As part of its focus on rehabilitation and resocialization, Brazil's national prison law mandates that prisoners have access to various types of assistance, including medical care, legal aid, and social services.148 In practice, none of these benefits are provided to the extent contemplated under the terms of the law, nor is medical care-the most basic and necessary of the three services-available at even minimally adequate levels to many prisoners.

Serious contagious diseases such as tuberculosis and HIV/AIDS have reached epidemic levels in the Brazilian inmate population. By denying inmates proper treatment, the prison system not only endangers inmates' lives, it facilitates the transmission of such illnesses to the general population through conjugal visits and upon prisoners' release. Since prisoners are not entirely cut off from the world outside, the unchecked spread of disease among inmates represents a serious public health risk. As the 1996 São Paulo parliamentary report on prisons stated, the existing state of affairs can be described in a word: "calamity."149

Prisoners' medical needs

Inmate populations everywhere tend to have greater medical needs than the population at large. Not only do prisons hold a higher proportion of persons at risk of illness, such as injection-drug users, but the prison environment is itself conducive to the contracting and spreading of disease. Among the factors favoring a high incidence of health problems among inmates are the stresses of imprisonment, unhygienic conditions, overcrowded cells that place inmates in close and continuous physical contact with each other, and physical abuse.

Prison violence sometimes results in serious injuries such as knife and bullet wounds, requiring emergency medical care. At the Casa de Detenção in São Paulo, inmate nurses reported that someone was stabbed a few days before our visit and that they see such injuries about every two weeks.150

Prison nurses reported a high incidence of respiratory infections, skin rashes, headaches, digestive problems, and venereal diseases among the inmatepopulation. A survey of prisoners in Manaus, Amazonas, found that 41 percent of inmates had health problems, nearly half of them involving respiratory illnesses, and another 11 percent relating to poor digestion.151 A study conducted by researchers of the University of São Paulo revealed that 18 percent of prisoners at the Casa de Detenção had syphilis.152 In addition, poor sanitary conditions are responsible for numerous bacterial and parasitic maladies.

But the most serious diseases that are common among prisoners are tuberculosis and HIV/AIDS. Often these diseases occur together, as once a person becomes ill with AIDS he is much more vulnerable to tuberculosis. In a study concluded in 1995, researchers found that 80 percent of male prisoners tested came up positive for the tuberculosis bacillus, as did 90 percent of female prisoners. These results showed a sharp increase over rates found a couple of years earlier, indicating that the problem is worsening.153 Approximately 10 percent of prisoners who test positive actually develop active cases of tuberculosis. Studies conducted at the largest São Paulo prisons, for example, have found that between 2 and 4 percent of prisoners suffer from the disease.154 In 1995, ten inmates at the Casa de Detenção died of it.

Human Rights Watch encountered tubercular inmates-many of whom were also HIV positive-in several facilities. At the Casa de Detenção, we reviewed the log book of inmate blood tests, which showed that of the forty-one inmates tested for tuberculosis in September 1997, five, or 12 percent, had the disease. We met one inmate undergoing treatment for tuberculosis who was confined in a stuffy punishment cell with little air circulation.

Describing prisons as "an ideal breeding ground for onward transmission of HIV infection," the United Nations AIDS Program (UNAIDS) has repeatedly cautioned prison authorities to take affirmative steps to prevent the spread of the virus. The high levels of HIV/AIDS found in Brazil's prisons certainly bear out their prognostications. In late 1997, researchers at the University of São Paulo estimated that some 20 percent of the Brazil's inmate population was living with HIV, after having collected data from around the country. According to their research, the highest levels of HIV infection are found in the prisons in thesoutheast of Brazil-an area that includes São Paulo and its enormous inmate population-in some instances affecting some 30 percent of the inmate population. The lowest levels of infection are found in the northeast, where only 2 to 3 percent of inmates are infected.155

Access to medical care

In recognition of the seriousness of health concerns among prisoners, the Standard Minimum Rules include a number of provisions requiring that prisoners be provided basic medical care and, in particular, that sick inmates be visited daily by a doctor.156 The failure of the prison authorities to provide such care is one of the primary sources of inmate complaints in Brazil.

