So good afternoon, everyone, and welcome back to the university after a break. I'd like to begin by acknowledging that we are gathered today in the ancestral and un-studied territory that we want people, and to give thanks for the opportunity to be here. My name is Joanna Erdman, and I am the Associate Director of the Health Law Institute at Dalhousie University. It's my pleasure today to welcome you to our first semester, our first seminar of the semester in our Health Law and Policy seminar series. This year, we're doing something a little different with the seminar. We're trying to celebrate the interdisciplinary nature of the field. So looking to different theories and methods that inform our study of law, and to try to challenge some of those theories and methods as well. And so our presenters this year come from many fields of health law and policy and many different disciplines of its practice. Today is no exception. It's my great pleasure to welcome one of our Institute colleagues and members. She's also an assistant professor here at Dalhousie, Adelina Iftenay. Adelina defines her research as highly interdisciplinary. It aims to answer questions in criminal justice by using legal and empirical social science methods. And that research includes the study of the rights of people in prisons to health and health care. This indeed is a subject that figures quite prominently in her forthcoming book to be published by the University of Toronto Press. It's titled Connishment for Aging, Older Federal Prisoners and the Challenge to the Canadian Correctional and Legal Landscape. So today Adelina will focus more specifically on a health issue presenting on chronic illness in prison, law, policy, and reality. In an article that was published last year on this subject, Adelina notes that improving care for chronic illness, including pain management, is about more than providing access to health care. It's about prison law and policy that gives consideration to the bodies and to the experiences of people and to the limits and challenges they face. So please join me in welcoming Adelina. Good afternoon, everyone. It's absolutely fantastic to be here today. This has been such an amazing series that Joanna and the others at the Institute have put together. It's just phenomenal to be part of it. And I am very happy to be able to share some of my research with you. As Joanna mentioned, my work is interdisciplinary. It's an overlapping of health law and criminal law and sentencing and imprisonment and social science and health science and a lot of things that are coming together to create the realities that prisoners are experiencing in our system. And in particular, in the last seven years, the majority of my work has been dedicated to looking at the problems that a new wave of aging population is experiencing when they are being incarcerated. Now, today I'm going to be looking at the chronic illnesses that these individuals are experiencing. And I do not want to be understood as saying that the health care system in prison, other than when it pertains to older people, it's working wonderfully because it's not. And I'm not saying that, but I think that older prisoners are a particularly interesting case study because when it comes to them, everything that can go wrong goes wrong. And because not unlike in the community, as we grow older, we tend to have more health problems. We tend to have chronic illnesses. We tend to have more emergency needs. We have terminal illnesses. And this is something that we are seeing in prison as well. But probably we're seeing it at a higher rate than in the community because of the previous lifestyles of people that are experiencing it and also because of the rigorous of incarceration. So I am going to go over that with you today. Please note before I start that all of my work has been completely in federal system, in the Canadian federal penitentiary system. So that is the system that holds people that have been sentenced to over two years in prison. Now, of course, there are the provincial systems where the majority of people experiencing incarceration go through because they are sentenced under two years. However, I focus on the federal system because that's where we're going to see people sentenced to life, people experiencing indeterminate sentences, long sentences, people who are going in and out of prison a lot. So that's where the bulk of aging individuals that are experiencing their golden years behind bars are going to be found. So I'm going to do two things today. I'm going to attempt to provide you with an overview of what the federal correctional system looks like and what is health care characteristics are. I am also going to give you an overview of the legal and policy framework that is governing the system. And I'm going to point out that actually the legal and policy framework is quite advanced. It's quite progressive and that is probably one of the better ones in the developed world. It has been a source of inspiration for a great number of other countries. And that's why there is this image about Canada has been particularly progressive in terms of incarceration and correctional system. However, as it happens in many other fields, the reality is not as pink. And that has to do a lot with how the laws are being implemented and upheld. So the second part of the talk is going to go through some of the findings of my study as they pertain to the image of the older incarcerated individual in penitentiaries and to the health care that is available to these individuals, despite the somewhat