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IX. MEDICAL AND MENTAL HEALTH SERVICES
Every facility we visited provided some basic medical services to detainees, and most youths reported that they were able to see medical staff upon request. Nevertheless, girls were not routinely offered gynecological examinations, and not all youths received a routine medical examination upon admission. Social workers and, in some centers, psychologists on staff play a valuable role in providing basic mental health services to youths in detention, even though such services are not their primary duty. We spoke to some youths who credited these professional staff for helping them through difficult periods of adjustment to life in detention. Finally, youths in all facilities with the exception of the Casa do Adolescente, the boys' detention center in Rondônia, told us that they received health information while in detention. General Medical Care
In facilities that rely on community health care services rather than having medical personnel on staff, however, youths reported somewhat longer waits. Lincoln E., held in the Aninga detention center, reported, "There's no nurse in the center. Every time we need to see the nurse, we have to leave. We go to the hospital." Even so, he told us that he sees a nurse within one day after he asks detention center staff.21 Similarly, youths who need treatment that the detention center staff could not provide generally reported that they were transferred to area hospitals quickly. Maurício B., held in the Dagmar Feitoza detention center in Amazônas, told us that when he was sick, "The nurse took me to a doctor. It happened the same day. I told the guard, then I went to the nurse, and then to the doctor in the hospital."22 In Graça Q.'s case, however, the delay was much longer. "I saw a doctor two times, here in the center," she said. "I wanted to see the doctor because I was sick, my throat hurt. I asked the educators. I waited three or four days to see the doctor."23 We heard from many youths, particularly those held in Pará, that they did not receive a medical examination upon admission. Josefina S. told us that she did not have a medical exam when she entered Aninga.24 But Damião P., a detainee in the Espaço Recomeço detention center, told us, "When I entered, I had a medical exam."25 Officials at girls' detention centers told us that they provided gynecological examinations upon request, although only a few of the girls we interviewed told us that they had asked for or received one. In Pará, Inês F.-seven months pregnant at the time of our interview-told us, "I haven't seen a doctor during the time that I've been here," during a period of at least four weeks.26 Officials in every state acknowledged that HIV and other sexually transmitted diseases were among the principal health concerns for youths in detention. Yet none of the detention centers we visited provided condoms to youths.27 This was the case even in centers that permit youths to spend weekends at their homes, although some detention officials acknowledged that those youths should have access to condoms. Most officials discounted the possibility that youths in detention may have sexual relations with each other, whether voluntarily or coerced.28 In Maranhão, youths are tested for HIV and other sexually transmitted diseases upon entry, according to Dione Pereira. She told us that there were no youths who were HIV-positive in the state's detention facilities at the time of our April 2002. Nineteen youths in detention had other sexually transmitted diseases, ten in the Esperança Youth Center and nine in the pretrial detention center.29 Because the timing of our visit meant that we could not interview youths in Maranhão, we were unable to determine whether medical staff obtained children's informed consent prior to conducting HIV tests and provided them with pre- and post-testing counseling. The International Guidelines on HIV/AIDS and Human Rights call for these steps, among others, to ensure that public health practices in response to HIV/AIDS are consistent with international human rights obligations.30 Officials in Amapá told us that they knew of one HIV-positive detainee, a girl. "Her daily life is normal. The other adolescents know that transmission isn't through talking to someone." They told us that she was receiving individualized medical care from the Department of Health.31 We did not speak to any youths who complained of poor medical care, but the Human Rights Commission of the federal Chamber of Deputies found that health services in the boys' pretrial detention center in Pará were inadequate when it visited in March 2001:
The commission expressed similar concerns about the Espaço Recomeço detention center, concluding, "The health situation of the detainees is troubling. Many have skin diseases; others suffer from dental problems as well."33 Mental Health
Youths who did receive mental health services felt that those services aided them during a difficult adjustment to life in detention. Patrícia D., who saw a psychologist shortly after her arrival at the Aninga detention center, in Amapá state, told Human Rights Watch, "She helped me, certainly. She helped me a lot." She reported that she still keeps in touch with the psychologist.34 We did see a girl in Rondônia whom the staff identified as mentally impaired. They told us that she was not a detainee; instead, she was living there because she had no other place to go.35 We did not hear of any detainees with mentally retardation or mental illness during our visits. In the Espaço Recomeço detention center, however, the Human Rights Commission of the Chamber of Deputies saw at least two mentally ill youths who in its judgment should have been placed in a nonpenal institution capable of caring for them.36 Access to Health Information
Youths commented that workshops and presentations were more effective than written materials that were not accompanied by explanations. "They gave us information in EREC [the Espaço Recomeço detention center] also," Henrique O. said, "but only by passing out pamphlets. Here they have presentations, various presentations."40 The Right to the Highest Attainable Standard of Health