The Human Rights Watch delegation that visited prisons did not include a doctor, and thus we were unable to assess the quality of care provided in specific cases. The overall deficiencies in the medical care provided in Brazil's penal facilities, however, were evident even to the inexpert eye. To cite an illustrative yet telling fact, we did not meet a single qualified doctor during all of our prison visits; instead, we encountered numerous prison infirmaries run by inmate employees, or perhaps a single outside nurse. Prison pharmacies, in many instances, were obviously understocked, and inmates complained that their families had to buy them the medicines they needed.

A recent report on the Manaus prison hospital, in the state of Amazonas, illustrates some of the deficiencies in the medical care provided in Brazil's prisons:

a) inadequate physical space, which is incompatible with the practices required for the exercise of medical-social activities; b) inadequate distribution of nurses and their assistants, who lackbasic training for the exercise of some duties, particularly the care and treatment of interns' mental health; c) nonexistence of monthly funding causing a lack of basic medications, which results in damage to patients' health; d) absence of technical equipment to facilitate attention to basic emergencies.157

Most prisons have at least one doctor on staff, although some-such as the Campina Grande prison in Paraíba, which has a part-time nurse to care for 650 prisoners-do not even have that. Few if any prison doctors work full-time. At Brasília's Center of Internment and Reeducation, which holds over a thousand inmates, there is a single doctor who visits twice a week. The doctor for the Central Penitentiary in Natal, Rio Grande do Norte, a prison with some 650 inmates, comes once a week for a few hours and sees about fifteen people.

At other prisons the wardens mentioned that they had two or more doctors, but when questioned regarding the number of hours each doctor works, it turned out to be the equivalent of one doctor working half-time, if that. At the Casa de Detenção, for example, even though several doctors are supposedly on the payroll, none of them appears to spend much time in the prison. Inmate nurses in the main infirmary reported that two doctors visit once a week, each staying for about five hours. At a satellite health clinic in another pavilion in the prison, inmate nurses stated that a doctor comes for two hours every Wednesday and usually sees about fifteen out of the nearly 1,000 inmates who live in that area.

Prisoners' complaints about the lack of medical care were frequent: "I have a tooth that hurts, but there's no treatment here. All they do is pull teeth." "There's a doctor here but no medicine; they don't give me any medicine. I've got an ulcer so they give me half a liter of milk every forty-eight hours." "My family brings me medicine, otherwise I wouldn't get any."158

Even at separate prison hospitals, inmates often receive terribly deficient care. A prisoner held at the prison hospital of São Paulo's State Penitentiary, for example, waited over two years to obtain the operation needed to mend his broken femur (leg). Over thirty appointments for the operation were made in outsidepublic hospitals, the first one just days after his leg was injured, but he ended up missing one after the other because of a lack of guard escort or transport vehicle.159

São Paulo's police lockups do not have in-house doctors or nurses. To respond to inmates' medical needs, they normally have only the most basic remedies on hand, like aspirin, skin lotion, and stomach medicine. Sick prisoners are sometimes brought to local first aid stations for medical attention, but prisoners complain that, given the extra burden that this places on precinct staff, it is difficult if not impossible to convince the authorities to bring them there. "It's pointless to ask," remarked an inmate with asthmatic bronchitis being held in the overcrowded ninth police precinct. Another prisoner with a fairly advanced case of AIDS, who was not receiving any medication, said, "When we ask the police to take us to the PS [first aid station], they just tell us thieves deserve to die."160

The sickest prisoners from the lockups can be brought to the prison hospital to receive medical attention; judicial authorization is necessary to do this, however, and it can be difficult to obtain because of the insufficient numbers of judges. Moreover, even extremely sick prisoners almost always receive out-patient treatment-returning to their original lockup by the end of the day-due to a shortage of hospital beds.