robust framework that we have in place. And as a last point, I would like to mention that the photographs that you're going to see on the slides are of actual older people incarcerated in Canada and the US. They are the courtesy of photographer Ron Levine, who has dedicated his career to taking pictures of older people in prisons. And I'd like to use them because it kind of reminds us that the reason why we do the work that we do, the reason why I talk, the reason why you came to listen, the reason why people are doing research is because there are people behind it. It's not just an attempt to show you some statistics or an attempt to make a legal argument. It is about the people that are behind it and are in actual need of change and reform. So the federal correctional system. As I mentioned, people sentenced over two years are incarcerated in federal institutions. Federal institutions are generally called penitentiaries. They exist throughout Canada, throughout the country, from coast to coast. And the federal correctional system is administered by an institution called Correctional Service Canada. It's a federal institution that responds directly to the Ministry of Public Safety. And it currently incarcerates somewhere around 13,000 to 14,000 men and women in its institutions. Over 2,000 of these men and women are over the age of 50. Now, I say age of 50 is the lower limit of seniority in prison research. And when I told this to my mom, she had a shock because she's like, what, that's not, it's not possible. The reality is, however, that people who are experiencing incarceration tend to present the problems of an individual who's 10 to 15 years older than them in the community. It is why we start our seniority prison research at the age of 50. And that's what I've done in my work. So they tend to be around just over 2,000 people that are incarcerated and are over 50 and their health is also being responded to has been taken care of through the Correctional System. So the healthcare in the federal system is not the prerogative or the attribute of the health care ministry, the provincial health care ministry, but rather healthcare is provided in the institutions by the Correctional Service Canada through Correctional Service Canada through people that are contracted by them. So a lot of times they are going to have a prison physician, they are going to have informaries in their institutions, they are going to have a contracted psychiatrist, they are gonna have a contracted dentist. And when they don't have them on contract, they are going to send the prisoners that are in need of particular specialized healthcare. They are going to send them to the community to civil hospitals and they are gonna be taken by escorts. They are also five regions. So the Correctional System is divided by regions. There are five regions from coast to coast. And in each of these region, there is what we call a regional treatment center. The regional treatment center is like a blend between a hospital and a prison. And they are actually psychiatric institutions. So individuals who are experienced acute psychiatric problems at a certain time during their incarceration, they are shipped to the regional treatment center where they are receiving some form of treatment and after they are being stabilized, they are turned back to their institutions. Okay, now the framework, the legal framework that is governing the Correctional Federal System is the major act, is an act called the Correction and Conditional Release Act and its regulation. As I mentioned, it is a very progressive piece of legislation. It came into force in 1992. It has been a lot of work by extraordinary people to bring it forward. It regulates the rights of individuals that are behind bars in the Correctional System. Again, only the Federal Correctional System. And it looks at everything from how the intake of the prisoner is going to take place, to the individual's rights, to their right to place grievances, to the oversight, to an external oversight mechanism that's governing the issues that prisoner or where individual may place complaints, which is called the Office of the Correctional Investigator. It regulates an independent chairperson that is going to oversee the disciplinary hearings. So it's quite progressive. And of course, it look at healthcare issues. And I put up this provision because it's particularly, it has a number of healthcare provisions, but this one is particularly important and it's particularly important because it says two things. One of them, it says that prisoners have the right to essential healthcare and they have reasonable access to non-essential healthcare. The second thing that it does is that it tells us that that healthcare, the healthcare that Correctional Service Canada is providing needs to be at accepted levels of the profession. So comparable to the healthcare that is being provided in the community. Now, you may wonder and you are right if you do of what essential healthcare is and what non-essential healthcare is. And we're gonna see that this is a trend. This is one of the issues that the legislation is having and unfortunately the policy documents are not much more enlightening on the matter. So that is gonna complicate things as we discuss about older prisoners. Now, the piece of legislation that I just mentioned to you is being implemented on the ground and in the institutions by a set of policy documents. Policy documents are emanating a lot of them from the national headquarters in Ottawa and they have different names. The most