The state also has an affirmative obligation to provide for the basic health needs of those who are deprived of their liberty. This obligation flows from the right of individuals deprived of their liberty to be treated with humanity and with respect for the inherent dignity of the human person, a right guaranteed by article 10(1) of the International Covenant on Civil and Political Rights (ICCPR). As the Human Rights Committee has observed, states have "a positive obligation toward persons who are particularly vulnerable because of their status as persons deprived of liberty."42 The U.N. Rules for the Protection of Juveniles, "intended to establish minimum standards accepted by the United Nations for the protection of juveniles deprived of their liberty in all forms,"43 call for the following measures, among others, to protect the health of children in detention: · Adequate preventive and remedial medical care, including dental, ophthalmological, and mental health care, provided if possible through health facilities and services in the community in which the facility is located.44
Children with Mental Illnesses
More fundamentally, children who are in need of care solely because of mental illness should never be held in detention facilities for young offenders. Such treatment is inconsistent with the international principle that children in need of protection should never be held together with those who are accused of or have been found to have infringed the law. It also runs counter to the purpose of the Inter-American Convention on the Elimination of All Forms of Discrimination against Persons with Disabilities, one of whose objectives is to promote the full integration into society of persons with disabilities.50 Information and Education on Health Issues
Information and education on health issues are particularly important components of any comprehensive response to HIV and AIDS. The Committee on the Rights of the Child urges that "[a]ccess to information as a fundamental right of the child should become the key element in HIV/AIDS prevention strategies," one of a series of recommendations it made after a day of discussion on HIV/AIDS and children in 1998.53 The U.N. Guidelines on HIV/AIDS and Human Rights, which provide guidance in interpreting international legal norms as they relate to HIV and AIDS, recommend that states "ensure that children and adolescents have adequate access to confidential sexual and reproductive health services, including HIV/AIDS information, counseling, testing and prevention measures such as condoms."54 APPENDIX 21 Human Rights Watch interview, Macapá, Amapá, April 16, 2002. 22 Human Rights Watch interview, Manaus, Amazônas, April 22, 2002. 23 Human Rights Watch interview, Centro de Internação de Adolescentes Femenino, Ananideua, Pará, April 11, 2002. 24 Human Rights Watch interview, Santana, Amapá, April 16, 2002. 25 Human Rights Watch interview, Espaço Recomeço annex, Ananideua, Pará, April 8, 2002. 26 Human Rights Watch interview, Centro de Internação de Adolescentes Femenino, Ananideua, Pará, April 11, 2002. 27 The International Guidelines recommend that prison authorities provide prisoners with means of prevention, including condoms. Ibid., Guideline 4, para. 29(e). 28 See also Chapter V, "Violence Among Youths." 29 Human Rights Watch interview with Dione Pereira, April 19, 2002. 30 Office of the U.N. High Commissioner for Human Rights and the Joint U.N. Programme on HIV/AIDS, HIV/AIDS and Human Rights: International Guidelines, U.N. Sale No. E-98-XIV.1 (1996), Guideline 3, paras. 28(b) and (c). 31 Human Rights Watch interview, Fundação da Criança e do Adolescente, April 15, 2002. 32 "Vários dos meninos apresentam problemas de saúde que são, simplesmente, ignorados. Pode-se afirmar que a maioria deles sofre com as doenças de pele - promovidas pelas próprias condições de encarceramento e pela rara exposição ao sol. Um dos jovens - R.S., 16 anos - relatou a necessidade de intervenção cirúrgica no estômago, já indicada há muito tempo. Há 28 dias, ele aguardava por algum encaminhamento no Ciam sem jamais ter sido examinado por um médico." Comissão de Direitos Humanos, IV Caravana Nacional de Direitos Humanos, p. 27. 33 "A situação da saúde dos internos é preocupante. Muitos possuem doenças de pele; outros tantos sofrem com problemas dentários." Ibid., p. 31. 34 Human Rights Watch interview, Santana, Amapá, April 16, 2002. 35 Human Rights Watch interview, Porto Velho, Rondônia, April 25, 2002. 36 Comissão de Direitos Humanos, IV Caravana Nacional de Direitos Humanos, p. 30. 37 Human Rights Watch interview, Centro de Internação de Adolescentes Femenino, Ananideua, Pará, April 11, 2002. 38 Human Rights Watch interview, Centro Sócio-Educativo Masculino, Ananideua, Pará, April 12, 2002. 39 Human Rights Watch interview, Macapá, Amapá, April 16, 2002. 40 Human Rights Watch interview, Centro Sócio-Educativo Masculino, Ananideua, Pará, April 12, 2002. 41 See International Covenant on Economic, Social and Cultural Rights, art. 12; Convention on the Rights of the Child, art. 24; CEDAW, arts. 11.1(f) and 12; International Convention on the Elimination of All Forms of Racial Discrimination, adopted December 21, 1965, 660 U.N.T.S. 195 (entered into force January 4, 1969, and ratified by Brazil March 27, 1968), art. 5(e)(iv); Protocol of San Salvador, art. 10. 42 Human Rights Committee, General Comment 21, para.3. 43 U.N. Rules for the Protection of Juveniles, art. 3. 50 See Inter-American Convention on the Elimination of All Forms of Discrimination against Persons with Disabilities, adopted June 7, 1999, O.A.S.T.S. No. - (entered into force September 14, 2001). Brazil ratified the convention on September 17, 2001. 51 Convention on the Rights of the Child, art. 24(2)(e). 52 U.N. ECOSOC, Committee on Economic, Social and Cultural Rights, 22d sess., agenda item 3, Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights, General Comment No. 14 (2000): The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social and Cultural Rights), U.N. Doc. E/C.12/2000/4, CESCR, para. 12(b), in U.N. Secretariat, Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.5 (April 26, 2001), p. 92. 53 Committee on the Rights of the Child, 19th sess., General Discussion on Children Living in a World With AIDS, U.N. Doc. CRC/C/80 (October 5, 1998), in Office of the U.N. High Commissioner for Human Rights, comp., Commitee on the Rights of the Child: Reports of General Discussion Days, p. 91, para. 234(d). 54 Guidelines on HIV/AIDS and Human Rights, Guideline 8(g).
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