist during the previous 12 months. However, in prison, about twice as many females as males saw a psychologist (21% of females, 9% of males) or a psychiatrist (21% of females, 11% of males). With the exception of nurses, males visited all other medical professionals either less or equally in prison than in the community. Females also visited a doctor/GP, alcohol or drug worker, social worker/welfare offcer, and/or Aboriginal health worker more in the community than in prison. There were few patterns by age other than the proportion of entrants having consulted with a doctor/GP in the community, which increased steadily from just over half (52%) of entrants aged 1824 years to more than three-quarters (76%) of entrants aged 45 years and over. Visits in prison to each of these types of professionals had no apparent relationship to the age of the prison entrant. Most of the findings about the prisoners aged 45 years and over were not surprising. It was interesting that the break was at age 45. It is clear that there is detailed data on the prisoners which could be used for further analysis. The 2010 report seemed to focus more on geographic location, gender and Indigenous and non-Indigenous status as well as what services were being provided.

Comparing Prisoners to Non-Prisoners

Smoking Within the non-Indigenous community, there were very large differences between the proportion of prison entrants who reported being smokers, and the proportion in the general non-Indigenous community who did so. Less than one-quarter of the general non-Indigenous community aged 1844 years were current smokers, compared with 80 84% of prison entrants in the same age group. In the general non-Indigenous community, younger people were much less likely to be smokers, with almost threequarters (72%) of those aged 1824 years reporting never having smoked. The proportion reporting being ex-smokers increased from less than 1 in 10 (8%) among the youngest age group, to almost 1 in 3 (29%) aged among those aged 3544 years in the general non-Indigenous community. Age patterns were less apparent among nonIndigenous prison entrants, suggesting that the trend away from smoking in the general community is not reflected among prison entrants. Among the non-Indigenous population, prison entrants were, on average, younger when they smoked their first cigarette than those in the general community. Prison entrants started smoking at an average age of 14.0 years, which is more than 1 year younger than people in the general community, whose average starting age was 15.5 years. Risky alcohol consumption

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Alcohol consumption was higher among Indigenous prison entrants than the general Indigenous population, for both the proportion who drank alcohol and the frequency of consumption. A higher proportion of Indigenous prison entrants reported having consumed alcohol in the previous 12 months compared with the general Indigenous population. Consumption of alcohol four or more times per week was more common among Indigenous prison entrants when compared with those in the general population, although the difference varied. The gap between the age groups in the two populations narrowed from the youngest to the oldest age group. In the general Indigenous population, consuming alcohol 4 or more times per week became more common with age, increasing from 7% for those aged 1824 years to 13% for those aged 3544 years; but this trend was not reflected in the prison population. In contrast to the Indigenous population, non-Indigenous prison entrants consumed alcohol less often than their general community counterparts, and were also more likely to report not consuming any alcohol in the previous 12 months. These differences were more apparent in the older age groups, with the proportion drinking alcohol more than monthly decreasing among prison entrants but not in the general community. Almost two-thirds (64%) of non-Indigenous prison entrants aged 1824 years reported drinking alcohol more than monthly, compared with half (51%) of those aged 3544 years. In the general community, this was just over two-thirds in each age group. Similarly, 17% prison entrants aged 1824 years reported being non-drinkers, compared with one-quarter (25%) of prison entrants aged 3544 years; proportions of nondrinkers in the general non-Indigenous community remained steady (about 11%). Illicit drug use Illicit drug use in the previous 12 months was more common among Indigenous and non-Indigenous prison entrants than among the general Indigenous and nonIndigenous population across all age groups. For the non-Indigenous prison entrants, illicit drug use peaked among prison entrants at 2534 years where 79% reported using illicit drugs in the previous 12 months. This is more than 3 times the rate of drug users in the same age group in the general population (24%).

Social Determinants
Education level Education attainment was lower among prison entrants than the general population. For all age groups, prison entrants were more likely to have completed Year 10 or below as the highest level of schooling, and less likely to have completed Year 12 than the general population. Of those aged 1824 years, only 16% of prison entrants had completed Year 12, compared with 58% of the general population, and 65% of prison entrants had completed Year 10 or below, compared with 13% of the general population Employment status

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For all age groups, prison entrants were less likely to be employed and more likely to be unemployed than the general population. Of those aged 1824 years, nearly half (45%) of prison entrants were unemployed, compared with 7% in the general community. The proportion of prison entrants who were unemployed decreased in the older age groups, but the rates were still much higher than those in the general population. Overall the analysis reported in The health of Australias prisoners 2010 was not that surprising. It is clear that a lot of information is being collected. The key issue is to decide what questions need to be asked in the future. It would be very useful to compare the questions being asked and the resultant data that is generated by the crime and criminal justice researchers with the health analysis work of the Australian Institute of Health and Welfare as well as looking at health differences in the different prison systems in the European Union and the rest of the world. Integrating the data collection of the US The Health Status of Soon-To-Be-Released Inmates: A Report to Congress (2002) with the Australian data could produce very useful information. The fact that Australia is starting to collect detailed information about its prison population on an annual basis is very encouraging. That the AIHW is classifying 45 age and older as the dividing line between younger and older prisoners is valuable information. It would be nice to have more detailed breakdown by age of the older and the older older prisoners . It is also not health data as much as it is disease data. As the WHO stated in 1946, health is more than the absence of disease. The more interesting data from the AIHW was the finding of a pattern of more moderate alcohol and illict drug use by the older prisoners- the 45 years and older. Is this pattern linked with the desistance from crime over time as the prisoner ages? Tony Ward argues that desistance is much more than just the aging process, rather it is the process of finding a meaningful way for good living. What is happening with the older prisoner and alcohol and drug use? That one finding invites further exploration.

Older Offender (New Zealand)

Rate of Incarceration New Zealands rate of incarceration is 199 per 100,000 (ICPS estimation based on estimated national population of 4.41 million at end of March 2011). In 1992 its rate was only 119 per 100,000. That is an increase of 236.81% from 1992 to 2011. It has the 5th highest rate in the OECD with only the Czech Republic, Mexico, Poland and the United States having higher rates. OECD countries such as Finland and Hungary maintained a steady incarceration rate from 1992-2011. Discrimination

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Like the United States, Canada and Australia, there is evidence of systematic discrimination in New Zealand. In general, Maori are more likely to be imprisoned than nonMaori but disparities are even greater in some age groups. For example, in 2009, 3 percent of old Maori men (age 25) were in prison; over seven times the rate of Pakeha men (age 25). In 2009, Pacific offenders made up 11 percent of the prison population, almost double t heir representation in the New Zealand population. A larger proportion of Pacific prisoners were sentenced for violent offences (48 percent) than Maori prisoners (38 percent) and New Zealand European prisoners (25 percent), but Pacific offenders have a lower avera ge risk of reconviction than Maori or New Zealand European offenders (Health in Justice, 2010: 22). Aging population In New Zealand the prison population is younger than the general population with offending behaviour peaking in the late teens and early 20s. However because of longer sentences, longer periods of offe nding, and the increasing use of the indeterminate sentence, the prison population is aging. Prisoners aged 50 and over are making up a small but rapidly increasing proportion of the total prison population. The group aged 50 and over grew from .5 percent of the prison population in 1991 to 9.1 percent in 2009 (health in Justice, 2010:22) Health The report Health in Justice stated that there was little good quality empirical evidence on the health status of New Zealand prisoners but the available evidence was broadly consistent with research in other developed countries. The report stated that In New Zealand and internationally, prisoners typically score poorly on measures of mental health, alcohol and other drug use, chronic disease, communicable disease, disability, head injury, health risk and protective factors, and oral health.. Regardless of the limitations and data gaps, the message is clear New Zealand prisoners have very poor health. Major depression, post-traumatic stress disorder, obsessivecompulsive disorder, and schizophrenia appear to be higher in the prison population than in the wider population. The lifetime prevalence of alcohol abuse and dependence among men in prison is Approximately twice that of men in the wider population. The lifetime prevalence of severe drug disorder is eight times that of the wider population. Research has found that 89 percent of prisoners have suffered a substance abuse disorder at some time in their lives, primarily alcohol and cannabis abuse and

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dependence. The same research found that nearly 60 percent of prisoners had a personality disorder (2010:24)

Indicators
Schizophrenia Daily Smoking Overweight or obese High blood pressure Any chronic disease Heart Disease Chronic obstructive pulmonary disease among 45+ Asthma

Adjusted rate ratios 95% confidence intervals

3.88 3.21 1.00 0,74 0.99 3.15 2.85 1.30

Table 6 Men prisoner population compared with New Zealand population adjusted for a ge Indicators
Schizophrenia Daily smoking Overweight or obese High blood pressure Any chronic disease Heart Disease Chronic obstructive pulmonary disease among 45+ Asthma

Adjusted rate ratios 95% confidence intervals

3.67 2.81 0.89 0.71 1.01 3.33 2.31 1,28

Table 7 Men prisoner population compared with New Zealand population adjusted for a ge and ethnicity Indicators
Schizophrenia Daily smoking Overweight or obese High Blood Pressure Any chronic disease Heart Disease Chronic obstructive pulmonary disease among 45+ Asthma

Adjusted rate ratios 95% confidence intervals

5.44 4.36 1.10 0.88 0.99 1.50 0.74 1.96

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Table 8 Women prisoner population compared with New Zealand population adjusted for a ge and ethnicity Mental health Condition
Major depression Post-traumatic Stress Disorder Obsessive-compulsive Disorder Biopolar disorder

Men Ratio
1.70 5.43 2.81 0.41

Women Ratio
1,53 4.26 4.06 0.22

Table 9 Specific mental health conditions prisoner population compared with general population
The Health in Justice study concluded that their research contradict[ed] the common perception that poor health among inmates is driven solely by high concentrations of racial/ethnic minority men in correctional systems. They believed that the data strongly suggested that negative influences on health arise from the prison environment. While the existing research did show that the pisoners come with significant problems which support the imporatation thesis, the report was explicit in the issue of deprivation as a significant factor in the bad health. Being in prison was a risk factor.. Prison environment negatively affects health Regardless of background, an individual arriving in prison enters a setting that is globall y recognised as unhealthy and nontherapeutic. Internationally, common catalysts for poor health within prisons include crowding, exp osure violence, illicit drugs, lack of purposeful activity, separation from family network s and emotional deprivation. Other major contributors to poor health are a culture of intimidation, exploitation, an institutional environment in which health needs are not prioritised, and, particularly for remand prisoners, the uncertainty and stress inherent in being in the criminal system. This is the same in NewZealand, although the Prisoners Health Survey 2005 recorded a few positive signs. Aspects of the prison environment that worsen health outcomes are the: physical environment, including poor building design, overcrowding, and subst andard living conditions

If youre in seg[regation] you cant go out to rec[reation] at the same time as mainstream so if theres any problems you just miss out. Sometimes you get left in your cell for days at a time with no access to outside ... I was in there for about a week and I 58

was sick of being stuck inside all day so I said to the guard come on man, its a beautiful day outside ...Ive been stuck in here for ages and Im getting depressed. I need some sunshine ...some vitamin D.And the guard just straight up said dont be stupid man, you cantget vitamins from the sun . Robert, Pakeha man, 2030 years (interview) social environment, in which assaults, sexual abuse, illicit drugs, and lack of purposeful activity are commonplace

Double-bunking basically means you dont get any privacy at all. To me thats a real issue. A real health issue. A mental health issue as well.No moments peace. Gets you irritated ... As soon as they shut the door [the cellmates] start beating up on each other. ...Ive known those situations where they fought for an hour and a half before the guards finally went down and dealt with it. High stress all of the effects of high stress. Over-production of adrenaline. Scott, Pakeha man 3040 years institutional environment, including prison practices such as stripsearches, fre quenttransfers, separation from family networks, and inappropriate use of atrisk units.

NGOs and Penal Reform in New Zealand

Like Canada, Australia, and England & Wales, there are NGOs in New Zealand that are active in Penal Reform. The issue of mass incarceration has become quite public. In 2006 Prison Fellowship New Zealand held its annual conference around the theme Beyond Retribution Advancing the Law and Order Debate. The conference had very good speakers including JohnPratt . About his own country, New Zealand, John Pratt wrote that It is shameful that we should find such high prison levels in New Zealand. It is shameful in terms of the financial cost: keeping people in prison in this country costs a minimum of $60 000 per year for each person in prison. How much is spent each year on educating children? A good deal less than this sum. It is shameful in terms of its social cost. Of course there are some very bad people who have to be in prison because they are too dangerous to be let out, but in very many more cases, lives that are already badly messed up because of illiteracy, drug addiction, mental problems, abuse, dysfunctional family histories, unemployability are going to be messed up even more when these people come out of prison. !is is because ... reports1 have illustrated in the last few months, prisoners spend most of their time doing nothing at all while inside nothing to make them more productive and employable citizens when they come out. And the unsurprising result is that 51 per cent of them are back inside within five years of release. And our high prison levels are shameful in terms of what they tell us about New Zealand as a society a society that likes to think it has a reputation for social justice 59

and tolerance. However, as Sir Winston Churchill commented nearly a century ago, the mood and temper of the public in regard to the treatment of crime and criminals is one of the most unfailing tests of the civilisation of any country (2006: 52) In July 2006, The Salvation Army and Prison Fellowship New Zealand decided to form a partnership to launch a public awareness campaign, Rethinking Crime and Punishment. Kim Workman agreed to direct the project. Workam had pepared a major planning document Towards an Agenda for Prison Reform Reflections on a Fact Finding visit to London, Amsterdam and Helsinki based on a study tour . In this document he discussed the role of PFNZ and the work on Andrew Coylc (ICPS) who set out three necessary conditions for penal reform: Three basic conditions are necessary if prison reform projects are to have a good chance of success. Political will and support from the top of the government ministry responsible for the penal system or from a powerful part of the government such as the presidential administration or a high-ranking official. Prison reform is not a high priority for most governments. It does not have the appeal of health, education or economic reforms. It rarely brings many short-term political benefits. If there is no part of the government machine committed to a reform project it will struggle to make any impact. If a project is operating in such unsupported circumstances it will need to build into its work some activities aimed at generating a wider public understanding of the need for change. An administration sufficiently well-organised to deliver some change and carry it through. Even if there is genuine commitment to change, the government might not have the capacity to deliver reform. If, for example, the prison system operates through deeprooted corrupt practices at all levels, reform will be needed at the wider governmental level. Some champions working in the system The project will need the support of some people who are well placed to help the project achieve its ends, prepared to show publicly their support of the changes proposed and likely to remain in the post for enough time to see a project through. In October 2009 it was decided to form a charitable trust known as the Robson Hanan Trust, to develop the project, and expand its work. Kim Workman is now the Executive Director of Rethinking Crime and Punishment.