important ones are call commissioners directives. Now, they are not pieces of legislation so you cannot take them to court and build your legal argument on them but they are mandatory for the daily operations in all the prisons that are governed by the correctional service Canada. And they have to be in accordance with corrections and conditional release act and they are supposed to provide guidance on how to implement that in practice. And we do have a couple of important commissioners directives. One of them is the health services provisions. Unfortunately, they are also not more illuminating on what essential healthcare is or what unessential healthcare is and so forth but they do exist. We have the palliative care guidelines very important for our talk today. It's again, it's not even mandatory for the institution it's just that a guideline to help the staff but it uses big words. It's talking, it's envisioning specific accommodations for people who are experiencing their end of life in prison. It's talking about a multidisciplinary team that is going to help individuals who are experiencing end of life. They have in their team psychologists and social workers and psychiatrists and different physicians and different kinds of specialist spiritual care and so forth. So they are using, they are creating this guideline that makes you think that it's actually similar to what people might have when they have multidisciplinary teams in the community. And then there is also the drug formulary which is a particularly important piece because as with any drug formulary it sets up the medical compounds that are available for a prison physician to prescribe to incarcerated individual. What it is particularly important is because the drugs that are not on the drug formulary cannot be prescribed by the prison physician and even if they are prescribed by the prison physician they cannot, there is no way to get them to the prisoner because they are not provided by the Correctional Service Canada and drugs that are not provided by Correctional Service Canada are contraband. So they cannot be used legally in the penitentiaries. Now the drug formulary covers more or less many areas of course. They are generally using the cheaper compounds, not very surprising. And we're gonna see there are a number of limitation in terms of medication available that generally pertain to security concerns. The last thing I wanna say about corrections and conditional release act and its policies is the fact that the legislator has envisioned even then in 1992 the fact that people will die in prison. And that people will get sick in prison and that prisons are not nursing homes. And even when you are trying to create these palliative care guidelines and to provide them with the best care possible that's not always going to be good neither for the prisoner nor for the staff or the other prisoners that are in the institution. So and also some of these individuals will get sick quite suddenly or we will not be able to perform whatever prison obligations that might have that is gonna help them obtain a release. So there has to be a form to allow for the release of these individuals who are very sick even though they cannot be mainstream and released through the normal parole options. So here it's 121 is the Canadian version of compassionate release which essentially says that individual who are terminally ill or who have health that's incompatible with incarceration or who risk that their health be continued to deteriorate while in prison may apply for parole by exception even if they are not meeting the general requirements for parole. So again, sounds really good. Finally, of course, we have the Canadian Charter of Rights and Freedoms. Very significant body of case law that is saying that constitutional rights still apply to prisoners. Individuals are maintaining their rights once incarcerated and basically all the legislation and all the policy documents need to be and obviously the treatment that is being inflicted upon the individuals need to be in accordance to the constitution. Particularly important and I want you to keep that in mind as I go through the study today is the right to life remainder of liberty and security of the person that people still have while in prison and they are right not to be subjected to cruel and unusual treatment and punishment. So please remember that as we're going through some concrete examples of what's happening. Okay, so let's talk a bit about the study. When I started the study as part of my PhD dissertation there was very little work done with older prisoners despite this galloping number. As I said, we are currently at 25% of our prison population being over the age of 50 and it's predicted that in the next two, three years it's gonna reach 30%. It's been a galloping number. It has doubled in the last decade and that has to do with some of the tough on crime policies of the former government but also with the general trend in the community and population. And despite that there has been a host of work that's been undertaken by Australians and Americans in England but not in Canada. So my research tried to come in and fill some of this void that existed. As a result I've interviewed 200 individuals in seven institutions in Canada. So 200 individuals would be 10% of the people that were at the time over the age of 50. It was seven institutions, all levels of security. From the assessment unit to minimum, medium and maximum security, all of them were male and the reason for that is because I did not receive access to interview