The most powerful experience from my week in Lima, Peru was our visit to a large prison. I am not going to name the prison because we are hoping to implement FAST there to reduce TB transmission, and there are privacy/political issues. Rather, I am going to share a few thoughts about prisons, drug use, and crime, based on one admittedly brief encounter, but also 35 years of being alive in this world. This essay is also informed by the recent violent murders in Oregon.
The Guatemalan Women’s Jail
This was the 3rd prison I’ve entered in my life. The first was a women’s jail in Guatemala that I visited in the summer of 2003. I was taking Spanish classes in Quetzeltenango (Xela), Guatemala at the time. As part of the community service component of the language school we visited this jail. I don’t actually recall doing anything there, but perhaps we dropped off some clothing or food to for the women. We didn’t speak with them and left rather quickly. I don’t remember the details of the prison, how it looked, etc.
The Mexican Prison
The second prison I ever visited in my life was in Ensenada, Baja California, Mexico, in February, 2010. A group from my girlfriend (now wife’s) Korean church was visiting the prison and invited her. She could not go, but I had the day off from work so I decided to join them on an adventure. The church’s pastor spoke Portuguese/Spanish, but besides him, very few in our group (average age about 70), spoke anything other than Korean. And I spoke no Korean. We crossed the border from the US into Mexican in a silver Lincoln Navigator and in a couple of hours were down in Ensenada. The pastor seemed to have a longstanding relationship with the prison and the churchgoers had brought a number of items in the trunk, including paper plates, cups, hot dogs, chips, soft drinks, and a few basic medications such as amoxicillin and tylenol. We passed into the prison rather easily. It was a moderately sized outdoor complex with a number of buildings and I recall a number of guards. One by one, in the heat, the prisoners lined up and we handed out our gifts. We left within an hour and drove to central Ensenada where we ate fish tacos. Then, we made our way back to Tijuana. At San Isidro border, we had an encounter like I’d never had before:
American Border Guard: Please show me your passports.
Korean Driver: (hands 7 passports over)
Border Guard: (scrutinizing passports)
Border Guard: Jim?
Jim: (smiles and waves hand)
Border Guard: Ji-Youn
Ji-Young: (smiles)- “hi!”
Border Guard: Han
Han: (raises hand)
Border Guard: Sang-il
Sang-il: (smiles, raises hand)
Border Guard: Jong-il
Jong-il: (raises hand)
Border Guard: (stares at 7th passport)
Border Guard: Philip?
Philip: raises hand.
Border Guard: What are you doing down in Mexico?
Philip: We are members of a Korean church in San Diego. We were down in the prison in Ensenada today helping out with the inmates.
Border Guard: (staring)
Border Guard: (still staring)
Border Guard: How’d you get involved with a Korean Church?
Philip: My girlfriend is Korean.
6 other members of Lincoln Navigator: (start laughing)
Border Guard: (staring)
Border Guard: Well I see you didn’t bring her with you.
Ji-Young: He’s 80% Christian!
And the Peruvian Prison
The third prison I ever visited in my life was this one in Lima, Peru. The prison had over 9000 inmates in a complex in the shadow of the hills/shantytowns of the city. It primarily held inmates who were charged/convicted of minor crimes like robbery/drug use, but not violent crimes like murder (they were sent elsewhere, to Peruvian versions of the Supermax prison). My interest in going into this prison was because of ongoing TB transmission there (this is a well known phenomenon), as well as my interest in health/human rights in prisons. In general, I am anti-prison, except in the case of heinous crimes like murder, where a prisoner serves as an ongoing threat to the safety of the community. I think the American culture of imprisoning people for minor crimes is leading to a vicious cycle, an epidemic of fear, guns, and violent crimes. The “War on Drugs” is one of the biggest failures of Ronald Reagan’s presidency. Prisons ruin many more lives than they rehabilitate, and we are squandering billions of dollars each year unnecessarily, as well as many lives. It truly is time to overturn America’s prison-industrial complex.
Getting in to the Peruvian prison was a bit more challenging. We had to leave most of our belongings in our car but were told we could bring in our cell phones and notebooks. After we got inside the first layer of security, however, we were told we had to leave our cell phones as well. After a nice discussion with the prison authorities, we were led into the security checkpoint. We were each fingerprinted, had to surrender our passports, and were given an oval, golden-metal token printed with a number on it. My token was number 2913. We were told that in order to get out of the prison, we had to present the guards our token.
After a quick pat-down, we were allowed inside the prison. It was a large complex with a number of buildings. There were prisoners wandering around, but only 3-4 uniformed guards that we saw. All of the prisoners were men, and there were a few female prison workers. The prisoners whom we saw looked like regular men you would see on the street, but to generalize, tougher. Many were tattooed and we saw some scars. They were all very cordial to us, greeting us, as we walked around. We were not accompanied by any guards, only a couple of prison/health officials. As we walked, I kept putting my hand back into my pocket to make sure my golden token hasn’t fallen out.