Older Offender (England and Wales)

The situation in the UK is very complex and even puzzling.

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The UK has a Prison Service Order (PSO 2855) for Prisoners with Disabilities which has a section on Older Prisoners. Chapter 7 Older prisoners 7.1 It is important to stress that age does not necessarily produce disability issues. However, studies have revealed that the health of older prisoners, statistically, is worse than the general population and therefore chronic illness, infirmity and disabilities will be more prevalent in older prisoners than in people of the same age group outside prison. 7.2 Older prisoners are increasing as a proportion of the overall prison population. There are now concentrations of older prisoners in specific establishments, and Governors and staff need to be aware of the challenges presented by this group. These prisoners require regular review to maintain well-being and identify and respond to the onset of any disability. 7.3 All governors and staff should ensure that specific Needs Assessments are carried out for such groups and look to make adjustments to routines for those older prisoners who have reached 55 and require help. The National Service Framework for older people sets out the standards of care. 7.4 As part of the Reducing Re-offending Action Plan all prisons are responsible for ensuring that Offending Behaviour Programmes as well as Education, Training and Employment Opportunities are available for all prisoners. The DDA applies and Governors and their representatives should look to make reasonable adjustments where appropriate. 7.5 Accommodation of older prisoners may be particularly difficult and it is essential that there is a clear distinction drawn between security and health needs. Governors should develop a clear understanding of the issues and consider: Setting up an older prisoner committee with prisoner representatives; Setting up a day room where older prisoners could go during the day, away from their cells and the wing environment; Appointing a member of staff to take the lead on considering the needs of older prisoners. 7.6 It is essential to ascertain and draw a distinction between the Health and Social Care needs of older prisoners and contact should be made with local Social Services Departments as part of the wider Prison/PCT Partnership Agenda. This is particularly important in advance of release to identify what local older people services could be accessed. Age Concern (contact details at Annex I) can advise on issues affecting older people and contact with them is encouraged as it is with other groups concentrating on the needs of older people in the community. 7.7 The medical and clinical care of older prisoners is age dependent mainly in relation to the management of their chronic conditions such as type 2 diabetes, chronic 61

obstructive airways disease, some cancers, and cardiovascular disease. The continuity of their care is an essential element of its overall quality, which is challenged as people move in to and between prisons, are managed across NHS and social care sectors, are released to the community and also in relation to ensuring care delivery at different times of the day. Continuity is assured by: Named case workers overseeing a case and ensuring full transfer support; The Older Prisoner Care Pathway (hyperlink) provides a framework for assessing and recording care needs. Shared electronic health and social care records, particularly with the community; Health and social care professionals delivering on their duty of effective referral and hand over; Multi disciplinary care planning and delivery, especially in relation to significant changes in condition or circumstances. 7.8 The outcomes of the management of older people with chronic conditions, which may contribute to their range of disabilities, should be no different for those who are in contact with the criminal justice system than for those who are not. All health and social care professionals should promote this vision and identify and mitigate all factors which might tend to impair excellent health outcomes in the criminal justice system.. PSO 2855 is important but it is not clear on when a person should be considered to be old unlike the situation in other prison systems. The US Federal Prisons use the combination of age 50 + Needs Assistance with Daily Living. This could work for the UK as well. The Prison Reform Trust notes that there is no overarching policy framework joining together the work of the Prison and Probation Services and Department of Health. There is no strand in the NOMS resettlement pathway that meets these needs. PRT argues that such a strategy is essential if the needs of older prisoners are to be met effectively across the estate. The UK has a Prison Service Order (PSO 4800) for Women Prisoners which has a section on Older Prisoners. In Section K of PSO 4800, it states that A much higher proportion of women 78% in HMCIPs survey, as opposed to 33% of men identified mental health needs in terms of depression or reactive depression as a result of trial or imprisonment. Many older women are less likely to be interested in new vocational skills. Those that do want to improve literacy or IT skills often see it as a way of improving their relationships with grandchildren. Older women are less likely to see employment as a realistic option for the future and will probably experience barriers in getting jobs. Some older women prefer to be located together others will rather live in mixed communities. Some older women will feel being located with or constantly surrounded by much younger prisoners tiring. Gender Specific Guidance 62

Older women (i.e. over the age of 50) should be consulted (at least once a year) to determine their need for particular activities, regimes and programmes. Managers and staff should be aware of the specific problems older prisoners and their older visitors, may face and consider these in allocation and all other decisions. Health Older women in prison should receive all the same services including health promotion and preventative treatment such as health screening for cancers, as older women in the community. Some older women will need support and assistance as they go through the menopause. Some older women may have particular needs such as special diets, dental care, eye care, physiotherapy, help with personal care or long term medical care. ETE ETE provision should take account of the needs of older women The pace of learning needs to be comparatively slow and the noise factor in classrooms may hinder learning. Some older women may wish to learn in small groups perhaps with their peers. Families Older women are often mothers even though their children have grown, and they are often grandparents. Opportunities to help older women in these roles should be provided perhaps by provision of special grandparents visiting days. This can be particularly beneficial for the children concerned. Influence on Younger Prisoners When older prisoners are used with their consent, to support other prisoners they should receive official recognition and reward. They are often seen as a calming influence on young prisoners. It should be understood however, that being constantly surrounded by young prisoners, can be very stressful for older women. The UK is well aware of the health needs of prisoners and the Offender Health Division, Department of Health is responsible for leading on development and delivery of a cross government Health and Criminal Justice Programme. The programmes common aim is improving health and social care outcomes for adults and children in contact with the criminal justice system, focusing on early intervention, liaison and diversion. It is an important component of the reducing re-offending and health inequalities agenda, with many offenders having mental health and/or substance misuse problems and social care needs. The National Health Service took over full responsibility for the provision of healthcare in prisons in 2006. Research (Hayton & Boyington, 2006) suggests that as a result of this reorganization, funding has improved and services now relate more to assessed health need. There is early but limited evidence that some standards of care and patient outcomes have improved. The reforms address a human rights issue: that prisoners have a right to expect

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their health needs to be met by services that are broadly equivalent to services available to the community at large. The UK is committed to the WHOs core health promotion principles as a route for reducing health inequalities. The UK actively supports the WHO Europe Health in Prison Project (HIPP) Paul Hayton is the Director of the Healthy Prisons Programme, Healthy Settings Development Unit at the University of Central Lancashire HSDU and also the Deputy Director of the WHO Collaborating Centre for Health and Prisons, based in Offender Health, Department of Health. There are two thematic reviews on the issue of the older prisoner that were done by Her Majesty's Inspectorate of Prisons for England and Wales (HMI Prisons). The HMI Prisons is an independent inspectorate which reports on conditions for and treatment of those in prison, young offender institutions and immigration detention facilities. HM Chief Inspector of Prisons is appointed by the Justice Secretary from outside the Prison Service, for a term of five years. HMIP report No problems old and quiet (2004) HMIP report Older prisoners in England and Wales: a follow-up to the 2004 thematic review. In the 2008 follow-up Ann Owers, then the Chief Inspector of Prisons, wrote that wrote The population of men over 60 in prison has risen slightly over that period, reaching nearly 3% of the population; at the same time, the population of women over 50 has increased significantly, reaching nearly 7% by mid-2007. It is well-known that prisoners are likely to have earlier onset of chronic health and social care needs than the general population. There have clearly been some positive developments over the last four years.... In addition, and importantly, non-governmental organisations, such as Age Concern, the Prison Reform Trust and NACRO have been extremely active, and Care Services Improvement Partnerships (CSIPs) in the south-west and the West Midlands have produced some excellent strategies and toolkits to manage health and social care needs. By contrast, however, the response from the National Offender Management Service itself has been disappointing. The new legal requirement in relation to disability has had some effect, though there is still some way to go. However, apart from short sections in the Prison Service Orders on disability and women, there remains no national strategy for older prisoners as such, supported by mandatory national and local standards. Eight of our key recommendations have not been implemented. In the study of Health of elderly male prisoners worse than the general population, worse than younger prisoners, Fazel et al ( 2001) compared the health of elderly prisoners, younger prisoners and older people in the community. Fazel studied 203 men from 15 prisons which held at least 10 older prisoners (over 60 years of age) and were within 100 miles of Oxford. Data was collected using semi structured 64

interviews and medical health records. Information was also collected describing younger prisoners and older people in the community for comparison. The results were as follows: 83% of elderly prisoners reported long standing illness or disability, 19% had a new illness thathad started in the previous 3 months and 85% had a major illness or disability recorded in their medical notes. The sample of younger prisoners and older people in the community showed much reduced numbers. 10% of older prisoners interviewed suggested they were functionally disabled in Activities of Daily Living, important in creating an appropriate living environment and ensuring extra help if needed. The illnesses recorded were varied including: psychiatric 92%, cardiovascular 71%, musculoskeletal 48%, respiratory 31% and genito-urinary 20%, endocrine 20%, and gastroenterological 20%. The level of self reported illness was similar, with the exception that only 18% considered they had a psychiatric illness and 88% thought they had musculoskeletal illness. Self reported illness in the younger prisoners (aged 18-49 years) consisted mainly of musculoskeletal and respiratory illness. With regard to smoking, 54% of elderly prisoners smoked, compared with 80% of younger prisoners (Prior, 1998). Health problems reported included high scores for cardiovascular disease and respiratory disease in the older group. Respiratory problems featured in 15% of the younger group. Only 19% of the older community population smoked and therefore reported less smoking related problems.

NGOs and the Older Prisoner

The NGOs in the UK are quite active in this area. NACRO developed the Working with Older Prisoners (2009) with the Department of Health. This training program noted that Older prisoners experience the same problems as younger prisoners: social exclusion the same need to engage in meaningful activities as their younger counterparts to feel they are part of something the same problems with respect to coping, entry shock, adaptation and psychological survival.

But on top of this, they also: are likely to have a long-standing chronic illness or disability (80%). Of these, more than 35% suffer from a cardiovascular disease, and more than 20% suffer from a respiratory disease are likely to have been in prison before (50%)

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 are often more vulnerable because they find it difficult to cope with the physical and mental stresses and demands of prison life have elderly spouses and parents who either have special requirements of their own or who need to travel miles to visit their loved one often have no family or community links are harder to resettle because they are more likely to become institutionalised have a multitude of resettlement needs, especially older sex offenders and those with disabilities have not benefited from prison programmes, which are geared to the needs of younger prisoners, especially offending behaviour, education, vocational and employment programmes may be unlucky in the quality and availability of care and welfare services in the areas to which they are released may have limited funds on release, such as a pension experience anxiety about the future pose fewer problems for prison staff, dont tend to complain and are often less demanding, which can lead to their needs being forgotten or neglected

Older Voices in UK Prisons

Prison Reform Trust (PRT): Doing Time: the experiences and needs of older people in prison, (2008) listened to some of these voices. I cant move around like I used to and until recently I could earn a little bit by working in my cell. But now that work has dried up. So all I get now is my prison pension of 3.25 [mandatory minimum] and when you take 1 off for television I have little left to spend from essentials from the canteen. Unlike some of the others I have no one who can send me any money. Almost half (48%) of the men interviewed had experienced bullying or intimidation either by staff or, more frequently, inmates. Over 60% of the male respondents felt unsafe (2008:8) Due to overcrowding we now have to double-up in our cells. The younger guy who moved into my cell insisted on using the bottom bunk and that I had better move to the top one or else. He took my mattress and I had to make do with an old one. Since then my hip joints have been keeping me awake most nights. I am afraid to complain but did have a quiet word with Mr X [prison officer] but he told me to sort it out myself and not make an issue of it, otherwise it could be worse for me. I am threatened on my wing by a few others who demand six bars of chocolate each week. I only have my small prison pension to buy treats. My one big fear is dying in prison and all alone. Sadly, X, who you met last time you were here, was rushed off to hospital but returned yesterday. He was found dead in his cell this morning. We are all depressed over this but no one, including the Chaplain, has been round to talk with us. We have been banged up all day.

