Health and human rights of women imprisoned in Zambia

In African countries, female prisoners comprise between one percent (in Burkina Faso) and 6.3 percent (in Mozambique) of the total convicted population [1]. Like their male counterparts, women in African prisons frequently face overcrowded and unsanitary conditions conducive to poor health and the spread of infectious disease [1]. Yet women are also confronted with unique challenges–related to menstruation; pregnancy and childbirth; care for children both inside and outside of prison; and violence and abuse (including sexual abuse) by prison officers or male prisoners with whom they are sometimes held [1]. Women prisoners often have experienced violence and sexual abuse prior to incarceration, and may suffer from post-traumatic stress disorders while detained [2]. Despite recognition of these challenges, there has been little research on this population to date.

In Zambia, female inmates comprise approximately 1.5 percent of the total prison population, with an estimated 250 female prisoners incarcerated nationwide in March 2011 [3, 4]. While one of Zambia's 86 prisons is dedicated exclusively to female inmates, and housed 66 women in March 2011 [4], women live in separate sections of prisons located throughout the country.

In addition to the international human rights law protections afforded to all prisoners and all women, female detainees benefit from special legal protections. African regional law, for example, provides that women in detention should be held in an environment "suitable to their condition" and ensures their right to be treated with dignity [5]. The Southern African Development Community Protocol on Gender and Development, which Zambia has signed, commits states by 2015 to "ensure the provision of hygiene and sanitary facilities and nutritional needs of women, including women in prison" [6].

This study examines women prisoners' experiences of imprisonment in Zambia, with particular emphasis on access to HIV and tuberculosis (TB) prevention, testing, and treatment, women's unique healthcare needs, and treatment in police and prison custody. The main objective of the investigation was to document and respond to specific human rights issues, monitor human rights conditions, and assess human rights protections in Zambian prisons. Analysis of male inmates' conditions of detention and the criminal justice system attributes leading to their extended detention in Zambian prisons has been published elsewhere [7, 8].

In July 2009, the Prisons Care and Counselling Association (PRISCCA) of Zambia sought approval from the Zambian Ministry of Home Affairs and Ministry of Foreign Affairs for a mixed-method study of health conditions in Zambian prisons. In September 2009 both Ministries granted permission. Between September 2009 and February 2010, researchers from PRISCCA, the AIDS and Rights Alliance of Southern Africa (ARASA) and Human Rights Watch conducted in-depth interviews with female prisoners in four Zambian prisons: Lusaka Central Prison (Lusaka province), Kamfinsa State Prison (Copperbelt province), Mumbwa Prison (Central province), and Choma State Prison (Southern province).

In each prison visited, researchers requested from the officer in charge a private location to conduct interviews. Officers identified prisoners who were then provided by researchers with a verbal explanation of the research (in English or French, and translated into Bemba, Nyanja, or Tonga if necessary), asked if they were willing to participate, and offered anonymity. Individuals were assured that they could decline to participate, end the interview at any time, or decline to answer any specific questions without negative consequence. The names of all prisoners who participated in this study have been changed to protect their anonymity and security. Responses were recorded in written notes and all interviews were conducted outside of the hearing of prison officers and other prisoners, in a private setting. The Zambia Prisons Service did not permit the use of recording devices.

Interviews took approximately 45 minutes and were conducted in English or French by female researchers from one of two organizations (Human Rights Watch or ARASA) or in Bemba, Nyanja, and Tonga, with translation to English provided by members of PRISCCA. Interviewers used a brief verbal questionnaire to gather information on the prisoner's incarceration history, medical care, and experience of HIV/AIDS and TB testing and treatment. Researchers then probed responses and asked further questions regarding prison conditions, discipline, and HIV/TB risk behavior in open-ended, in-depth interviews.

Qualitative prisoner data were hand-coded by the authors, who conducted a content analysis to identify key themes corresponding to the interview guide, as well as emergent topics. In the first analysis of the data, an initial set of codes was generated to capture key constructs. Subsequent analyses were undertaken to examine the consistency of reports across themes and examine negative evidence [9].

At each facility visited, researchers also requested interviews with the officer in charge, deputy officer in charge, medical officer and female officer in charge; additional officers were invited to participate if sufficient time allowed. Prison officers were provided with an explanation of the purpose of the study and how the information obtained would be used; they were given the opportunity to decline the interview or to end the interview at any time. Prison officer interviews focused on HIV and tuberculosis testing and treatment availability in the prison, healthcare delivery, deaths in custody, prison administration, prisoner discipline and treatment, and prison officers' working conditions.

Interviews with key informants from government and national and international non-governmental organizations (NGOs) were also conducted, prior to and following prison-based interviews, to identify salient issues and probe specific findings raised in the research.

In addition, national legislation and policy governing the administration of the prison and criminal justice systems were reviewed. Researchers reviewed all existing Zambian legislation, extracting relevant portions related to prison administration, criminal procedure, criminal law, and immigration law. All available national policies related to HIV/AIDS, health, and prison administration were also examined.