Because the system is so overwhelmed, severely ill and even dying prisoners may remain together with other inmates in lockups. A couple of months before Human Rights Watch inspected the Depatri police facility, near Carandiru in São Paulo, a prisoner there died of meningitis. One of his former cellmates described what happened:

He was twenty-five years old, a black guy. He had been sick for about a month, and had been lying down on the floor, sweating like crazy. They took him out to get air about twenty times or so. Once they took him to the PS [first aid station]. He was always asking for medical care. Finally they took him out whenit was clear he was almost dead, and the guards said later that he had died.161

At that same facility, about a month later, an epileptic prisoner died. "He had a seizure and started banging his head on the cell bars. He was taken to the hospital and then returned, and he died in the visiting room."162

Although comprehensive national statistics have not been compiled, it is believed that AIDS and tuberculosis-often together-are the leading causes of death in Brazil's prisons. Many prisoners die of these diseases after having received little or no medical care. Inmates in São Paulo's police lockups do not receive AIDS medication, although they do receive out-patient treatment for tuberculosis. In most states' prisons, sick inmates are not transferred to the prison hospital or infirmary until they are in the advanced terminal stages of their illness. (In accordance with international standards, prisoners who are HIV-positive but not showing symptoms of AIDS are not segregated from other prisoners.163) Although compassionate release (known as humanitarian pardon [indulto humanitário]) is theoretically available to dying prisoners, procedural obstacles and delays mean that in practice relatively few prisoners obtain it.164

At least fifty-eight Casa de Detenção inmates died during the year prior to our visit there, most of AIDS and tuberculosis. One of these prisoners died of AIDS only a few days before we arrived; a notation in the infirmary log book described the circumstances of his death:

On November 24, 1997, patient [X] died in this infirmary. Prior to this death, the prisoner in charge of the infirmary, [Y], requested that [X] be sent to the Central Hospital but staff member [Z] said that [X] had been examined only on November 21 and since he had just arrived in the infirmary, he could not be sent to the hospital.

As this case exemplifies, only a small minority of the severely ill prisoners in São Paulo's prison system end up in the main prison hospital, the Central Hospital of the Health Department of the Prison System (Hospital Central do Departamento de Saúde do Sistema Penitenciário). This hospital, located on the grounds of the State Penitentiary, has only eighty-four cells and is normally far under capacity. Human Rights Watch was unable to visit the facility, but we note that a judicial delegation that inspected it in April 1997 made the following findings:

The food furnished is not in accordance with minimum medical specifications . . . . [T]he doctors of the Central Hospital are not conducting daily visits to each of their patients . . . which is absolutely unacceptable, above all since it is known that all of the patients interned there, with extremely rare exceptions, are in a condition that requires intense care and constant vigilance . . . . In theory the Central Hospital should be the establishment that centralizes all hospital care for the convicts in the [prison system], but the small number of patients interned there demonstrates that it is far from being able to attend to such needs.165

Rio de Janeiro reportedly provides better health care than most state prison systems in Brazil; it has seven prison hospitals, including one for inmates with AIDS where patients receive the modern drugs that have proven effective in stopping the advance of the disease.166 These drugs are also reportedly available in the AIDS sanitorium of the São Paulo prison system's central hospital; however,the small number of beds in that facility limits their use to a tiny fraction of the total number of prisoners suffering from AIDS.

Condoms are distributed in some prisons as a preventive measure against the spread of HIV. In Rio de Janeiro, for example, the prison department (Desipe) announced in late 1997 that it gave out an average of 10,000 condoms a month for the 13,000 inmates in the system.167 At the High Security Penitentiary of Rio Grande do Sul, prison officials told us that the roughly 300 inmates in the prison receive about one hundred condoms every visiting day.168

The National Ministry of Health advocates several additional preventive measures and, in some states, funds their use in the prisons. These measures include the creation and distribution of educational materials for prisoners, such as pamphlets describing prevention techniques, and the training of nurses and others who work in the prisons. Among other interesting efforts, the Ministry of Health supports the publication of an HIV/AIDS-focused journal written and edited by prisoners in the Porto Alegre Central Prison, in Rio Grande do Sul, which is distributed among the inmate population. Besides discussing sex, drugs, and HIV/AIDS prevention openly and bluntly, the journal serves as a forum for inmates to speak their mind about prison problems and abuses.169

Consistent with international standards, Brazil does not have mandatory HIV testing of prisoners.170 Many prisons, moreover, have little voluntary testing because of resource constraints.