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Natalie Mann (2010,2012) also listened to these voices Everything is hurry, hurry, hurry and they dont seem to realise that some of us cant keep up. Theres no consideration in prison for the fact that people are getting older, therefore they are gonna slow down a bit. Theyre expected to be ready and out by the same time as the youngsters, theres no consideration for the fact that it takes them longer to do things - Cliff Its the lack of activities, the lack of making your own decisions. Everything is done for you here, youre told when to lock up, when to stop work, when to go to bed, you dont have to think for yourself...even now I cant think of words or I cant think of names; its going up there (his mind)- -Eric I cant tell you the number of times Ive seen the old men struggle to get up there and stand in a queue for hours to get their medication, then get bullied for their medication, get slagged off because of their offence and its a horrendous experience and I know there are old men who are too frightened because of all that, to even go to healthcare Hughie There are a lot of people in this prison who are old and not just old but very ill and infirm and they do struggle, and I think its very sad that they are expected to function normally in this prison. They are genuinely and physically struggling in here with the routine and simple things like stairs. I mean, Im extremely lucky, Im fit and well with no serious problems, but Im not typical of my age group.- Brian The younger men take the mickey out of them [older prisoners] and try to bully them but I know how to handle them, keep away from them because they dont know that theyll probably be back in within six months of going out, but all the young blokes are so rude, one new one had a go at me the other day. He called me this and he called me that and I said: are you gonna carry on?; he shouts: what you gonna do about it?, so I pushed him up against the wall, threw a few punches and he didnt like it... I feel sorry for them [vulnerable older prisoners] because they will get bullied: if lifers who are fit get aggro then the frail ones certainly will.... There is bullying in here and Ive been bullied but Ive always sorted it out myself and I havent had no nickings [from my cell] for the past two years. If I saw a younger kid bullying an older guy, Id put him straight. But these young kids cant get it through to their brain that you cannot bully an old bloke because of his age. I was in a fight one day and there were four young kids and six of us [older prisoners] and they threatened to sort us out, what a mistake they made, they were the ones who got sorted out! Ageism, thats all it is. I can still look after myself - Bernard

Friendship
Mann found that the older prisoners managed to find ways to maintain hope and coping. She writes that for many Friendship (has) emerged as one the most important coping strategies, with many men forming extremely close attachments with their fellow prisoners. Some had been 67

surprised by the amount of friends they had made, and whilst some intended to continue these friendships on release, others took a more practical approach and saw these friendships as a current necessity which resulted from the confined environment within which they lived....(Sadly) there were a number of men who were not able to enjoy the comradeship provided by friends or acquaintances, as for some, the risk involved in forming attachments and then being transferred to another prison, was simply not worth the distress it would inevitably cause. These men were so fearful of being left alone, that ...friendship is avoided. ...Whether the avoidance of friendship resulted from a fear of loss, or a fear of associating with lesser individuals, for both these groups of men prison life was made slightly more difficult without the camaraderie and support which friendships provide. In his Who Shall Survive (2nd Edition, 1953) Jacob L. Moreno wrote about the importance of social ties. We can know a lot of individuals, most are not important, but we all need to have a critical few that do matter to us. These few are the ones who mean something in some degree and in respect t o some criterion; the individual is attracted t o them or rejects them. There will be some, whether the person knows it or not, individuals to whom that person means something, who are attracted or who reject the individual. Moreno called this small critical unit the social atom. He studied the crews of American bombers in WW2. If the men had choosen who they were flying with, then the losses were smaller than if the men had no choice. In his 2009 study of Loneliness, John T. Cacioppo reviews the scientific evidence that loneliness: a sense of isolation or social rejection disrupts not only our thinking abilities and will power but also the immune system, and can be as damaging to our health as obesity or smoking. Having friends in prison can determine just how well one survives the prison environment.

Existential Choice
Another choice is to stand alone. Mann describes Bernard thus: Bernard was a 77 year old life sentence prisoner, who had committed murder. He had approximately ten more years to serve. He was a guarded man who took a long time to open up during our interview. He was seen as somewhat problematic by prison staff and was well versed in the Prison Complaints Procedures. Bernard is quite clear about his relationships. The guard, the screws, are the enemy who must be taught to respect him and leave him alone. But you have got some power in here! Theres an old saying, The pen is mightier than the sword. Ive got a good solicitor. Ive made it my business to get to know all the rules and regulations and if I have any hassle, I phone him straight up and hes onto it. They [the officers] just come out with so much bull that they dont understand it themselves, so you have to know what youre talking about otherwise theyll walk all over you. I know my rights. Ill say: you cant do that, and theyll say: well how do you know that?. They try it on, but theyll leave you alone when they see you know what youre talking about. The other prisoners, he ignores as much as possible. Though he also says that If I saw a younger kid bullying an older guy, Id put him straight. But these young kids cant get it 68

through to their brain that you cannot bully an old bloke because of his age. So he is always ready to defend himself. He is basically guarded, a loner withoutfriends, because he will not let himself be vulnerable. He does not want to depend on anyone. He says that I can still look after myself. In prison you can only have acquaintances, just hello in passing and that suits me. I dont wanna get too close because the first thing you find out is that that person wants something from you. I dont have people in and out of my cell all the time. You see weve been on our own for years and years and we dont want anyone coming into our cell. We dont want people coming in because lifers would not be allowed to talk to the others because a lot of short termers are scared of lifers, but I dont think were a threat to anyone. I know someone in Kingston [prison], been there forty years and now hes in a wheelchair, cant get up, cant wash, cant dress and he committed a crime sixty years ago. I did used to intimidate people, I did that years ago, and I tended to get a bit nasty, so now they keep away. Bernard deals with the prison from a social constructionist perspective (Gergen & Gergen, 2010). Through active negotiation and collaboration , or by an implicit threat, to people, he achieves a certain understanding . The guards dont bother him because he can cause too much trouble, and the young men need to learn that he is just too hard to be bullied. He has his style of resilience in a context where many older men feel powerless and vulnerable.

Resilience in the Prison

Resilience is a key concept in the aging literature today. In this model it links the process of dealing with physical and mental problems that are usually associated with aging and the personal sense of health and well- being. In the classic study Psychological Survival: The Experience of Long-Term Imprisonment Cohen & Taylor are really talking about resilience in a damaging environment. Todd Clear used the term penal harm in his study of contemporary corrections (1994) because he wanted to be very clear. We intend the prison to be a painful experience. Even when it is a Finnish open prison, the experience is painful even if it is a Gentle Justice (Ikponwosa Ekunwe, 2007) when compared to other penal systems. In defining the prison, it is important to be as explicit as possible. The prison is an act of deliberate evil by the state. It is an evil because it is designed to cause suffering to a member of the society. Like war, it may be necessary, or a lessor of evils, but it should never be considered a social good or just. The thesis of a just war on crime needs to be rejected, and we should also reject the idea of deserved or just punishment (Hilborn, 1996,2004,2011). The Venn diagram in Figure 1 shows how the three areas interact around the themes of resillence, salutogenesis, and the healthy prison.

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The Quality of Care and the Quality of Prison Life for the Aging Prisoner

Health & Well-being

Salutogenesis Resilience

Age, Disease and the Aging Prisoner

Penal Policy & Practices

Healthy Prison Figure 1: The Quality of Prison Life for the Aging Prisoner (Q) Resilience can be defined as normal development in the face of adversity to include facets such as recovery, plasticity, regenerative capacity, maintenance of health function (e.g., mobility) in the face of disability or disease, and access to psychosocial and technologicalecological resources that may facilitate maintenance and improvement of physical and emotional health with age (Fry and Keyes, 2010). Adult resilience has become a hot topic as the size of the older population has become so large in comparison with other historical period. Resilience is about staying healthy despite all the slings and arrows of outrageous fortune, and this is done not by choosing suicide, but rather by recovery and new growth. It is about finding health despite the limits of the real situation. Bernard has found his own way to be healthy in an unhealthy place. You might not like him, but you will respect him.

The Brains Neuroplasticity

Until quite recently we had accepted that with maturity, there is the start of aging which had to mean a process of an inevitable decline of body, mind and spirit. As an example we used to believe that the brain reached maturity in the late teens, and then there was no further growth, instead aging meant a process of brain decline. Comfort had argued against this negative expectation. He wrote that clinical observation showed that the healthy persons brain did not just decline into Dementia or Alzheimers disease these were diseases.

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The human brain does not shrink, wilt, perish or deteriorate with age. It normally continues to function well through as many as nine decades. Comfort was right. We now know why. The brain can be resilient to aging because of neuroplasticity. Simply put, the brain can change itself (Doidge, 2007). Doidge writes that the adult human brain, rather than being fixed or hard-wired, can not only change, but it has to change in order to function. It is neuroplastic: neuro for neuron, the nerve cells in the brain, and plastic in the sense of adaptable, changeable, and malleable. Neuroplasticity is the property of the brain that allows it to change its structure and function in response to what it senses, what it does and even what it thinks and imagines. Neuroplasticity is the way the brain works. In the Encyclopdia Britannica article on neuroplasticity , it is defined as the capacity of neurons and neural networks in the brain to change their connections and behaviour in response to new information, sensory stimulation, development, damage, or dysfunction. Although neural networks also exhibit modularity and carry out specific functions, they retain the capacity to deviate from their usual functions and to reorganize themselves. In fact, for many years, it was considered dogma in the neurosciences that certain functions were hard-wired in specific, localized regions of the brain and that any incidents of brain change or recovery were mere exceptions to the rule. However, since the 1970s and '80s, neuroplasticity has gained wide acceptance throughout the scientific community as a complex, multifaceted, fundamental property of the brain. It would be misleading to suggest that we fully understand the brains plasticity, or that the deliberate rewiring of the brain is going to be that easy. Norman Doidge has now made two films, The Brain That Changes Itself (2008) based on his book, and Changing Your Mind (2010) . The first film shows examples of profound recovery from major neurological damage. One approach is the use of Constraint-Induced Movement therapy which is a physical rehabilitation method derived from behavioral neuroscience studies of deafferented monkeys that uses the brains neuroplasticity to improve motor function degraded by either focal injury to the CNS, as in stroke and traumatic brain injury, or by slow dementing processes. Gitendra Uswatte and Edward Taub (2010) have written a review of this work with the wonderful title You can teach an old dog new tricks: harnessing neuroplasticity after brain injury in older adults. The results are amazing but gained through massive amounts of hard work. The brain must be driven to rewire. Doidges latest film, Changing Your Mind (2010) looks at how the brains neuroplasicity can give rise to, or even perpetuate, mental illness such as post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD) and even some of the cognitive problems associated with schizophrenia. The brains neuroplasticity is now being used to help these patients to better understand both the way their brains plasticity has lead to their mental illness, and how to now use the neuroplasicity move toward mental health. Dr. Norman Doidge is quite clear that neuroplasicity is not always our friend, but understanding of, and using it, is vital for both recovery from mental illness and for resistant. The brains plasticity is a two-edged sword. 71

We do know that meditation changes the brain because of neuroplasicity, and some reports do suggest that meditation can be help the prisoner find meaning despite incarceration.

A Good Age
Dr. Alex Comfort is best known for his The Joy of Sex (1972) but his most important work was done in Gerontology. In his A Good Age (1981) he wrote that Older people are, in fact, young people inhabiting old bodies and confronted with the physical problems of reduced vigour, changing appearance and specific disabilities affecting such things as sight and agility. His essential message was that there is a critical distinction between the two kinds of agingone biological, and the other sociogenic. The biological process is a slow senescence. Comfort never denied the reality of the biological process but he thought it was not as important as societys reaction to the biologic process. Agism is the notion that people cease to be people, cease to be the same people or become people of a distinct and inferior kind, by virtue of having lived a specified number of years Sociogenic aging is the role society imposes on people as they reach a certain chronological age when they can be condemned as unemployable, unintelligent, crazy, and asexual. Even the conservative Encyclopdia Britannica article on human aging agrees with Comfort since The most outstanding psychological features of aging are the impairment in short-term memory and the lengthening of response time. Both of these factors contribute to lower scores of the elderly on standard tests of intelligence. When the aged are given all the time that they wish on tests that are not heavily dependent on school skills, their performance is only slightly poorer than that of young adults. Age decrements are negligible on tests that depend on vocabulary, general information, and wellpracticed activities. Experimental studies on learning show that, although the elderly learn more slowly than the young, they can acquire new material and can remember it as well as the young. Age differences in learning increase with the difficulty of the material to be learned. Aged people tend to become more cautious and rigid in their behaviour and to withdraw from social contacts. These behaviour patterns may be the result of social institutions and expectancies rather than an intrinsic phenomenon of aging. Many persons who age successfully make conscious efforts to maintain mental alertness by continued learning and by expansion of social contacts with individuals in a younger age group (emphasis added).

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Comfort thought the only option to the discrimination of agism was active resistance. The aging population must demand four things: As an 'old person' you will need four things-dignity, money, proper medical services, and useful work. (These are the things you always needed.) Needing assistance with daily living (ADL) is a biological fact. But Biology is not the same as Social Destiny, for as Comfort argued, " 'Oldness' is a political institution and social convention." The same critical distinction between biology and social role has been made in the fight against sexism, ones biological identity is not the same as ones social identity. The need for active resistance was best expressed by the poet Dylan Thomas in his poem

Do not go gentle into that good night

Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light. Though wise men at their end know dark is right, Because their words had forked no lightning they Do not go gentle into that good night. Good men, the last wave by, crying how bright Their frail deeds might have danced in a green bay, Rage, rage against the dying of the light. Wild men who caught and sang the sun in flight, And learn, too late, they grieved it on its way, Do not go gentle into that good night. Grave men, near death, who see with blinding sight Blind eyes could blaze like meteors and be gay, Rage, rage against the dying of the light. And you, my father, there on the sad height, Curse, bless, me now with your fierce tears, I pray. Do not go gentle into that good night. Rage, rage against the dying of the light.

No False Hope
Comfort did not offer false hope. He wrote that Gerontology will not abolish old age; it will make it happen later. The extra years, unless we persist in clock-watching in defiance of all reason, will be years of extra vigor, not dependence. Old age itself will not be longer, only later.

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Resilience is about the personal construction of health for as long as that is possible. Resilience is a critical dimension of health. Each person must find his or her own style of resilience and pathway to meaning despite the reality of certain extinction. Resilent Aging is all about finding meaning in even in our aging, The brains resilence allows a person to continue to grow and to better know oneself, and to choose each day to realize the potential meaning that is inherent and dormant even in the final moments of ones aging and death. Death is not the ultimate horror of aging, it is the fear of a disease such as Dementia that can take away the awareness of our existence or its end. It is why Terry Pachett has been so clear that he will choose the time of death before he loses his awareness that he exists.

