A cruel and unusual punishment

We justify depriving people of their liberty for transgressing social norms on the grounds of protecting society or rehabilitating the person. However, in the case of illicit drug use, there is little evidence that either of these objectives is achieved by current approaches. Imprisonment exposes injecting drug users to greater risks of infection with bloodborne viruses (such as hepatitis Band C) than in the community. About half of all injecting drug users have histories of imprisonment; about half of all prisoners have histories of injecting drug use; and about half of all imprisoned injecting drug users inject drugs in prison.' Infection with hepatitis C virus (HCV) is common among Australian injecting drug users and prisoners. Butler and colleagues' study of prisoners entering the New South Wales correctional system (page 127 in this issue of the Journal) showed that almost a third were seropositive for HCV, rising to twothirds of those with a history of injecting drug use. HCY infection was significantly associated with a history of previous imprisonment, which accords with the results of other studies.? Similarly, surveys of Australian injecting drug users find that histories of incarceration are among the strongest associations with HCV seropositivity," A major survey of prison entrants in Victoria found high incidences of infection with both HCV and hepatitis B virus (HBV) among returning prison entrants 41 per 100 person-years among young male injecting drug users.' While these data do not prove that infections are acquired in prison, the prison environment makes spread of bloodborne viruses more likely. The boredom, frustration and hopelessness felt by many prisoners potentially contribute to drug use. Many prisoners have no investment in the future, which will probably contain little except unemployment, further drug use and further imprisonment 64% of prison entrants in Victoria have been imprisoned previously." They may believe they have nothing to lose (and some escape to gain) from drug use. In addition, prison policies may aggravate the problem of disease transmission. For example, sharing of injecting equipment is much more common in prison (where equipment is very scarce) than outside (where it is relatively freely available).' Efforts to detect drug use, such as urine screening, may drive prisoners from smoking marijuana (which has metabolites that can be detected in the urine for many days) to injecting heroin and amphetamines (which are rapidly cleared from the body). Prison practices may also prevent prisoners taking precautions against spread of bloodborne viruses. For example, despite official policy, urine screening is alleged by prisoners to be anything but random; in some prisons, prisoners claim that a request for bleach (for disinfecting injecting equipment) is followed the next day by a urine test." Sanctions against drug use, such as loss of contact visits as punishment for a "dirty" urine, simply reinforce the original reasons for drug use." Prisons take people from diverse settings who would not otherwise meet, create the opportunity to spread bloodborne