To their credit, justice and health officials acknowledge the seriousness of the HIV/AIDS epidemic among the prison population.171 They emphasize, in particular, that the constant stream of inmates leaving the prison system facilitates the spread of HIV/AIDS among the general population. According to their estimates, every year some 12,000 HIV positive inmates are released, becoming "focal points for the propagation of the disease."172

Paraplegic prisoners

A tragic case illustrating the penal system's lack of medical care is that of a group of paraplegic prisoners who were until late 1997 held in a special ward of the prison hospital at São Paulo's State Penitentiary. These prisoners, consisting of thirty-six paraplegics and two tetraplegics, received almost no medical care. Not only was physical therapy not provided them, but they were not even turned in their beds very often, and as a result many of them developed painful bedsores on various parts of their backs, buttocks and legs.173 In March 1997, thirty-five of the paraplegic prisoners sent a letter to the Prison Ministry describing their plight, which the ministry forwarded to the Human Rights Commission of the São Paulo Legislative Assembly. The letter stated that the authorities were not providing them any medication; that the only people taking care of them were other prisoners with no knowledge of medicine; that they were "living in the midst of rats,cockroaches and other pests," and that "much of the time, or most of the time, the deaths that occurred were because of lack of care."174

That same month, the paraplegic prisoners were visited by the legislative commission, which confirmed the dreadful conditions in which the inmates were held. A report of the visit found:

It is other well-intentioned prisoners, who lack medical training, that care for the [paraplegic inmates] . . . including doing minor surgery when necessary . . . [These other prisoners] "operate" on the sores, cutting off the dead skin/flesh and applying home-made remedies . . . [T]he most commonly used remedy of these prisoners for the treatment of bedsores is sugar and coffee grounds . . . [A]ll the paraplegics use a type of homemade catheter ( . . . a plastic tube running from a 2 liter soda container). Urethral infections are common among paraplegics . . . . There are paraplegics who were assured by doctors at the public hospitals where they were held when they were first caught that they would be able to walk again, if the bullet(s) in their bodies were extracted and if they received physical therapy. But the bullets still have not been  . . . and the patient's physical condition has deteriorated to the point that his legs have locked in place, in the fetal position, doubled under his chest.175

In June 1997, two of the tetraplegic prisoners died, and in August, the paraplegic prisoners announced a hunger strike to protest the lack of medical care. Finally a judicial investigation was initiated to examine the situation, but in October 1997the São Paulo prison authorities closed their ward, transferring all but eleven of them out of the hospital and distributing them among at least twelve different prisons.

Eleven of the paraplegic prisoners were transferred to the Franco da Rocha Penitentiary. There, because of the absence of even minimal infrastructure to provide for their medical needs, the local judge of penal execution sent them home for their families to care for them, converting their sentences into terms of house arrest. It is known that at least one other paraplegic prisoner was transferred to the State Penitentiary of President Venceslau, a prison located in the interior of the state far from the inmate's family. This prison reportedly lacks all resources necessary to cope with his special needs.176

One reason that many prisoners do not obtain the benefits available to them under the national prison law is the scarcity of legal assistance. Although public defenders are supposed to provide legal services to prisoners, they are little in evidence in many of the country's penal facilities.177 "I've only seen them once," remarked the head of a São Paulo police facility that held 343 prisoners, when asked if any legal aid lawyers had visited during the seven months he had worked there.178 Many prisons have several lawyers on staff, or receive visits from outside public defenders, but it is evident that the demand for legal assistance far exceeds the supply.

To compensate in part for the lack of sustained legal assistance, many state prison systems sponsor periodic sweeps (mutirões) by which groups of lawyers and law students enter prisons and assess inmates' legal status, evaluatingwhether they are eligible for early release or other benefits. The Brazilian Bar Association frequently sponsors such events, as do local law faculties.

148 Lei de Execução Penal, art. 11.