Logotherapy
To be human, to exist, is to know the I will suffer and die. Albert Camus fully appreciated that fact which is why he saw suicide as the central question that every person must face each day of ones life. Victor Frankl would sometimes ask his patients who were suffering from a multitude of torments great and small, "Why do you not commit suicide?" Each of us must find our own answer. No one can give us faith or hope. Whether religious or secular, we all face the existential fact of our own existence and its certain end. In the Jewish Torah, in Ecclesiastes 3, this reality is faced directly by these hard words. 1 There is an appointed time for everything. And there is a time for every event under heaven. 2A time to give birth and a time to die; A time to plant and a time to uproot what is planted. 3A time to kill and a time to heal; A time to tear down and a time to build up. 4A time to weep and a time to laugh; A time to mourn and a time to dance. 5A time to throw stones and a time to gather stones; A time to embrace and a time to shun embracing. 6 A time to search and a time to give up as lost; A time to keep and a time to throw away. 7 A time to tear apart and a time to sew together; A time to be silent and a time to speak. 8 A time to love and a time to hate; A time for war and a time for peace. 9 What profit is there to the worker from that in which he toils? 10 I have seen the task which God has given the sons of men with which to occupy

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themselves. ...... 19 For the fate of the sons of men and the fate of beasts is the same. As one dies so dies the other; indeed, they all have the same breath and there is no advantage for man over beast, for all is vanity. 20 All go to the same place. All came from the dust and all return to the dust. 21Who knows that the breath of man ascends upward and the breath of the beast descends downward to the earth? 22 I have seen that nothing is better than that man should be happy in his activities, for that is his lot. For who will bring him to see what will occur after him? In trying to answer his own question about suicide, especially given his own losses in the Nazi concentration camps, Victor Frankl wrote that we must accept a tragic optimism. First ask ourselves what should be understood by "a tragic optimism." In brief it means that one is, and remains, optimistic in spite of the "tragic triad," as it is called in logotherapy, a triad which consists of those aspects of human existence which may be circumscribed by: (1) pain; (2) guilt; and (3) death. This .... raises the question, How is it possible to say yes to life in spite of all that? How, to pose the question differently, can life retain its potential meaning in spite of its tragic aspects? ....... what matters is to make the best of any given situation. "The best," however, is that which in Latin is called optimumhence the reason I speak of a tragic optimism, that is, an optimism in the face of tragedy and in view of the human potential which at its best always allows for: (1) turning suffering into a human achievement and accomplishment; (2) deriving from guilt the opportunity to change oneself for the better; and (3) deriving from life's transitoriness an incentive to take responsible action. .....optimism is not anything to be commanded or ordered. One cannot even force oneself to be optimistic indiscriminately, against all odds, against all hope. And what is true for hope is also true for the other two components of the triad inasmuch as faith and love cannot be commanded or ordered either. To the European, it is a characteristic of the American culture that, again and again, one is commanded and ordered to "be happy." But happiness cannot be pursued; it must ensue. One must have a reason to "be happy." Once the reason is found, however, one becomes happy automatically. As we see, a human being is not one in pursuit of happiness but rather in search of a reason to become happy, last but not least, through actualizing the potential meaning inherent and dormant in a given situation (138-140) Frankl had no great interest in hedonistic (subjective/emotional) well-being but he would have appreciated the work being done by positive psychology on flourishing and the new ideas about resilent aging. Life may be tragic but we can choose Life despite everything - to make 75

the best of any given situation. And in that choice, there is the creation of personal meaning and thus the individual can experience Health even in the face of Disease and Death. But what exactly is health?

Health
The WHOs definition of health is embedded in its constitution. The CONSTITUTION OF THE WORLD HEALTH ORGANIZATION (1948, 1977, 1984, 1994 and 2005 ) Parties to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. That health is not merely the absence of disease or infirmity has helped justify the very existence of the World Health Organization, and later the development of the concept of health promotion , the idea of the healthy prison, its work on violence and road safety,as well as its present work on the social determinants of health That key definition of health was accepted by the representatives of 61 States in July 1946, and entered into force on 7th of April 1948. It has not been modified since despite ongoing criticism. It has allowed the WHO to work on diseases such as HIV/AIDS, problems of alcohol and tobacco abuse, and also expand the public health discourse into a wide range of social problems. To the question what is health?, the WHO seems to have answered What is not health? especially if health is linked closely to the pursuit of happiness and meaning. The problem ever since 1948 is exactly what is a state of complete physical, mental and social well-being, and how is it to be measured? The recent definition of health in the Dictionary of public health promotion and education : terms and concepts (2004) starts with a slight modification of the WHO basic principle. The physical, mental, social, and spiritual well-being and fitness that individuals enjoy. Health is not just freedom from disease but is multidimensional and is to a large extent culturally defined. And then continues with more definitions of health: Health may be defined as the quality of a persons physical, psychological, and sociological functioning in a variety of personal and social situations (Bedworth & Bedworth, 1992).Health is also the ability to survive or adapt to disruptions among the structural, social, and personal components of the individuals health system, as well as to the environment in which the person lives (2004: 53). 76

The Encyclopdia Britannica article on health is a rejection of the WHO definition since it states that health is in human beings, the extent of an individual's continuing physical, emotional, mental, and social ability to cope with his environment. .... even by this definition, the conception of good health must involve some allowance for change in the environment. Bad health can be defined as the presence of disease, good health as its absence particularly the absence of continuing disease, because the person afflicted with a sudden attack of seasickness, for example, may not be thought of as having lost his good health as a result of such a mishap. ..... physical condition and health are not synonymous terms...... There are further problems in settling upon a definition of human health. A person may be physically strong, resistant to infection, able to cope with physical hardship and other features of his physical environment, and still be considered unhealthy if his mental state, as measured by his behaviour, is deemed unsound. .... In the face of this confusion, it is most useful, perhaps, to define health, good or bad, in terms that can be measured, can be interpreted with respect to the ability of the individual at the time of measurement to function in a normal manner and with respect to the likelihood of imminent disease. The Encyclopdia Britannica article rejects the imprecision of the WHO model of health as a state of complete physical, mental and social well-being. Bad health is simply being defined as the presence of disease, and good health as the absence of disease or infirmity. In 1948 the WHO had proclaimed the rather radical idea that good health should not be seen as merely the absence of disease or infirmity. By doing so, the WHO had opened the door to a consideration of the links between health and a wide range of social concerns. Examples would be its work on Violence, or Road Safety or the publications of the WHO City Action Group on Healthy Urban Planning. The review by Czeresnia and Soares on Health and Disease, Concepts of (2010) helps to clarify the situation. Czeresnia and Soares write that with health, It is impossible to provide a precise, generic definition, because there are various ways of experiencing health. The concept of health is a qualification of existence, and there are different ways of existing with quality of life. Health is not amenable to scientific definition; it is first and foremost a philosophical question and relates to each persons life. Czeresnia and Soares (2010: 135) provide two tables to better clarify the difference between the scientific concept of health and the fundamental philosophical question as well as the inherent conflict between the patient who wants help with the subjective experience of illness

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and the doctor who is looking for data to identify a disease and therefore select the correct treatment.

Table 1 Health
Scientific concept Absence of disease Statistical normalcy Biological function Philosophical question Value Normativeness Capacity to withstand environmental adversities

Table 2 Illness disease

Illness Subjective experience Suffering Primary intuition Need Disease Objective scientific concept Disease diagnosis Medical intervention Demand

The scientific solution to the question of what is health is to define health in terms that can be measured. Instead of an ideal concept of health, there need to be several measurements that look at different aspects of persons ability to function in an adequate way in a specific situation. Boorse (1977) had argued that the medical concept of health can be described by two elements: Biological function and statistical normalcy. According to Boorse, the concept of health as absence of disease provided a value-free scientific definition. Boorse is both right about the value-free scientific definition and also missing the value statement, and even a clear political intent, behind the WHOs definition of health. Today one can speak of a human right to health or the social determinants of health - a discussionwhich is much more than the absence of disease. Basically when you ask a question about a persons health, then you are really not asking for a scientific statement of what is, but rather asking for an evaluation of the individuals sense of coherence or the present quality or meaning of ones life. Either the person must give a general and vague response such as Im ok or else stop, reflect and then give a detailed personal answer. Czeresnia and Soares write that The definition of health by the World Health Organization (WHO) as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity has been criticized in its philosophical manifestation on the grounds that it expresses hope for a reality free of obstacles, an ideal situation unrelated to the life of any human being. Yes it is true that it is a rather utopian dream. It probably never will be fully realized but it is still a worthwhile goal to strive toward. Today tools to measure the quality of life, wellness, well-being , salutogenesis and its sense of coherence, as well practices such health promotion, the WHOs Healthy Cities movement, and the WHO Europes Health in Prisons Project make the dream a little closer to reality.

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Like the Numberg Trials (1945-46) , and the UNs Universal Declaration of Human Rights (1948), The WHOs Constitution (1948) with its unique definition of health was a reaction to the horrors of World War 2 and the Holocaust. Today it is still a valuable political statement that affirms the value of human life and the need for action in response to many forms of suffering, especially the suffering caused by intentional violence and discrimination . The WHO definition of health alerts us to the need to strive toward a better world. Today the WHO is focusing on a public discourse to develop a better understanding of the social determinants of health, and working to moblize governments to take action to reduce these social inequities. It could be argued that the present pattern of mass incarceration is part of this social inequity.

Wellness
In the positive psychology literature there are references to the concepts of wellness and wellbeing. Both concepts have their roots in the WHO definition of health. The Dictionary of public health promotion and education : terms and concepts (2004) states that wellness is A dimension of health that goes beyond the absence of disease or infirmity and includes the integration of social, mental, emotional, spiritual, and physical aspects of health. The concept of wellness was first introduced in the United States in the 1970s as an expanding experience of purposeful and enjoyable living.Wellness refers to a positive state, illness to a negative state. The reality is that the term was developed not in the 1970s but a decade before by Halbert L. Dunn, M.D., Ph.D. who had been the Chief, National Office of Vital Statistics, Public Health Service. In his final year with the U.S. Public Health Service he was the Assistant Surgeon General for Aging. He was trying to build on the WHO health definition and looking for new terminology to convey the positive aspects of health that people could achieve, beyond simply avoiding sickness. After his retirement, Dunn sketched out his concept of high-level wellness, which he defined as an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable, within the environment where he is functioning ....This definition does not imply that there is an optimum level of wellness, but rather that wellness is a direction in progress toward an ever-higher potential of functioning. (1961). Dunns definition was quite precise. Carol Miller writes that according to Dunn essential criteria for wellness included (1) a movement toward higher potentials of functioning, during daily living and times of challenges; (2) attention to the total person, including physical, mental, emotional, social, and spiritual dimensions; and (3) maintenance of balance and purposeful direction of each unique person in his or her environment (2008:7). It took almost another 50 years for the term wellnesss to become so popular that it is now well established in everyday use in America. Wellness has become a popular term that is 79

widely used to market a wide range of services from spas to dog food. It is especially used by many practitioners within alternative or complementary medicine including faith healers, advocates of energy medicine, raw food advocates, and other associated quackery. A lot of these wellness practices are worthless and may even be dangerous. Dunn would be horrified by the loose way the term is now being used. While the WHO has always been willing to consider many issues under its very broad understanding of health, it has also always strived to be evidence-based unlike many of these quasi-wellness practitioners. In terms of branding, wellness has proven to be much more successful term than the WHOs model of health, and certainly it is more widely known than Antonovskys salutogenesis. There has even been a rapid growth in wellness centers. These are Facilities organized and operated mainly by health professionals, such as health education specialists, preventive care specialists, nurses, therapists, nutritionists, medical doctors with an interest in prevention, and health administrators, to provide people with learning opportunities about health behavior, risk reduction, and issues related to the health of the population. Learning opportunities may involve health education workshops, weight maintenance and control clinics, exercise demonstrations, cooking demonstrations, nutrition classes, and stress management programs. The practitioners in these wellness centres may not be medically qualified unless they are combining alternative or complementary approaches with a regular (allopathic) practice. At their best, these centres are active in health promotion through evidence-based individual skill development. A good example of the positive potential is the work of Carol A. Miller, MSN, RN-BC, AHN-BC who has written a Nurse's Toolbook for Promoting Wellness (2008) with contributions from other nurses and health specialists. Overall the content is good even if the writing style is deliberately more suited to a popular magazine than a professional text. The work as a whole went through a peer review by a nursing committee. Miller wrote several chapters on the model of Wellness Nursing. She writes that My uncomplicated answer to the question What is wellness? is the statement, Im OK and I want to be better. Similarly, the brief answer to the question What is wellness-oriented nursing care? is in the statement, Youre OK and you can be better. She is using the Transactional Analyis language of Im OK, Youre OK (Harris, 1968) . TA is making a bit of a comeback the different therapies go in and out of fashion. Perhaps wellness will be a forgotten term in a few years, but the issue of how we can describe and evaluate health is not going away. Miller makes the following points: A more detailed description of wellness uses the following components: balance through all phases of health, bodymindspirit connectedness, personal responsibility, and relationships with self, others, and the environment. 80

Because wellness is a dynamic and multidimensional process aimed at reaching ones highest potential during all phases of health, people can work toward wellness at all times Nurses have key roles in addressing bodymindspirit connectedness as an integral component of health care. Nurses have many opportunities to promote personal responsibility by teaching patients about actions they can take to foster a higher level of health.