female prisoners and we can talk about that in the Q&A. So I interviewed them based on structured protocol. We went over issues that they are experienced. They are health problems. They are access that they are having to different programs, discipline, victimization, release and a number of other issues. What I'm going to try to do today, I am going to, it is a fully self-reported study because I did not receive access to speak to officers and I did not receive access to look at their medical records even with their consent. So I had to do the best with what I've had. I'm going to try to take you through some of the trends that the study illustrates. We are going to look at the image, the physical health and the mental health of an individual over 50 in prison. Again, it doesn't really do justice to what these people are experiencing but I had to kind of choose and pick something that's gonna help you give you an image of what's going on. And then we're going to look at the treatment that is actually available, the services that are available to this individual and so forth as it comes out from my study. And please keep in mind and carry with you through the study, through the discussion, the legal framework, the provisions and the constitutional rights that these individuals are having. Okay, so it's interesting to mention the fact that from the 200 individuals that I've interviewed, half over half of them were serving life or were serving in determinate sentences. The rest of them were individuals that were incarcerated for the first time at an older age, many of them. And the reason was because they had underwent trial for a historic crime. So a crime that has happened 30 years prior. Or they were what we call habitual offender in and out of prison. The individual that's over 50 is almost guaranteed to have at least one chronic problem according to my study but most likely is that he presents comorbidities. So comorbidities are described as an individual who has three chronic conditions. In my study, the bulk of the individuals had four to seven conditions. And a lot of their conditions were in the area that the medical literature is defining as associated with aging, whether they are cancer, severe arthritis, heart problems, lung problems, kidney problems. And many of them were significant disability problems. So over 50% of the individuals reported at least one significant physical disability. And when I say physical disability, I refer to something that is affecting their ability to function. Their activities of daily living or prison activities of daily living. Such as going up and down the stairs, walking, toileting, eating, standing for count, doing work, going to programming and so forth. In my study, it was a statistically relevant connection between disabilities and chronic pain. Very high rate of chronic pain. Chronic pain described as something that is constant and severe and cannot be, and individuals, I only counted that one that they said that it doesn't respond to over-the-counter medication. And according to the study, a significant, the majority of pain reports were also associated with people that were reporting diseases associated with aging. You can see the ones that are being highlighted there. Very unfortunate, the 5% were already had a terminal illness diagnosis. Terminal illness being something that's within months of dying. So we're gonna see how that's been responded to. And a number of other issues had to do with, for instance, incontinence, probably under-reported, but a very high rate of people reporting incontinence. And problems such as disabilities and chronic illnesses and incontinence and pain were issues that were actually making these individuals feel particularly vulnerable. It led to a lot of isolation among this group, significant rates of isolation. And a lot of times they would ask to be placed in higher levels of security, to be placed in protective custody.   So once you've been there, you're not coming out because you have a target on your back. So a lot of these individuals, even though they might have had nothing to do with the particular crimes that would be stigmatizing, if they wanted to protect themselves, they would have to be placed in protective custody from where they would never be able to come out. And that obviously means a lot of isolation. Unfortunately, mental health-wise, they were not doing much better. It's probably under-reported again, the rate of mental illness. Almost 50% did report a diagnosis of mental illness. The majority of them were chronic depression, which is not unusual according to the medical literature for older people to experience higher rates of chronic depression. The higher rates of psychiatric problems were in maximum security, where you see a rate of over 70% reporting mental problems. And mental issues and chronic depression were also associated with suicidal ideation in the study. What was also associated interestingly with mental issues was the use of segregation and the disciplinary charges. So this was a very calm population, very low on disciplinary issues, very, very, very low percentages of disciplinary reporting disciplinary charges or time-spending segregation. However, individuals who did report a mental illness reported almost double the time-spending segregation and reported also significantly higher disciplinary charges. And the same with peer abuse. People who did report, now the rates of peer abuse were very high among with this population, but the ones who did report a mental illness reported almost double the rates