First we were taken to the prison clinic/hospital. For reasons mentioned above, I am not going to describe the prison in detail, but suffice it to say that there are major challenges in the provision of quality TB/HIV care to these prisoners. There also are a significant number of MDR-TB and XDR-TB patients undergoing treatment and a large amount of ongoing TB transmission. The prison is currently identifying TB cases at an astronomical rate, 4000/100,000, and we think this is an underestimation, as there are a large number of undiagonsed TB cases which are fueling ongoing transmission.
We were led to a “pavilion” where the prisoners lived. Apparently no guards entered there, as the prisoners policed themselves. We were told it was the nicest pavilion in the prison, as they didn’t want to take us to the bad pavilion. We had to pass through a fence where apparently a prisoner collected a small amount of money from the prisoners who wanted to pass through. We were told that there was a large burden of ongoing drug use inside the prison, primarily cocaine/crack but also marijuana and other drugs, but apparently no intravenous drug use (no opioids like heroin). The pavilion was basically a self-contained city. It actually reminded me of a “swap meet” in Los Angeles that I had visited in the past. There were small stores, even with televisions, where the prisoners were selling food/belongings to each other. We walked past row after row of cells (all the doors were open) and we got into an open courtyard where prisoners were milling around, playing basketball, and squash. We talked for about 15 minutes and then exited the pavilion and prison. We gave our golden tokens and received our passports and were fingerprinted and soon we were in the car on our way to the office.
Overall, the prison was dreadful, although everyone from the guards/prison officials to the inmates had been very extremely friendly to us. I felt like the prisoners were receiving cruel/unusual punishment not only because of the crowded and poor conditions, but also because of the ongoing transmission of drug resistant TB there.
From Lima back to Boston– thinking about crime and drugs
I will finish this blog post with a few more thoughts about crime and drug use. Just before leaving for the airport to Lima, I checked the New York Times on my computer and was greeted by the awful news of another massacre in Oregon, and the response of craven politicians. When will we learn, Americans, when will we learn? And when will we act?
Upon arriving back in Boston today from Peru, I was greeted by a cold rain and after catching up with my family spent some time reading about the HIV outbreak in Indiana which occurred earlier this year, driven by intravenous drug use. Drs. Steffanie Strathdee/Chris Beyrer recently wrote a perspective article in the NEJM about the outbreak. Yesterday, a reply from an Indiana health department official was published in the NEJM, along with Dr. Strathdee/Beyer’s rejoinder. I agree completely with Drs Strathdee/Beyer in this debate.
After reading this encounter, I emailed it on to several of my colleagues and one wrote me back. His perspective:
“Phil, are you familiar with the industrial hygienist hierarchy of exposure control? Elimination > Substitution> Engineering Controls > Administrative Controls> Personal Protective Equipment (PPE). PPE, like needle exchange, is supposed to be the last line of defense, not the first line. Like PPE, needle exchange is important, but not as important as all the upstream steps. Forget about needle exchange (excuse my language) in the absence of strong substitution (methadone, proactive treatment) and engineering controls (remove easy access to opioids) and administrative controls (remove the person from the enabling environment). Google “industrial hierarchy of exposure control”, and think of an addict getting their fix as “their job.” Then think of yourself as OSHA. What do you have to do to protect the worker? And Phil, even if you love ID, think about Occupational Health. We need people like you that see the big picture. Hey, you can even be like me and have an occupational ID niche!”
I think my friend does make some very good points, but I disagree with his argument where he says to “forget about needle exchange.” We need to deal with the opioid epidemic on all levels. I wrote to him that I am very involved in TB infection control and we use this occupational hierarchy in our work. Also, I think the politics in Indiana/USA around harm reduction/ prisons have been atrocious and we need a comprehensive approach, including early childhood education, a dramatic reduction in the supply of opioids, better policing, needle exchange, and other preventive measures. But as long as opioids are rampant in our communities, and our justice system is broken, needle exchange alone won’t resolve our problems. But it is a necessary component of a multimodal strategy, as has been demonstrated in many other settings. Perhaps even the mainstream media is even beginning to take up some reforms?
Finally, I would like to expand our thinking about prisons. from the physical to the psychological. The Peruvian prisoners I met are locked up behind bars, hoping some day to be let free. But each of us are locked up in our own prisons. I think we are each imprisoned by our thoughts; our patterned behaviors; our memories; how we were reared; our language and culture. For me, I think I am a prisoner of my ego and my procrastination.
What are you a prisoner of, and will you be able to escape?