The most important point in Millers model of Wellness Nursing is the message that the individual can learn new skills to maintain their present functioning or even to continue lifelong improvement. Occupational Therapy has its own model of Successful Aging which suggests that elders could, by pursuing three main goals, live their lives with a sense of satisfaction and wellbeing. The three goals ... are as follows: 1. Avoiding disease and disability 2. Maintaining high cognitive and physical functioning 3. Staying involved with life and living The third of these recommendations has been explicitly identified as being within the domain of occupational therapy (American Occupational Therapy Association , 2002). The occupational therapys concept of successful acting is very close to the idea of wellness,

Well-being
With the rise of Positive Psychology, for the past two decades, psychologists and sociologists have started to systematically study the causes, correlates, and consequences of flourishing mental health and states of well-being. Hedonistic and eudaimonic traditions in well-being research have evolved from different philosophical and theoretical roots, yet modern day hedonistic (subjective/emotional) and eudaimonic (psychological and social) aspects of wellbeing appear to be closely related components of psychological functioning.

Hedonic Well-Being
The hedonic model of well-being has been the most extensively studied. Hedonic well-being is also commonly referred to as subjective or emotional wellbeing or happiness. Work in this area was pioneered by Ed Diener and his colleagues, They have defined hedonic (or subjective) well-being as the frequent experience of pleasant emotions and moods, the infrequent experience of negative emotions and moods, and high levels of self-reported life satisfaction. This model of well-being is an extension of the philosophy of hedonism, which identified the pursuit of pleasure and avoidance of pain as the primary goals in life, and is predicated on the belief that individuals are the best judges of their happiness or well-being. Decades of research provide support for hedonic well-being as a reliable and valid conceptualization of well-being.

Eudaimonic Well-Being
The eudaimonic tradition of well-being focuses on the aspects of human functioning 81

that promote and reflect the pursuit of meaningful life goals. Carol Ryff and colleagues have identified six related but distinct factors that were proposed to encompass the eudaimonic idea: 1) 2) 3) 4) 5) 6) autonomy; environmental mastery; personal growth; positive relations with others; purpose in life; self-acceptance.

Individuals high in these aspects of well-being are independent and primarily driven by their own standards (autonomy), able to effectively identify and pursue external opportunities (environmental mastery), continually looking for opportunities to grow and develop (personal growth), engaged in mutually satisfying, warm, and trusting relationships (positive relations with others), able to identify and pursue meaningful goals (purpose in life), and have a positive attitude about both their personality and self (self-acceptance). This model is an extension of the Aristotelian philosophical tradition, which identified the pursuit of ones daemon, or true self, as the ultimate purpose in life. Sociologist Corey Keyes of Emory University has argued that the failure to consider the importance of an individuals social condition and relationship reflects an intrapersonal bias in psychological research. He has a model of social well-being that draws upon classical sociology. Keyes model of social wellbeing focuses on primarily public phenomena that reflect whether individuals are flourishing in their social lives. Social well-being has five factors that represent the extent to which individuals are overcoming social challenges and are functioning well in their social world. The five factors are social acceptance, social actualization social coherence social contribution social integration.

Keyes social well-being is an extension of the eudaimonic tradition of well-being from the intrapersonal focus of Ryff s model to the interpersonal realm.

Flourishing: An Integrated Model of Well-Being

Hedonic and Eudaimonic well-being are now being integrated into a comprehensive model of flourishing mental health. This integrated model of well-being maintains the theoretical distinctions of well-being, while simultaneously demonstrating that these models and components are strongly related to one another. Keyes believes that individuals described as flourishing have a combination of high levels of emotional well-being, psychological well-being, and social well-being. Keyes states that mental health may be operationalized as a syndrome of symptoms of an individuals subjective well-being. 82

To complete, or operationalize, the definition of what it means to be functioning optimally, or flourishing, there has been diagnostic criteria created for a flourishing life And Individual must possess a high level of well-being as indicated by the individuals meeting all three of the following criteria: Individual must have had no episodes of major depression in the past year

1) High emotional well-being, defined by 2 of 3 scale scores on appropriate measures falling in the upper tertile. Positive affect Negative affect (low) Life satisfaction 2)High psychological well-being, defined by 4 of 6 scale scores on appropriate measures falling in the upper tertile. Self-acceptance Personal growth Purpose in life Environmental mastery Autonomy Positive relations with others 3)High social well-being, defined by 3 of 5 scale scores on appropriate measures falling in the upper tertile. Social acceptance Social actualization Social contribution Social coherence Social integration Keyes believes that the WHO was right in 1948 when it argued that health and illness were seperate realities. Health is not merely the absence of disease. He writes that Based on these findings, we can discern support for the enduring proposal that health is a complete state (World Health Organization, 1948). Mental health is not merely the absence of mental illness, nor is it merely the presence of high well-being. Rather, we defined mental health as a complete state consisting of (a) the absence of mental illness and (b) the presence of high-level well-being. The model of complete mental health combines the mental illness and mental health dimensions, thereby yielding two states of mental illness and two states of mental health. In this model, mental health consists of a complete and an incomplete state; mental illness also consists of an incomplete and a complete state. Complete mental health is the syndrome that combines high levels of symptoms of emotional well-being, psychological well-being, and social well-being, as well as 83

the absence of recent mental illness. Thus, mentally healthy adults will exhibit emotional vitality (e.g., high happiness and satisfaction), will be functioning well psychologically and socially, and will be free of recent (i.e., 12-month) mental illness. Incomplete mental health, on the other hand, is a condition in which individuals may be free of recent mental illness, but they also have low levels of emotional, psychological, and social well-being. Complete mental illness is the syndrome that combines low levels of symptoms of emotional well-being, psychological well-being, and social well-being and includes the diagnosis of a recent mental illness such as depression. Adults with incomplete mental illness may be depressed, but they also will show signs of moderate or high levels of psychological and social functioning and will feel relatively satisfied and happy with their lives. Conceptually, adults with incomplete mental health are similar to high-functioning individuals who have a serious alcohol problem but can successfully hold onto their jobs (Keyes, 2002:49-50)..

The signifance of wellness and well-being

The importance of the work being done on wellnees and well-being is that it is providing tools for the measurement of the complex and dynamic state know as high-level wellness or flourishing. In 1948 the WHO had stated that health was a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. This lofty idea of health as a distinct and separate state from disease had seemed to be quite unrealistic, a utopian vision. However the vision of the WHO would seem to be more realistic and measurable than had been suggested possible a decade ago. Dunn saw high-level wellness as a direction in progress toward reaching an ever-higher potential of functioning. Aging is a fact. There is a sequential or progressive change in that leads to an increased risk of debility, disease, and death; senescence consists of these manifestations of the aging process. But senescence is only part of the story. The other part of the story, which is only starting to be told now is the human capacity for resiilent aging (2010) and the choice to make the best of any given situation. There are two ways of thinking about health and resilience (Kern and Friedman, 2010). The first is the traditional way with health being defined as a lack of disease, disability, and pathological breakdown, thus one is considered to be healthy until illness. We usually recover from illness and therefore become healthy again. The resilient people are those who survive an illness. Aging is a natural, progressive breakdown of physiological systems that ends in death. Successful aging involves accepting and managing the decline. The second way of thinking about health and resilence is in terms of the general quality of ones life- the personal sense of well- being or flourishing that can evolve over time, and it refers not only to physical, but also the mental, social, the spiritual, etc. to the totality of health and meaning (WHO,1948). Health is not a singular or static outcome, rather it is a process of challenges, negotiations, wins and losses, with ongoing adaptations over the life84

course. Individuals develop specific skills, select situations, build resources across multiple domains of life, and then maneuver to face the challenges. We change what we can, and hopefully acquire the wisdom to accept what we cannot change. We always are a mixture of health and disease (Antonovsky,1997). Thus people with serious disabities such as blindness or being crippled usually report that they have the same level of happiness as the rest of the population. From this life-course biopsychosocial perspective, success means dealing with a wide range of challanges across the lifespan. We are healthy when we can manage a balance of the different life domains. Resilience can be defined as successful functioning despite serious challenge or even chronic stress. Keyes might define this as Incomplete mental health but perhaps it is just Frankls tragic optimism making the best of a bad deal. Or is resilience Dlyans rage against that good night?. Comfort believed that the greatest virtue for the old is to be bloody-minded and to assert ones human dignity and rights. To choose to strive to the full until the end is perhaps the best thanks one can give for existing. The Venn diagram in Figure 1 shows how the three areas interact around the themes of resillence, salutogenesis, and the healthy prison
The Quality of Care and the Quality of Prison Life for the Aging Prisoner

Health & Well-being

Salutogenesis Resilience

Age, Disease and the Aging Prisoner

Penal Policy & Practices

Healthy Prison Figure 1: The Quality of Prison Life for the Aging Prisoner (Q)

Salutogenesis
Salutogenesis links health and well-being with penal policy and pracices. It is interesting that both Aaron Antonovsky developed his model of salutogenesis (1976) and Victor Frankel his 85

model of logotherapy (1992) in attempts to try to explain why some survivors had been able to find personal meaning despite having experienced the intentional trauma of the Nazi Camps of World War 2. Antonovsky was confronted with a group of female survivors of the Holocaust who didnt show the expected signs of post-trauma stress disorder. They had maintained their personal sense of coherence even though they were in a Nazi concentration camp. As the film Schindler's List shows so clearly, the design and operation of the camp was intended to not only use the individual as slave labor to work the individual to death in a few months- but to also destroy the individuals sense of coherence, to destroy any sense of personal dignity. They were to be reduced to a non-human status, to be something of no value, with no human rights, being unfit to live. The Nazis could tell themselves that they were not murdering fellow human beings, rather it was a necessary public health measure. These women had not only survived the slave labor, they had also maintained their sense of coherence, of being human and of fundamental value. They showed Antonovsky the essence of what health is. Antonovsky rejected the idea that health was the absence of disease. He saw a health ease/disease continuum. Salutogenesis Pathogenesis

Health ease Disease Continuum

Salutogenesis was the study of health development. This approach contrasted with the concept of pathogenesis or the study of disease development. Pathogenesis works retrospectively from disease to determine how individuals can avoid, manage, and/or eliminate that disease. Salutogenesis works prospectively by considering how to create, enhance, and improve physical, mental, and social well-being. He wrote that We are all terminal cases. And we all are, so long as there is abreath of life in us, in some measure healty He was interested in those factors that move the individual toward the healthy end of the continuum. Today one might use the term positive deviance (Pascale, Sternin, & Sternin, 2010) we expect to see the 71 percent who show the PTSD, but then there are the others, the positive deviants, the 29 percent of a group of concentration camp survivors were judged to be in reasonable mental mental health....To have gone through the most unimaginable horror of the camp, followed by years of being a displaced person, and then to have re-established ones life in a country which witnessed three wars ...and still be inreasonable health (1987: xi). Sense of Coherence (SOC) is a concept that includes the measurable independent variables of meaningfulness, manageability, and comprehensibility that Antonovsky documented to be associated with better health. Antonovsky believed that salutogenesis should be the theoretical basis for developing, testing, and implementing plans and practices that enhance health and well-being. Specifically, he offered three ways to do this: 86

(1) look at the data differently: instead of looking at those who have succumbed to a problem to find out why, look at those who are succeeding and try to find out why they are doing well; (2) persuade practitioners and researchers to ask about the factors related to success, not just factors related to problems; and finally (3) stimulate the formation of unique hypotheses generated to explain desired outcomes. Results from studies and practices that promote and develop positive health outcomes could then be the recommendations for promoting health. The prison is usually a good example of pathogenesis. It works retrospectively from the criminality (disease) to determine how individuals can avoid, manage, and/or eliminate that criminal behavior ( disease) - thus the focus on risk factors. Salutogenesis works prospectively by considering how to create, enhance, and improve physical, mental, and social well-being. It promotes health. The prison can be a health promotion setting if its design and operation is based on salutogenic thinking rather than on pathogenic thinking. A good example is a recent article, Exceptional prison conditions and the quality of prison life: Prison size and prison culture in Norwegian closed prisons (2011) that discusses the quality of prison life and prison size in relation to the notion of Scandinavian exceptionalism. Salutogenesis is an important part of Scandinavian thinking in health promotion and social policy including the penal model of Nordic Minimalism (Laine, 1993). The Folkhalsan Research Center in Helsinki, Finland is quite active in the study of salutogenic pathways to health promotion. In Promoting mental health: concepts, emerging evidence, practice (WHO, 2005) , Bengt Lindstrom and Monica Eriksson wrote a section on salutogenesis and argued that Promoting mental health as a positive concept belongs to the family of salutogenic concepts, that is, concepts that explore the origin of health not disease (Antonovsky, 1979, 1987) ... health is a relative concept on a continuum and the really important research question is what causes health (salutogenesis) not what are the reasons for disease (pathogenesis). The fundamental concepts of salutogenesis are generalized resistance resources (GRRs) and sense of coherence (SOC). The GRRs are biological, material and psychosocial factors that make it easier for people to perceive their lives as consistent, structured and understandable. Typical GRRs are money, knowledge, experience, social support, culture, intelligence, traditions and ideologies. ... GRRs help the person to construct coherent life experiences. Even more important than the resources themselves is the ability to use them, the sense of coherence (SOC). The GRRs lead to life experiences that promote a strong sense of coherence a way of perceiving life and an ability to successfully manage the infinite number of complex stressors encountered in the discourse of life. The salutogenic concept is a deep personal way of thinking, being and acting, a feeling of an inner trust that things will be in order independent of whatever happens. The inner trust developed by internalising the SOC concept leads us to identify, benefit, use and re-use the GRRs from our surroundings. 87

Three types of life experiences shape the SOC: consistency (comprehensibility), load balance (manageability) and participation in shaping outcomes (meaningfulness) (Antonovsky 1979, 1987). A fourth experience has been added to the SOC concept emotional closeness which refers to the extent to which a person feels emotional bonds and experiences social integration in different groups (Sagy & Antonovsky, 2000). SOC applies at the individual, group and societal level. Antonovsky postulated that it mainly is formed in the first three decades of life and that only very strong changes in life would upset and change the SOC thereafter..... The salutogenic approach claims health is open-ended and dependent on the skills to organize the resources available in society, the social context and self. These skills enable people and populations to develop their health and deal with the fragmentation and chaos of reality through using cognitive and emotional perception, behavioural skills and motivation developed through meaningful frameworks based on culture, tradition and belief systems. The salutogenic framework could guide public health in a new direction. This framework suggests that what we perceive as being good for ourselves (subjective well-being) also predicts our outcome on objective health parameters. In other words, if we create salutogenic processes where people perceive they are able to live the life they want to live they not only will feel better but also lead better lives (2005:50-51, emphasis added) The Folkhalsan Research Center has just published The Hitchhikers Guide to Salutogenesis (Lindstrom & Eriksson, 2010) which is a comprehensive review of the salutogenesis literture. This salutogenic idea was behind Tony Wards development of the Good Lives Model of Offender Rehabilitation (Ward & Maruna, 2007) based on his work with sex offenders. The goal is the help the offender to achieve their primary goods and associated narrative identities, but in more socially acceptable ways of realising them. Ward has a clear salutogenic focus. The increased interest in the process of offender desistance (Maruna, 2001) needs a study of the successful minority the positive deviants- who successfully re-enter society from prison. We need to look at those who are succeeding and try to find out why they are doing well. Antonovsky focused on the 29 percent of a group of concentration camp survivors were judged to be in reasonable mental mental health. The 30% of offenders who are able to desist should be as important a study.