of peer abuse. And what was particularly worrisome, but not fully surprising, was that 4% had a diagnosis of first stage of dementia or significant cognitive impairment. And we're gonna see how that plays out, but that was a particular issue. Now, I'm going to take you through some of the treatment and accommodation that is available to these individuals. Again, that's just a rough image from the data. There is so much more that could be said about their health status, but those are just some of the ideas that come out of the study. One of the big issues in responding to the high rates of chronic illness and disability did not have to do directly with medical care, but had to do with accommodation and infrastructure. We turned out to be particularly problematic for this group. Very significantly, in two of the institution, there were not even the most basic disability accommodation. There were no elevators. All the cells were at the second level, so they would have to go up and down the level. This was minimum security as well, so high rates of older people. They would have to go up and down the stairs every day to get to the place where they would have food, to get to the canteen, to get to programming, to get to the yard, to get everywhere. So they would go up and down the stairs. There weren't any disability accommodations in the shower. They would not have any kind of rails. They would not have any wheelchair ramps or anything like that. And in the other institutions, even when they did have all of these accommodations, some of them were placed in very, very large spaces where the distances from one building to another were particularly large, like Workworth is one of those institutions in Ontario, for instance, where to get, for instance, from the place where you have your bed, where your unit is, to get to the programming, it's a good five-minute walk, even if you are completely a 10-minute walk, if you are full-bodied. So for these individuals, it took a very long time and they were always in a hurry because it's a high-medium security institution. They would have to be in certain places at the right time or they would get charged. Hence, the 72% rate of falling within the previous winter, very high rate, especially on improperly clean passways, on the stairs. The other big issue was double banking. Double banking were somewhere within the 30% rate of double banking in Canada and this is no exception for places where older individuals are serving their time. So double banking can mean that the beds are one on top of the other or they are side-by-side. The rule, the prison rule is first come, first serve. So the person who comes last in the cell is the person who goes on top bunk and that doesn't really matter how old you are. Also, another prison rule is the fact that if you are the weak one, you're going to have to do what the stronger one says. And a lot of times it would end up that if you are bunked with a younger, stronger, obnoxious, young man, you are going to spend the whole time in on the top bunk. And that means that it doesn't matter whether you have disabilities, it doesn't matter if you have chronic pain, it doesn't matter if you can get up or down, it doesn't matter that it takes you 10 minutes to get on the top of your bunk, that's the reality they are facing. You'd think that the side-by-side beds were a little better. One of the individuals was telling me, cause double banking means two beds in the cell for one. So one of the images was described by the individual, he was in a wheelchair and he said that basically he could get, there was no problem, he could get in his bed, but the wheelchair would not fit in the cell. So what he had to do, he would have to leave the wheelchair at the entrance and crawl himself up in the bed. So, and that happened quite regularly with people that were using wheelchairs in a double bunk place. The other issue had to do with the fact that 92% of these individuals were taking some form of prescription medication and they would have to go, so unless you're in maximum, everywhere else you have to go and stand in line to pick up your medication in the morning and or evenings. So the lines are forming, you have to stand for somewhere at around an hour and in 60% of these places, the lines are formed outside.  Same thing, you have to stand up for an hour to pick up your pain medication. It is why the prisoners were generally calling healthcare death care. Now, the other problem had to do with the fact that a lot of the items, non-medical items sometimes that were helping this individual's cope with their problems were not readily available. So it could be issues such as wheelchairs or canes or knee braces or back braces or mattresses, even small things like an extra pillow to put behind under your legs if you have circulation problems or say an extra blanket if you're suffering from hypothermia or what not. So even those small things in some institutions were not readily available and they were generally at the discretion of the warden and some of the bigger institutions like Workworth that has 600 individuals in it had a general ban on asking for any of these kind of items. Only two institutions had peer caregivers. And even though they were particularly poorly trained and there were a lot of reports regarding medication that was stolen off the prisoners or food stolen off the prisoners by their peer caregivers, so a lot of issues in that regard. And I think also particularly concerning was the fact that there was no accommodation for people who are experiencing their