Human Rights Watch does not generally identify its work as "research", defined as seeking to develop "generalizable knowledge" [10]. Rather, its investigations aim to document and respond to specific human rights issues, monitor human rights conditions, and assess human rights protections in Zambian prisons. Each of these purposes is consistent with what has been defined as "public health non-research" [11] or practice [10]. However, because public health non-research and practice also raise ethical and human participant protection issues, all investigations conducted by Human Rights Watch are subject to rigorous internal review, and external ethics and subject-area experts are consulted when investigations involve particularly difficult settings, populations, or issues. The present study's methods, and human participant protections associated with the research, were reviewed by PRISCCA, ARASA, and Human Rights Watch prior to undertaking this study, and all interviewers were trained in human participant protection and information security. Following the interviews, and after initial reports of the study had been released, PRISCCA and Human Rights Watch continued to monitor to ensure no adverse consequences to subjects from participation.

Thirty-eight adult female prisoners from four Zambian prisons were interviewed, including 20 convicted, 14 pre-trial, and four immigration detainees. Their ages ranged from 22 to 77 years, with an average age of 37 years. Thirty-two of the 38 women (84 percent) were of Zambian nationality. Female prisoners interviewed reported having been detained at the facility at which they were interviewed for an average of nine months (with a range from zero to 44 months). Twenty-one (55 percent) of the women had reached secondary-level education or higher, while six (16 percent) had received no education and 11 (29 percent) had only a primary-level education. In addition, 22 prison officers and 18 Zambian government officials from relevant ministries were approached for interviews; one prison officer declined. Twenty-eight representatives from local and international NGOs and donor governments and agencies were also interviewed.

This study is the first independent research conducted on issues related to the health and human rights of female detainees in Zambian prisons. Our findings indicate that both the healthcare available to and the abuse endured by women in detention in Zambia violate international human rights law. Women in Zambian prisons are not provided with healthcare services to address their specific health needs, and are underserved by the HIV and TB testing which does exist.

While there has been relatively little research conducted to date addressing the distinct healthcare needs faced by women in detention worldwide [2, 39, 40], and even less in Africa, news accounts suggest major problems, including: poor conditions and no medical care for women detained in a Sudanese prison [41]; physical abuse against women in a Mauritius prison [42]; and rape and sexual violence against female detainees by male inmates in the Democratic Republic of the Congo [43].

Understanding the human rights abuses impacting female prisoners' health in incarceration facilities is key to devising appropriate, effective services for this population, and may become increasingly important in coming years: Female prison populations have increased in both absolute numbers and in proportion to the male population in some countries recently [44].

Under international human rights law, people in detention retain their human rights and fundamental freedoms–aside from such restrictions on their rights as are required by the fact of incarceration [17, 45, 46] and except as necessary for the justifiable segregation or the maintenance of discipline [17]. States have an obligation to ensure medical care for prisoners at least equivalent to that available to the general population [47–49]. The current lack of access to health care–evidenced by the lack of facilities in Zambian prisons and the evaluation of medical needs by untrained and unqualified guards–falls far below the equivalent standard of available treatment in the community. Further, the Convention on the Elimination of All Forms of Discrimination against Women obligates states to ensure to all women–in and outside of prison–appropriate services for pregnancy, including adequate nutrition [50].

Respecting female detainees' human rights is also essential to preventing abuse and ensuring the health of female detainees. The most fundamental protection for detainees is the absolute prohibition on torture, inhuman or degrading treatment or punishment. In addition to being a well-established norm of international law by which Zambia is bound, the prohibition is also reflected in the Zambian Constitution and in several of the human rights treaties to which Zambia is a party [47, 48, 51, 52]. Yet the physical abuse suffered by Zambian female detainees in police and prison custody violate national and international law prohibitions on torture or cruel, inhuman or degrading treatment or punishment, as well as having negative consequences for their health.

There were several limitations to our research. Women prisoners in only four of 86 prisons nationwide were interviewed, and the recruitment of prisoners required cooperation of prison officers. Researchers did not have access to the one female prison in Zambia, and so were restricted to interviewing female detainees held in primarily male prisons. Because the prisons where interviews took place were participating in an ongoing HIV prevention program run by a non-governmental organization (PRISCCA), and subject to visits by NGO staff, conditions may have been better than in prisons not participating in the program. Similarly, the selection of prisoners by prison officers likely biased the sample to healthy prisoners not currently in punishment cells, who were possibly more likely to portray prison staff and conditions in a positive light.

However, using mixed-method approaches and triangulating information from prisoners with in-depth interviews with prison officers and NGO and government representatives strengthened our confidence in our main findings. Even if our results suggest more positive conditions than those experienced by a more representative sample of female Zambian prisoners, the findings identify serious human rights abuses and failures to provide healthcare that compel further investigation, monitoring and response by the Zambian government.

Although women detainees are entitled to protection under international human rights law and enjoy specific protections under regional human rights standards, in Zambia, incarcerated women's specific health needs are not being met, and they are underserved by general health services. There is an urgent need for healthcare services targeted to female inmates, including prenatal care, to be expanded, and for general prison health campaigns including HIV and TB prevention, testing and treatment to include women prisoners. Abuses against women both in police and prison custody which violate their rights and compromise their health must be eliminated.