Quality of Life
In the WHO Health Promotion Glossary (1998) Quality of life is defined as individuals perceptions of their position in life in the context of the culture and value system where they live, and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept, incorporating in a complex way a persons physical health, psychological state, level of independence, social relationships, personal beliefs and relationship to salient features of the environment. Reference: Quality of Life Assessment. The WHOQOL Group, 1994. What Quality of Life? The WHOQOL Group. In: World Health Forum. WHO, Geneva, 1996. 88

This definition highlights the views that quality of life refers to a subjective evaluation, which induces both positive and negative dimensions, and which is embedded in a cultural, social and environmental context. WHO identified six broad domains which describe core aspects of quality of life cross-culturally: a physical domain (e.g. energy, fatigue), a psychological domain (e.g. positive feelings), level of independence (e.g. mobility), social relationships (e.g. practical social support), environment (e.g. accessibility of health care) and personal beliefs/spirituality (e.g. meaning in life). The domains of health and quality of life are complementary and overlapping (1998:17, emphasis added). Quality of Life is really about how to evaluate the meaning of a situation. In the UK the ESRC Growing Older (GO) Programme (1999- 2003) had eight dominant themes: Meaning and measurement of quality of life Inequalities in quality of life The environments of ageing Family and economic roles Social participation Social isolation and loneliness Frailty, identity and social support Bereavement.

The UK researchers believed that hese eight themes covered the great majority of issues concerning quality in later life. Together theUK ESRC Growing Older (GO) Programme had 24 research projects looking at the different factors and processes relevant to QoL. They identified three primary dimensions of QoL termed being, belonging and becoming. Being refers to the physical, psychological and spiritual aspects of QoL; belonging is concerned with the adequacy of an individuals interpersonal relationships and their physical, social and community environments; while becoming encompasses personal aspirations regarding purposeful activity, instrumental activity, leisure pursuits and personal growth. QoL consists of both eudaimonia and hedonic happiness. Blane et al. (2002) conceptualized QoL as consisting of the satisfaction of needs in four areas: (1) control the need to be able to act freely in ones environment; (2) autonomy the need to be free from the undue interference of others; (3) self-realization the need for selfrealization; and (4) pleasure the need to enjoy oneself. Thus, these GO programme researchers propose that QoL consists of both hedonic happiness (pleasure) and what could be taken as important elements of eudaimonia, namely control, autonomy and, central to eudaimonia, self-realization(2005:18-19, emphasis added). These primary dimensions of QoL being, belonging and becoming are in practice quite similar to Antonovskys concept of Sense of Coherence - consistency (comprehensibility), load balance (manageability) and participation in shaping outcomes (meaningfulness) along with emotional closeness which refers to the extent to which a person feels emotional bonds and experiences social integration in different groups (Antonovsky 1979, 1987; Sagy & 89

Antonovsky, 2000) The issue of emotional closeness was central in Manns study of older prisoners frienship ( 2010,2012). Alison Liebling (assisted by Helen Arnold) has developed a tool for Measuring the Quality of Prison Life (2004, 2010). The central dimensions are these: Dimensions measuring the moral quality of prison life Dimension Harmony dimensions Entry into custody Respect/courtesy Staff-Prisoner relationships Humanity Decency Care for the vulnerable Help and assistance Professionalism dimensions Staff professionalism Bureaucratic legitimacy Fairness Organisation and consistency Security dimensions Policing and security Prisoner safety Prisoner adaptation Drugs and exploitation Conditions and Family Contact dimensions Regime decency Family contact Wellbeing and Development dimensions Personal development Personal autonomy Wellbeing Distress .875 .664 .786 .561 .705 .635 .751 .734 .623 .780 .885 .801 .820 .836 .618 .886 .867 .889 .636 .803 .772 Reliability

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Together these give a measurement of the quality of life. Lieblings work allows for the analysis of the quality of prison life both within one prison, to compare different prisons and even different prison systems. The measurement of the quality of prison life can help in the design of programs and support the development of a healthy prison. Lieblings MQPL fits within the salutogenic pathways to health promotion.

Health Promotion
If the WHO had a definition of health in 1948, it took until 1986 to have a developed strategy for Health Promotion that made its vision into an operational goal. There is no simple answer for what is meant by health promotion. Mittelmark, Kickbusch, Rootman, Scriven and Tones (2008 ) reviewed the defintions of the World Health Organization, the American Journal of Health Promotion and the US Center for Disease Control and Prevention. definitions, They write that The definition of health promotion given by the World Health Organization (WHO) in 1986 is in the Ottawa Charter for Health Promotion, and reads: Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to wellbeing.. Then there is the definition of health promotion given by the American Journal of Health Promotion (AJHP) in 1989 which has a slightly different emphasis: Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior, and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change. (American Jour nal of Health Promotion: http://www.healthpromtionjournal.com) World Health Organization What is Health? Resource for everyday life American Journal of Health Promotion Optimal state balancing physical, emotional, social, spiritual, and intellectual aspects Science / Art Lifestyle change Help people change their lifestyle.

What is health promotion? What is health promotions aim? How does health promotion reach its aim?

Process Go beyond healthy lifestyle well-being. Enable people to increase control over their health

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Contrasting definitions of health promotion

Finally there is the mission of the Center for Disease Control and Prevention (CDC) for its Coordinating Center for Health Promotion (CCHP): was created as a result of the changes in the landscape of public health. Today, many of the leading causes of death and disability are preventable through lifestyle modifications and better understanding of family history. To meet the needs of these new challenges in the area of disabilities, chronic diseases, and birth defects, CDC has strategically created Coordinating Centers that allow the agency to be more responsive and effective when dealing with the public whose health we protect. (Coordinating Center for Health Promotion, Centers for Disease Control and Prevention: http://www.cdc .gov/cochp). Thus it is important to be clear about what is meant by health promotion. This essay uses the Ottawa Charter for Health Promotion which is the foundation for most of the WHOs work including the Healthy Cities movement and the WHO Europes Health in Prison Project. Mittelmark et al note that it is also important to emphasize that Disease Prevention is not the same as Health Promotion. Although the terms are often used in tandem, health promotion is distinguishable from disease prevention. Disease prevention has in practice mostly to do with reducing the burden of chronic and infectious diseases by preventing their expression in the first place, by reducing the levels of risk factors for the diseases, and by intervening at early stages so diseases do not progress to more serious stages.... Health promotion is less concerned about specific diseases, although much of what is labeled as health promotion does include disease prevention as characterized above. However, health promotion places great emphasis on how individuals choices are limited by circumstances beyond their control. It is believed that policies are needed in all societal sectors, including the private sector, that create environments that support healthy living. There is also emphasis on empowering people to control their own health, and building individuals and communities capacities to identify and solve the health issues that are their own priorities. Because health inequalities within and between societies are exacerbated by social injustice, health promotion is compelled to enter the political arena, and advocacy for social change is an important health promotion strategy. The WHO has to spend a lot of its time and resources on Disease Prevention and Control but its main rationale for its existence has always been Health and therefore Health Promotion.

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The Ottawa Charter for Health Promotion

The logo for the 1986 conference

The Ottawa Charter was a foundational document for the new public health (Baum, 2002). The Ottawa Charter had five key action themes. These themes are all important in the evolution of the healthy prison. 1) Build healthy public policy Health Promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors to be aware of the consequences of their decisions and accept their responsibilities for health. Healthy public policies aim to achieve greater equity. For example, free and universal education, legislation, taxation and welfare. The aim is to make the healthier choice the easier choice for people and also for policy makers. Dr. Trevor Hancock has always emphasized the need for integrating health into all aspects of policy, planning and program delivery. Thus it is important to talk about healthy penal policy 2) Create supportive environments for health Social, economic and physical environmental factors are important in shaping peoples experiences of health. Health promotion creates living and working conditions that are safe, satisfying and enjoyable. Alan Dilani, Ph.D. writes about Psychosocially Supportive Design. His has an article on A Health Promoting Approach on Prison (2008). He notes that 93

the physical environment has often been an important concern, due to security reasons and most prisons are designed from a security and functional standpoint. It is of course important to focus on security aspects, but in this article, we prefer to highlight factors in the prison environment that do not often get much attention. It is time to build prison environments that are psychosocially supportive and health promoting for both prison employees and inmates. A prison environment that is psychosocially supportive is better for health promotion. However most prisons are not designed to be psychosocially supportive, in fact many seem to be designed to not be supportive. The Ottawa Charter talked about settings for health. The prison could become a setting for health in the same way as the school, workplace and family. 3) Strengthen community action for health Community development strategies increase the ability of communities to achieve change in their physical and social environments. This occurs through participation in collective decision making and action on issues that impact on their health and wellbeing. Greater power and control remains with the community themselves. Efforts at Justice Reinvestment and an appreciation of Community Justice critical to strengthen community capacity for action especially in those communities impacted by mass incarceration. 4) Develop personal skills Acknowledges the role of behaviour and lifestyles in promoting health and how people can be supported to build skills that will help them make positive changes. Provides information, health education and helps people to develop the skills they need in order to increase options available for people to increase control over their own health and environments, and to make healthy choices. The Reasoning & Rehabilitation program (1984) was the first cognitive-behavioral program designed to develop the personal skills that would be helpful in the desistance process. There is now two decades of evaluation results that show the R&R program reduces recidivism by 12-15% on average (Ross & Hilborn, 2008; Hilborn, 2011) 5) Re-orient health services enable, mediate and advocate Health promotion is everybodys business. Health systems need to shift their focus from disease care (eg institution - based treatment ) towards a system that is community-based, more user-friendly and receptive to client needs, which focuses on health and wellbeing. It is critical to re-orient the criminal justice system from a dependcncy on mass incarceration to an inclusive penal moderation. This re-orientation process has started to happen in the United States of America after 35 years of the experiment in mass incarceration. Those systems that are still moderate, such as the Nordic prison systems, need stakeholder, media and political support against the pressure of penal populism.

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Health Promotion Setting

In the WHO Health Promotion Glossary (1998) there is the definition of a setting for health. Settings for health The place or social context in which people engage in daily activities in which environmental, organizational and personal factors interact to affect health and wellbeing. A setting is also where people actively use and shape the environment and thus create or solve problems relating to health. Settings can normally be identified as having physical boundaries, a range of people with defined roles, and an organizational structure. Action to promote health through different settings can take many different forms, often through some form of organizational development, including change to the physical environment, to the organizational structure, administration and management. Settings can also be used to promote health by reaching people who work in them, or using them to gain access to services, and through the interaction of different settings with the wider community. Examples of settings include schools, work sites, hospitals, villages and cities.

Source: Grossman & Scala (1993) The settings approach thus not only recognises that contexts influence health and the achievement of the core goals of a setting, but also suggests that effective health improvement requires investment in the social systems in which people spend their daily lives.