end of life in prison. So I said we had a 5% rate of terminal illnesses and they were housed together with absolutely everybody else. So they were housed in the general units, in the general cells, there was nothing that was actually made for them specifically. Now many of them were sent to this institution that's a minimum security institution in Ontario. It was called Pittsburgh at that point. Now it's called Joyceville Minimum Security where there were about 70% of the individuals were over the age of 50 and they were calling it the death camp. It was kind of known that you're going to go there to die because it was called the more friendlier of the institutions, right? Now since my study has been completely, they've modified something. So they've decided that okay, maybe keeping everyone who's dying in prison is not in those units, is not the greatest of the ideas. So what they've done, they are shipping people that are terminally ill to the Regional Treatment Center. So I, if you remember, we talked in the beginning about the Regional Treatment Center, they are psychiatric facilities where they are treating acute prisoners, right? And they are in significantly lacking space, beds, stuff and everything else. But they didn't know what else to do so they are sending the terminally ill people in the Regional Treatment Centers. So that was the solution. Now to give you an example of how this works, in practice in Pittsburgh there was, I didn't talk to him because I was not allowed to, but all the guys that I talked to were telling me about this individual who had just two weeks prior to my arriving there had been moved from a medium security institution. He was diagnosed with terminal cancer and he was in unreal pain. So he was moved to Pittsburgh because there he would have access to morphine. Morphine as we're gonna see is not readily available everywhere. So, however, as it so happens in a lot of the cases we transferred, the paper trail doesn't really follow you very soon. So sure, you are transferred from this institution to another, but the paperwork, the medical paperwork might be like a month behind you. So until that happens, what happens is that you don't get your medication, whatever that medication is. And it so happened that this guy's paperwork because he was kind of sending a rush, did not follow him. So for one month, as it turned out, at that point it was two weeks, but there were another two weeks after that, he did not receive any pain medication, nothing at all. So he was in together in a house with some healthier individuals, I don't know, five of them, screaming in pain and in horrible sweats for a month, one month. So what the guys did, they put money together and they bought a bottle of Advil from the canteen for him. Now a bottle of Advil is a week's work for one prisoner. So because they had no idea what to do with this guy. Well eventually after a month they gave him some morphine and then he died. So it's the most horrific state of affairs that one could imagine. And in part it has to do with access to medication. And access to medication, I'm only gonna talk about the pain medication here. And 20% of individuals who reported chronic pain said that their medication is effective. And the reason why it's so is because A, well not as I said, not everywhere, there are only two things that you have access to. According to the drug formulary that I mentioned to you before. One of them is morphine if you're in certain institutions. And if you get the special prescription and all of that. And B, Tylenol-3. There is nothing in between them. And Tylenol-3 in the community is used to treat mild to moderate pain. So like I don't know, to surgery or what not. Well in prison is used to treat anything from serious migraine to last stages of cancer if you don't qualify for morphine. So that's what they get. They get Tylenol-3. And it was the situation with the guy that I was telling you about. Another example of what the problems can be when you only have these two options was in maximum security. He came in, the guy who came in with a very serious outstanding wound from a car crash. He had completely disabling headaches and he was put on morphine. And it took them two weeks to realize why he was not responding to morphine. And that was because he was a heroin addict. So you'd think that they'll know but they didn't. So their response was to put him on Tylenol-3. So at the time when I saw him, he was on Tylenol-3 and it was not going very well. The other problem is access to medical professionals. Now of course, and a lot of say, well, you know, there are long waiting times for people in the community. So yeah, of course, there's just a general chronic problem of our healthcare system. There is a long waiting time for everybody. Prisoners are not an exception. You do have to wait for very long times from a few months to a few years to see a specialist. The problem comes in terms of the fact that even the most basic needs, remember these guys cannot go to ER. There's no ER for them, right? So they are relying on the healthcare that is providing in the institutions. But in half of the institution, there was no nurse available around the clock. So you'd better not have a heart attack after the working hours. And clearly, as it so happens, they did have heart attacks after working hours. And one of the guys was telling me of a time when he had a heart attack at seven in the evening in the yard.  