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The international conference on health protection in prisons, held in Madrid in October 2009, is now seen as meeting at the right time and in the right place, and with the right mix of experts and practitioners so that a valuable outcome was obtained. It was the right time, as after 20 years of considerable research, of collection of evidence and experience across the wide field of communicable and other diseases in prisons, it was appropriate to consider what progress had been made and where further development was required. Being in Spain, it was the right place for such a conference as Spain had real experience in the subject which others needed to know about. It was also the right mix of world experts, research workers and practitioners from some 65 different countries so that the outcome, The Madrid Recommendation on health protection in prisons as an essential part of public health, is a short but influential document coming with such support that it should be considered by every health department and public health agency concerned with the better control and the prevention of such important diseases as HIV and TB. Why was prison health issues selected to be the central focus of the meeting? The sad fact is that in every society in Europe, the greatest preponderance of serious life threatening diseases is likely to be amongst those held in prisons and places of compulsory detention. Communicable diseases such as HIV and Tuberculosis, addictions to various substances and drugs and mental health illnesses and inadequacies, either together or on their own, affect the vast majority of the prison population in every country of Europe and beyond. A deadly mix of old buildings with poor facilities and often in an overcrowded state, of men and women from the least favoured sections of society and with little in the way of social, educational and health understanding and skills and the overlap between certain behaviours and criminal law, has lead to the build up there of several of the greatest challenges facing public health today. The starting point for the Recommendation were the facts and figures regarding communicable diseases such as HIV/AIDS, tuberculosis, hepatitis and sexually transmitted infections prevalent in prisons worldwide. These are accompanied by high numbers of prisoners with mental ill health and with substance abuse and addictions so that prisons and places of compulsory detention had become focal points for life threatening conditions and for multiply disadvantaged people who, if not helped while inside, would quite often in short times carry their health and other problems back to their home communities. But the other important starting point was that there is now overwhelming evidence that health protection measures, including harm reduction measures, are effective within the settings of prisons, despite the well known tensions between places where secure detention is a primary goal and the basic requirements for health protection, treatment and prevention. There was wide recognition of the proven beneficial results obtained by the government of Spain in the health protection initiatives it had undertaken in its prisons. The Madrid Recommendation therefore arose from these two facts, that there was a real public health problem in prisons as far as communicable and other diseases were concerned, and that considerable evidence had shown that much could be done in prisons to prevent the spread of these conditions and indeed to contribute to improving the health of the community. Before finalising its actual recommendations for action, the meeting recognised the considerable differences of opinion which existed throughout Europe and elsewhere about what should be done. As with any public health problem, the availability of evidence, while probably the key factor in producing policy reviews and changes was not the only consideration. Each society has its own view, tradition and history about for example the use of illicit drugs and these opinions cannot be ignored in deciding what is possible to be done.

El actual reto de la protección de la salud: Por qué todos los ministerios de sanidad deberían considerar la Recomendación de Madrid