Healthy Prison
Discussion about a conference to develop the idea of the healthy prison goes back to 1993 and the Healthy Cities movement. An International Conference on Healthy Prisons was held in Liverpool in 1996. The UK Health of the nation (1997) identified prisons as one of the settings in which health could be promoted. Suicide is Everyones Concern: A Thematic Review (1999) HMI-Prisons included a chapter on the Healthy Prison. He wrote that 95

We believe the phrase healthy prison is useful in helping to demonstrate positive aspects of custody but the term in no way implies that prisons, even those that are very well run, are healthy in the full sense of the word. What is important is for prisoners and staff to be enabled to live and work in prisons in a way that promotes their wellbeing(1999:59). A safe prison must at least: create a safe and predictable environment regularly monitor the well-being of prisoners to establish that they are safe have an effective anti-bullying strategy have an incentives scheme that encourages responsible behaviour and does not just reward conformity have rules which are necessary, that are explained to prisoners and are fairly administered keep good records of individual prisoners. Test 1 - the weakest prisoners feel safe Test 2 - Prisoners are tr eated with respect as individuals Test 3 - Prisoners ar e fully and purposefully occupied and are expected to improve themselves. Test 4 - Prisoners can str engthen links with their families and prepare themselves for release. The HMI-Prison also looked at staff. A healthy prison for staff is one in which: staff feel safe they are treated with respect as individuals they are informed and consulted within their sphere of work they have high expectations made of them they are well led they respect their own health. Recommendation . It should be a priority to use the principles of a healthy prison in order to identify establishments in which the treatment of prisoners is undermined by inappropriate cultures; alternative healthy cultures should be promoted (1999:60-65). The next HM Chief Inspector of Prisons for England and Wales, Ann Owers continued the development of the Healthy Prisons model with Expectations: Criteria for assessing the conditions in prisons and the treatment of prisoners (2006. 3rd Edition). Expectations focused on the same four core themes Safety Respect Meaningful Activity Resettlement 96

Expectations provided a very detailed description of all the steps of the individual prisoners movement through the sentence until re-entry. The next Chief Inspector in the latest Inspection Manual 2008 made it clear that it should be read together with the three volumes of inspection criteria Expectations: for adult prisons, juvenile prisons and immigration detention. Together they form a robust and internationally recognised methodology for the inspection of the hidden world of closed custodial conditions. The Inspection manual and the three volumes of inspection criteria Expectations are available for download at http://www.justice.gov.uk/guidance/inspection-and-monitoring/hmiprisons/index.htm. Together they provide valuable resources for making the healthy prison into an operational reality. The International Centre for Prison Studies has published A Human Rights Approach to Prison Management: Handbook for Prison Staff (2009) which covers the same core themes as the Expectations volumes. . Its author is Andrew Coyle who is both a Professor of Prison Studies and he also spent 24 years working as a prison director in the UK system. The ICPS has also published a set of detailed guidelines on penal reform. Over the past 19 years the UK has developed a solid operational understanding of what needs to be done if a prison has the protential to be a setting for health promotion even as the HMIPrisons did state that the term healthy prison should not imply that prisons, even those that are very well run, are healthy in the full sense of the word. A prison is still an act of violence by the state which is designed to cause pain. The hope that this prison setting may also become a place for health promotion as well- the healthy prison does not have to be an oxymoron. Nick de Viggiani (2006, 2007) argues that health inequalities are enmeshed within the workings of the prison system itself and therefore he is quite critical of potential of the HIPP to transform these unhealthy prisons . The work of Alison Liebling and the HMI-Prisons does suggest that a healthy prison may be similar to pacifism on a battlefield, difficult but not impossible.

Health in Prisons Project (HIPP)

This description was taken from the WHO Europe HIPP web site. WHO established HIPP in 1995 is to support Member States in improving public health by addressing health and health care in prisons, and to facilitate the links between prison health and public health systems at both national and international levels. HIPP has since developed into an international movement to promote health in prison settings. HIPPs main activity is to give technical advice to Member States on the development of prison health systems and their links with public health systems and on technical issues related to communicable diseases (especially HIV/AIDS, hepatitis and tuberculosis), illicit drug use (including substitution therapy and harm reduction) and mental health.

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As part of HIPP, WHO/Europe established a network of national counterparts and international partner organizations to liaise between WHO/Europe and Member States. The network currently includes 44 national counterparts, and meets once a year to discuss specific topics. HIPP aims:

to encourage cooperation and establish integrated work between public health systems, international nongovernmental organizations and prison health systems to promote public health and reduce health inequalities; to encourage prisons to operate within the widely recognized international codes of human rights and medical ethics in providing services for prisoners; to help reduce reoffending by encouraging prison health services to contribute fully to each prisoners rehabilitation, especially but not exclusively in relation to drug addiction and mental health problems; to reduce prisoners exposure to communicable diseases, thereby preventing prisons becoming focal points of infection; and to encourage all prison health services, including health promotion services, to reach standards equivalent to those in the wider community.

The HIPP demonstrates the tension that exists in most WHO projects- 1) the need to focus on disease prevention and the development of disease focused healthcare, and 2) the WHO mission of health and health promotion. It is important to remember that healthcare has as its main focus the detection and treatment of disease. As Dr. Trevor Hancock likes to put it Medicine has little to do with health, so I moved from medicine to health. Who Europe HIPP has published several worthwhile documents focusing on and prison healthcare. Patient or Prisoner: Does it matter which Government Ministry is responsible for the health of prisoners? (2010) The Madrid Recommendation: Health protection in prisons as an essential part of public health (2010) Trencin statement on prisons and mental health (2009) Moscow Declaration on Prison Health as Part of Public Health (2003) Promoting the health of young people in custody (2003)

Health in prisons : A WHO guide to the essentials in prison health (2007) is a good basic overview. The limited section on suicide was included within the discussion of womens health in prisons. A separate and more detailed section that looked at depression and suicide for both women and men would have been valuable but the WHO already had its manual on Preventing Sucide: A Resource for Prison Officers (2000) as well as Promoting Mental Health (2005). The WHO HIPP has made the issue of womens health in prisons one of its priorities. Womens health in prison: Action guidance and checklists to review current policies and practices (2011) Womens health in prison. Correcting gender inequity in prison health (2009) 98

and assisted in the development of Handbook for Prison Managers and Policymakers on Women and Imprisonment (UNODC, 2008) Women and HIV in prison settings (UNODC,n.d.) The other WHO-HIPP priority has been prisons, drugs, HIV-AIDS and MDR-TB. Prevention of acute drug-related mortality in prison populations during the immediate post-release period (2010) Prison health HIV, drugs and tuberculosis (2009) Status paper on prisons and tuberculosis (2007) Status paper on prisons, drugs and harm reduction (2005) Progress on implementing the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and central Asia (2004) Prisons, drugs and society (2001)

There is a lot of concern about HIV/AIDS and also the increase in MDR-TB. The WHO states that The risk of developing tuberculosis (TB) is estimated to be between 20-37 times greater in people living with HIV than among those without HIV infection. In 2009, there were 9.4 million new cases of TB, of which 1.2 (13%) million were among people living with HIV. Of the 1.7 million people who died of TB, 400 000 (24%) were living with HIV. TB is a leading cause of morbidity and mortality among people living with HIV. In response to demands from countries, WHO recommends 12 TB/HIV collaborative activities, including the Three I's for HIV/TB. The WHO HIV/AIDS and TB Departments and their partners, including community groups, work collaboratively on joint HIV/TB advocacy, policy development and implementation in countries. WHO also develops and promotes tools and guidelines to support countries in improving their TB/HIV collaborative action in order to achieve universal access to HIV and TB prevention, care and treatment services for all people in need (http://www.who.int/hiv/topics/tb/en/). The WHO Global health sector strategy on HIV/AIDS, 20112015 guides the health sector response to human immunodeficiency virus (HIV) epidemics in order to achieve universal access to HIV prevention, diagnosis, treatment, care and support. The strategy: reaffirms global goals and targets for the health sector response to HIV identifies four strategic directions to guide national responses outlines recommended country actions and WHOs contributions

The reality is that prison directors should be very worried about HIV/AIDS and TB,especially the directors in Central and Eastern Europe. Injecting Drug Users (IDU) were the main source of HIV/AIDS in countries such as Estonia but now HIV/AIDS has started to move from the IDUs and the prison systems into the general population. A recent study on multi-drug resistant tuberculosis (MDR-TB) was aptly entitled Timebomb: The Global Epidemic

of Multi-Drug-Resistan Tuberculosis (Reichman & Tame, 2002).

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Prison Suicide
There are several good national and international prison manuals that attempt to deal with the issue of prison suicide. The WHO has devloped its manual on Preventing Sucide (2000:6) stating that As a group, inmates have higher suicide rates than their community counterparts. For example, in pretrial facilities housing short-term inmates, the suicide rate is ten times that of the outside community. In facilities housing sentenced prisoners, the suicide rate is three times higher than in the outside community. Also, for every completed suicide that occurs, there are many more suicide attempts in prison (emphasis added). The answer to the question of Why Suicide may be very simple and painful: Why Not?. In an article on Suicide Methods in Prison (2008) there were these comments about why prisoners might decide to kill themselves. When discussing factors contributing to the desire to kill oneself while incarcerated, the answer seems self-evident; social isolation, harsh discipline, lack of privacy, constant threat of violence, fear, guilt, hopelessness, and depression all take a heavy toll on the human spirit. However, several common stressors typically precede an inmate suicide: 50% of suicide victims in New York prisons recently experienced inmate-inmate conflict, 42% experienced recent disciplinary action, 40% were in a state of fear, another 42% were physically ill, and an overwhelming 65% had either lost "good time" privileges or had severed relationships with friends or family. Many suicide victims saw a mental health service-provider before their suicide, but the majority of suicide victims are not mentally ill (Way, Miraglia, Sawyer 2005). While increased security measures have likely reduced the number of suicides (and likely increased the total budget of correctional departments), the motivation to commit suicide must be equally considered in prevention. This, however, represents a paradox, particularly for lifers: how do we make an inmate want to live within a disciplinary environment that makes the inmate want to die? (emphasis added).

Penal Moderation
At the level of the US Federal prisons there is a slight decline in the number of prisoners and people on probation for the second consecutive year. The Bureau of Justice Statistics (BJS) reported 15.12.2011 that the number of offenders under adult correctional supervision in the U.S. had declined 1.3 percent in 2010, the second consecutive year of decline since BJS began reporting on this population in 1980. At yearend 2010, about 7.1 million people, or 1 in 33 adults, were under the supervision of adult correctional authorities in the U.S. In addition, the total U.S. prison population fell to 1.6 million at yearend 2010, a decline of 0.6 percent during the year, the first decline in the total prison population in nearly four decades. This decline was due to a decrease of 10,881 in the number of state prisoners, which fell to just under 1.4 million persons and was the largest yearly decrease since 1977. The federal prison 100

population grew by 0.8 percent (1,653 prisoners) to reach 209,771, the smallest percentage increase since 1980 (2011, emphasis added). As mentioned earlier, there is a growing political consensus that mass incarceration is not that effective at crime prevention or rduction, too costly and there is unacceptable collatoral damage to families and communities. It is becoming politically possible for a politican to start to suggest a more moderate course of action. But it is still going to be risky. In November 2011 Congress passed a 2012 budget for the U.S. Department of Justice that increases funding for the Federal prisons while cutting back on COPS (Communiy Oriented Policing Services) by 33.4% , Juvenile Justice by 37.4% and the Second Chance Act by 37%. Thus funding for community involvement with the police, evidence based early intervention and diversion, and funding for re-entry support was cut back by about 1/3. These areas were never a high priority and represent only a small part of the overall budget. In the United States there is a massive investment in the existing network of prisons and jails. It will be very hard to slow down or even to reverse the trend of the past 40 years. This is also true in England and Wales, Australia and New Zealand. Penal moderation is a lot better policy. It increases the chances that there will be time and resources for prison healthcare and even health promotion. When prison managers are trying to deal with issues such as nsufficient staffing and over- crowding then the emphasis is going to be on control. The UK has developed a model of healthy prison practice and expertise in evidence-based rehabilitation programs but it also has A high rate of incarceration for the EU at 154 per 100,00 A prison population of 86,131 An official capacity of 77, 512 so it is at 112.7% occupancy level.

England & Wales Belarus Hungary Latvia Lithuania Estonia Finland

Rate of Incarceration 154 per 100,000 381 per 100,000 163 per 100,000 314 per 100,000 276 per 100,000 252 per 100,000 59 per 100,000

Prison Population Occupancy Level 86, l131 36,533 16,328 7,055 9,139 3,381 3,189 112.7 % 106.7 % 132.4% 78.4 % 100% 97.2 % 99.6%

Comparing different European Prison Systems

England & Wales has a middle rate of incarceration and occupancy but the largest prison population Belarus has the highest rate of incarceration but a middle level of occupancy 101

Hungary has a middle level of incarceration and the highest occupacy high occupancy level. Lithuania and Estonia have high levels of incarceratio and moderate occupancy level Latvia has the 2nd highest rate of incarceration but the lowest occupancy level Finland has the lowest rate of incarceration and prison population, and a middle occupancy level. So which system is suffering from mass incarceration? Perhaps England & Wales because of the numbers, the high operating cost, the public debates and occupacy level. Belarus has the highest rate of incarceration, a high number of prisoners but not the high operating cost, the EU concerns about its Human Rights and lack of Democracy. Hungary has the highest occupancy and a larger prison population then the Baltic States Finland has the lowest rate of incarceration and the lowest prison population. It should find it to be fairly easy to develop a healthy prison system.

Finland: From Mass Incarceration to Nordic Minimalism

There are complex reasons why Finland moved in the 1970s to 1990 from a system with a fairly high rate of incarceration- quite similar to todays Baltic neighbours down to 70 per 100,000 by 1992, and have maintained a low rate despite the level of crime in Finland. It is a excellent illustration of the simple fact that the rate of incarceration is determined by cultural and political forces. John Pratt has written about both Penal Populism and the . His presentation at the Prison Fellowship New Zealand put it most simply. Prison levels in Finland began to fall when they did because key people in that society people who actually knew something about penal policy and the consequences of imprisonment: academics, judges and senior civil servants felt that the high prison population was shameful (Lappi-Seppala 2000). The level it had then reached similar to New Zealands today made Finland seem more in line with the values of Eastern Bloc totalitarianism rather than the exemplars of Western liberalism and tolerance as practised by its Scandinavian neighbours (and reected in their prison levels). And today we see the results. As the prison population of New Zealand has climbed to the heights that Finland used to have, Finland has moved in the opposite direction showing what can be done when penal policy is entrusted to the care of people who know what they are doing: academics, judges and senior civil servants. This is how the great changes were engineered in Finland even if it might come as a surprise to some people in New Zealand that a government was prepared to leave the making of penal policy to those people who actually had some idea of what they were talking about. is radical shift also shows what can be done when governments are serious in wanting to reduce the levels of imprisonment. At the same time, law and order has never been a political issue in Finland. There is also a great deal of satisfaction with the Finnish criminal justice system and there are high levels of trust in the government and its ocials (2006: 52-53). 102

Its Not Crime! Its Politics!

