France: beyond the stigma

Doctors of the World. We have taken an “outreach” approach. A “community facilitator” works with prisoners on a daily basis, in their cells, on walks… This person also meets with the prison staff and health unit professionals. The goal is to create a space for communication between the prisoners, supervisors and health unit staff, so that they can find solutions together. Establishing a climate of trust and proximity is absolutely essential, so that people are comfortable discussing the subjects that are important to them.

We insist on the community nature of this work, and prisoners are truly at the centre of this project. As much as possible, we want to take a back seat so that prisoners are completely free to make their voices heard.

We have been very clear from the beginning: without the prisoners’ participation, this project could not exist. In concrete terms, the “community facilitator” meets with the prisoners and, based on their issues, identifies a subject to be addressed. Working groups are then set up to address the issue and work collectively to find solutions.

Solutions are then presented to the prison administration and health staff by the prisoners themselves, accompanied by Doctors of the World representatives. Our role during this phase is primarily to ensure that the prisoners are heard and that their position is taken into account. If there is agreement on a solution, it is adopted, and the working group can move on to another topic. We have been pleased to see that prisoners have become invested in this system and are now initiating proposals. For example, they have created communication tools to share information about these meetings with fellow prisoners.

DOTW. For Doctors of the World, harm reduction is a highly valued approach. We have worked toward this extensively on the outside, and we are concerned with these issues inside prison facilities. Unfortunately, there are no such measures in place within the Nantes prison. The law relating to modernising the health care system has reaffirmed the value of harm reduction in prisons, but for now there is no requirement for implementation. As a result, there is nothing in place either in the Nantes prison or at the national level.

Any existing harm reduction measures within prison walls are the result of professional risk-taking. Such initiatives may come from doctors in the health unit who, for example, write syringe prescriptions so that a prisoner is not punished if injection equipment is found in their cell. The CSAPA and CAARUD¹ can provide this type of equipment. In these cases, let’s be clear that the prison administration has collaborated on the initiative. While it is encouraging to see that people are setting up such measures, unfortunately there is no systemisation. The day the doctor giving out syringes retires, the whole system stops. This really raises the question of how sustainable these initiatives are.

We organised the visit of the Nantes facility’s director to the Champ-Dollon prison in Switzerland, where harm reduction practices are well established. We wanted to show him that the system works and that there are no insurmountable obstacles to its implementation. We also wanted to make him aware that it does not only benefit the prisoners.

In Champ-Dollon it was the wardens themselves who launched this initiative, with the aim of avoiding their own risk of infection in case of contact with material.

Harm reduction is often a source of stigma. We would like to help the teams at Nantes implement this practice inside the prison, but in the proper way. We think the initial focus should not be on needle exchange, which is a sensitive topic. There are other ways to practice harm reduction, and risks are not limited to those surrounding substance injection. We can also address sexual health, tattoos, piercings…. In Nantes, the distribution of condoms in prison is non-existent, despite being provided for by law.

In France, the only existing measure inside prison facilities is the distribution of bleach in the kit given to incoming prisoners. This is absolutely not sufficient. The bleach is diluted to 12° to limit the risks of intoxication and suicide by ingestion. There is no proof that such a low concentration can properly disinfect anything.

DOTW. These topics are taboo, but as the discussions went on, the bond of trust grew stronger. Some people felt ready to talk about these sensitive subjects. Others were able to talk about suicide. These topics took time to emerge and were discussed individually at first. The working groups around these issues include only those prisoners concerned.

Talking about substance use is not easy for prisoners. They fear being stigmatised or having their substance use disorder revealed to others. Not all staff in health units are comfortable with the issue. Some prison psychiatrists, for example, see addiction as a psychological issue that needs to be treated. For them, harm reduction is tantamount to condoning and encouraging drug use.

They are unable to fit this approach into their role as caregivers. They see harm reduction as giving prisoners the tools to perpetuate bad behaviour.

Prison guards, for their part, face an ethical dilemma. It is hard for them to accept the idea of facilitating the use of a substance which is not only illicit, but should not be on site in the first place. We cannot deny the difficulties faced by surveillance staff, and it is essential to listen to them; even though they are not caregivers strictly speaking, they do play a vital role in prisoners’ well-being.

The strength of our programme is that we make space for each person. Every individual is free to share their difficulties and feelings with us. In this way, we are able to find the most acceptable solution for everyone.