In Finland there was an unusual combination of factors in the 1970s. High trust in the experts, the government, the criminal justice system, media support and no politicans trying to use fear of crime to achieve political ends- together these factors made penal reform possible within a short period of time (Tapio Lappi-Seppala, 2004). Thomas Mathiesen in Norway has discussed how such an alliance of the media, politicans and stakeholders in the criminal justice system (especially the police) have prevented further penal reform. In Finland the same alliance of media, politicans and police made the reform possible as much as it has been impossible in the United States or New Zealand. Pratt notes that the rise in imprisonment in New Zealand in recent years has not been driven by rising crime, but by political expediency. What we have seen being put into eect is a strategy not unique to New Zealand (2006:53, emphasis added) It is important to understand the shared value that supported this consensus in Finland in the critical period of penal transformation. In 1993 there was a conference on Penal Reform in Estonia. Matti Lane from Finland made a presentation on the Nordic (Scandinavian) Model. Lane described the Nordic (Scandinavian) Model thus: The Scandinavian or Nordic model has al so meant many prac t i cal changes in everyday prison servicc and administration. The basic approach is to keep the prison system as small as possible, with prison seen as the last resort in crime prevention. Especially when it comes to juvenile delinquency, prison sentences have been seen as very harmful and we have tried to avoid using them as far as possible ...(there are) three cornerstones of modern correctional philosophy in Nordic countries. They are normalization, openness and responsibility. A. Normalization The idea of Finnish prison legislation is that prison sentence means only the deprivation of liberty and no more (in practice, of course it always means many other things). So at least the idea is that such things as coldness, darkness, hunger or restricted diet, prohibition of cigarettes, books, magazines, loss of civil rights etc. Are necessary elements of imprisonment .... B. Openness This principle is surely a kind of paradox. The task of the prison is to close people inside, away from normal life. At the same time, we try to keep the prison as open as possible. Openness means many kinds of things: open prisons; good possibility for visits; uncontrolled conjugal visits; basically no limitation or censorship in correspondence; possibility to study and work outside prison (so called night prison); and prison leave.... C. Responsibility 103

For the last two hundreds years, the basic problem of most western prisons has been that the main thing they teach inmates is how to live in prisons, how to survive. These skills are not always the best for living life in free world. We know that this is often a typical feature of total institutions. When I was in the military servi ce, we were oftenvdiscussing what is the basic skill you learnvin the army. Very often the answer was:vhow the avoid your responsibilities, how to live lazy life. When everything is done for you, whenva special person opens the door in front of and behind you, that does not strenghten your sense of responsibility. Western prisons can be like large hotels in a negative sense, and the effects can be seen.vWhen I was working about ten years agovin the special after-care unit of paroledvformer prisoners, it happened very oftenvthat a newly released man couldnt shutvthe doors behind him. ... it as possible and positive that prisoners buy and cook their own food, wash and repair their own clothes and take responsibility for their own treatment. We must not forget thatvprofessional help can very often deepen the process of institutionalization prisonization. One of the main ideas of the prisonvlegislation reform in Finland in the middle of 1970s was that a prison sentence is always harmful for the offender. Because of its total and punitive character, it cannot rehabilitate inmates and usually makes their situation worse. That does not, however, mean that the harmful effects are always the same. It is possible to influence these and so the task was given to minimize the harmful effects of imprisonment. Crime and Punishment Around the World EUROPE Volume 4 had an excellent section on Punishment in Finland. (Markku Heiskanen and Anna Vuorelainen, 2011:111-113)

Punishment
Finland has pursued a conscious, systematic, longterm criminal policy. The decrease of the prison population is one of the outcomes of this policy. Several reasons can be found behind the decrease of the Finnish prison rates. Nordic penal policy has been described as a pragmatic, less politicized, and nonmoralistic approach, which has had a clear social policy orientation. There has been a strong political will among professionals and practitioners in Finland to decrease the prisoner rate. The comprehensive planning instruments of the welfare society have been utilized. The slogan effective social policy is the best criminal policy describes the intertwined structure of the areas: measures against social marginalization and inequality are also effective means against crime. At the same time there has been in the Nordic countries a strong debate emphasizing the ineffectiveness of an extensive use of the prison system. In Finland, an extensive theoretical cost-benet analysis was used aiming at the minimization of the costs and harmful effects of crime and of crime control, and the fair distribution of the costs among the offender, society, and the victim. Costs in this connection referred not only to the material costs, but also to the immaterial costs to all of the three parties. As a consequence, many laws have been enacted to decrease 104

the prison population. The development of punishments has in practice been directed toward an increased use of nes.

Types of Punishment
The following nancial punishments are described in the Finnish penal code: Day-ne. The idea of the day ne system is that the penalty is in relation to the offenders economic situation. One unit of ne represents approximately 1 out of 60 of the total monthly net income of the person described Conversion sentence. In case a ne cannot be collected, it can be transformed into a custodial sentence. One day in prison makes up for three day nes. A conversion punishment must last for at least 4 and no more than 60 days. Penalty ne. The penalty ne is a less serious nancial punishment than a day ne. The sum is xed and cannot be more than 200. The penalty ne varies and is always a set amount for a particular offense. An unpaid penalty ne cannot be converted into imprisonment. Police offcers and other officials (carrying out a statutory function) have the right to issue penalty nes, while nes are imposed by the prosecutor or the court. The following custodial punishments are described in the Finnish Penal Code: Conditional sentence. When a prison sentence is conditional the execution is postponed until the end of a probation period. The period lasts for at least one and no more than three years. At the end of the probation, the sentence is cancelled. Unconditional sentence. A custodial sentence consists of the loss or restriction of freedom. A prison sentence is either a temporary or a life sentence, although the latter is not to be taken literally in practice. An inmate serving a life sentence is eligible for parole after 12 years of incarceration. A single temporary sentence ranges from 14 days to 12 years, and the maximum length of a combined sentence is 15 years. Offenders who are classi ed by the health authorities as unaccountable are given psychiatric treatment in closed institutions, but this is not considered as a punishment. Probation. Most convicts are given the chance to spend the end of their sentence outside the prison. It is possible to apply for parole when two-thirds of the sentence are served. If the convict was younger than 21 years old at the time of the sentencing, he or she is eligible for parole after one-half of the custodial sentence. Trial freedom under surveillance. Since 2006, it has been possible, to facilitate social inclusion, to release a prisoner into the society no more than six months before probation, accompanied by an electronic surveillance device. The convict must commit to complete sobriety.

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 Community service. Community service is a common punishment initiated in the 1990s, which can be applied instead of a no more than 8 months prison sentence. Depending on the length of the sentence the duration of the community service is 20 200 hours. When imprisonment is converted into community service, one day in prison equals to one hour of community service. Restraining order. Finland started using restraining orders in 1995 (extension involving family members in 1999). It is not a punishment, but a preventive measure to protect a potential victim. It states that the receiver is forbidden from approaching, contacting, following, or watching the claimant. The maximum length of a restraining order is one year, in cases involving family members, three months.

Typical Punishments
Typical punishments for crimes are as follows: Rape: at least 1 and no more than 6 years in prison, up to 8 years if aggravated. Murder: a life sentence, which is in practice at least 12 years in prison, less for killing with mitigating circumstances. In 2005 the average punishment for manslaughter was more than 9 years in prison. For an attempted manslaughter the punishment was around 3.5 years. Assault: a ne or custodial sentence of no more than 2 years; at least 1 and no more than 10 years in prison if aggravated. The average punishment for aggravated assault was just under 2 years in 2005. Theft/burglary and aggravated theft/burglary: varies from a ne to a 1-year-and-6month custodial sentence. If the offense meets the conditions of an aggravated theft or burglary, the sentence goes up to 4 months to 4 years in prison. Serious drug offense: varies from 1 to 10 years in prison. In 2005 the average sentence was a little more than 3 years. Prison The imprisonment act was renewed on October 1, 2006. Five regional prisons were established. All prisoners begin their sentence in the regional prison of their residential location. A personal needs and risk assessment is made to measure the factors that have contributed to the development of the convicts criminality and the required level of security. The convicts must be placed in institutions near their homes to preserve relationships between inmates and their families. Other factors that are taken into account are age, gender, health, number of convictions, previous offenses, the convicts own preference, and possibilities to take part in productive activities while incarcerated. A convict can be placed directly into an open prison, if he or she is serving a conversion of a ne or less than one years sentence and commits to sobriety. There are in total 26 prisons in Finland, of which four are open. The largest prison is the Turku prison, which houses approximately 350 inmates. Inmates of all kinds are placed in the Turku prison, from juveniles and rst timers to those serving life imprisonment, as well as people serving a ne conversion sentence. In 2007, there were 3,551 prisoners on the average, out of which 7 percent were women and 9 percent foreign nationals. At the beginning of the 1950s Finland had about 200 prisoners per 100,000 inhabitants, while the gures in Denmark, Norway, and Sweden were around 50. By the beginning of the 1990s the prisoner rates in Finland had 106

decreased to the Nordic level, which had during the years remained rather stable (about 60 prisoners per 100,000). The number of prisoners was lowest in 1999 (2,743 persons incarcerated on the average), and since 1999, it increased until 2005 (3,888 persons). The changes in the prisoner rates can partly be traced to changes in legislation. Most law reforms from the 1960s up to the beginning of the 1990s were launched to decrease the number of prisoners (more than 25 law reforms). However, from the middle of the 1990s, the punishments for assault, rape, and drug-related crimes increased. In 2006 and 2007, the number of prisoners has been slightly lower than in the antecedent years. The reasons for the decline have been the decrease in theft convictions, while violence has not increased. At the same time the number of default prisoners has decreased. During the recent years, about 35 percent of the prison sentences up to eight months have been converted to community service. The number of community service sentences has been approximately 3,700 per year, and the share of successfully completed sentences has been about 80 percent. One-half of the crimes leading to community service were aggravated drunken driving cases. .................

Work and Education while Incarcerated

Approximately 40 percent of the prison population takes part in employment. About half of them work in maintenance and other activities related to the everyday running of the prison. Another half are employed in the production of goods sold in the prison shops and over the Internet. The prisons collaborate with local schools to provide teaching in both general knowledge and practical skills. It is not stated on the certicate that the degree was accomplished in prison. In 2007, a total of 1,737 inmates participated in education while incarcerated. One-third of them were heading for a vocational degree and almost as many for a high school diploma. Most of the teaching was arranged within the institution, but in some cases the inmates were granted the permission to take part in education outside the prison. Keeping in touch with the World Outside An inmate can be awarded permission to make phone calls outside of the prison. The phone calls can be tapped in case there is a suspicion of misuse, but both the recipient and the caller must be informed about it. The inmates are allowed to exchange letters without any quantitative restrictions. They can be searched for illegal substances or read for security reasons. Friends and relatives are allowed to spend time with the prisoners during speci ed visiting hours. The prisons provide an apartment for family visits, for the prisoners to meet their loved ones in a more homelike environment. Family meetings are not monitored, therefore, the visitors must meet security requirements. A prisoner can be granted a temporary leave after two-thirds of the sentence has been spent or if there are special circumstances. The reliability of the inmate is assessed and in some cases a chaperone (guard) is appointed for the duration of the leave. The maximum length of a leave is in total three days to two months. 107

This description shows how the principles of normalization, openness and responsibility can be made into operational policies and practices. It also shows that penal harm can be minimized and there can be movement toward a healthy prison. There are concerns that penal populism could destroy the Nordic model. There is less political consensus in the Nordic countries. A lehtal combination of the media, politicans and sectors of the criminal justice system could be as destructive as it was in the United States in the 70s and now in Canada. Tapio Lappi- Seppata belieives there is still room for some optimism since Overall the prisoner rates are still low Very few of the social, political, economic and cultural factors apply in the Scandinavian the same way they did in the US and the UK The social and security of the Nordic Welfare State may continue to bea backup to the tolerant crime policy Judges and presecutors are career officials with a sensitive professional touch in such matters Political culture still encourages negotiations and appreciates expert opinion John Pratt is less optimistic but he also has the New Zealand experience. In some ways the Right on Cime in the US gives reason for guarded optimism since things can change for the better as while as for the worse.

The Coming Age Wave

Throughout this essay the emphasis has been on the negative impact of mass incarceration and the aging EU population. However there didnt seem to be any data on the age makeup of the different EU prisons. At last a source was found in the Council of Europe Penal Statistics.

Country

Prisoner s

Estonia Finland Hungary Latvia Lithuani a

3,555 3,589 16,459 6,999 8, 295

21 less than 25 530 408 1535 850 2826

25 less than 30 741 663 2670 1112

30 less than 40 1121 1152 5687 1450 2143

40 less than 50 565 776 3364 778 1079

50 less than 60 249 376 1382 262 426

60 less than 70 60 89

70 less than 80 5 10 266 67 109

80 and Older 1 0

Council of Europe Annual Penal Statistics SPACE 1- 2009

Estonia and Finland have similar size of total prison population but the Finnish population is already rapidly aging . So there are more older prisoners in the Finnish system. Finland aging prisoners may represent the future for Estonia. Estonia also still gives longer sentences than Finland. 108

Hungary has a large number of older prisoners but like Latvia and Lithuania it does not collect details on the prisoners over 60. The Council of Europe data does support the thesis of more older prisoners as the overall population changes. The data from other countries, especially the United States documents the increased physical and mental health needs and also the massive increase in costs.

Social Inequalities
One solution is move from High Levels of Incarceration to Penal Moderation if not the goals of Nordic Minimalism. However the Nordic Minimalism model is supported by Nordic Social Policy and the Nordic Welfare System. It has been argued that social determinants of health (WHO, 2003 ; Wilkinson,1996) play a large factor in social and health problems and the level of crime and imprisonment in a society. In The Spirit Level: Why Greater Equality Makes Societies Stronger ( Pickett and Wilkinson, 2009) make the link explicit. The thesis is that the more social inequality in a society, the more the use of prison to control the population. Tapio Lappi- Seppata has made a similar argument to explain the Finnish success in reducing its prison population, The thesis is shown in this chart from The Spirit Level.

It is an interesting thesis beyond the scope of this essay but it may be a critical factor in both the rate of incarceration and the ability of a society to reduce its rate. 109

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