The officers, though they are trained in CPR, mind you, he couldn't perform CPR. So they went and told the keeper and the keeper finally said, I think we should call an ambulance. So somebody did call an ambulance and the ambulance, it was a remote location as well because such are some institutions. And the ambulance arrived an hour and a half later. So he did survive, surprisingly. Other have to do with the fact that, again, has to do with the fact they are in very remote, inaccessible locations. In Pittsburgh, I was telling you about the death camp. It's one of those spaces where it's a lot of, it's more like the units are like houses. So you can walk through them, but you cannot get with the car through them. So one of the guys had an heart attack there also after working hours, go figure. And they called the ambulance. They come, the ambulance comes, but the ambulance cannot get in. So they stop at the entrance and the guy, propped by a couple of other prisoners has to walk after having the heart attack to the ambulance. So, of course, those are just issues that have to do with the provision of emergency care and the ability to cater to a population that is increasingly having these kind of problems. Very significant lack of psychiatric care. Not in all institutions, in some institution, it was definitely better than in others. In some institutions, it was fairly solid, but think of work worth 600 individuals, as I mentioned before. There was one psychiatrist, one psychologist. So what that meant is that if you were not suicidal and I've interviewed many people there, some 40 and something.  And if your answer was no, you wouldn't get to say, well, then you're gonna have to wait. And if you said yes, then you would be put under suicide watch in segregation. But you would see the psychiatrists. Now, you were entitled to see the psychologist three times during your stay. Now, some people stayed there for like 15 years. So three times per stay. And some of the other issues had to do in terms of accessibility to the specialist in the community. Again, waiting times similar to what we're experiencing in the community. A few months to a few years. However, the problem is that you are dependent when you're in prison to escort. So you have to have an officer take you to your appointment. And the best of the institutions, which was Pittsburgh, had five escorts per day. So if you happen to be the sixth guy with an escort that day, you would not go to your appointment. So you went back to the end of the line and waited for another two years to see a specialist. So those are just some of the issues that these individuals have, you know, experience in some of access to their, to care. Now, some of you might say, okay, well, you know, it's true, it's kind of bad. It's kind of grim. Clearly this population has higher needs than the rest. Clearly, you know, prisons are not nursing homes. Clearly, there are a lot of barriers in terms of security. So probably why are we keeping this prison, these individuals in prison? We just saw that we have the very progressive parole by exception. We can release them if they are, you know, sick and if they suffer from terminal illnesses. Well, here's the catch. If you are serving life in prison, you can only be, you can apply for parole by exception only if you're terminally ill. For instance, dementia is not terminal illness. So you cannot access that. I had one of the guys who was basically cried his way through the interview. He had the first stage diagnosis of dementia. He was in maximum security. He was serving life. And he was basically saying by the time I'm gonna even be eligible to apply for parole, that's like 10 years down the road. I'm not even gonna remember my name, let alone why I'm here. And yet he had no release option whatsoever. And the way they deal with people, for instance, with dementia, instead of releasing them or helping them get help somewhere else. One of the guys, the warden actually told me about this guy. He was, he used to be in minimum security, but he became a wanderer. So at night he would get up and he would get confused and he would bother the other prisoners and the staff. So what they did, they shipped them to medium security to put him in segregation so that he doesn't bother anybody. So that was their response to a significant mental illness. And again, an individual serving life, no access to release. His parole were way down the road and compassionate release did not apply to him because dementia is not a terminal illness. Now you think, okay, fine. Dementia looks, it's a grim situation, but what about all the other situations, all the other illnesses? How about all the people who are not serving life? Why aren't they released? So the parole by exception has been used exactly four times in the last decade. None of the individuals that I talked to has ever heard of this provision, ever. They didn't even know that it existed. And I've done quite a bit of work as to why, so we can discuss more about that. But I think it's fair to say that the system of compassionate release is something that doesn't currently exist in Canada. And in terms of being released on general parole, that's a very significant problem because a lot of times they are actually spending more time in prison than they are younger counterparts. Why? Well, because for instance, they might not have finished their programs because of disability and other problems because they may not have a great release plan because maybe there isn't anybody who wants to take them. They don't have where to go. They don't have family support. Their family might have died 30 years ago. You know, they might have lost connection. So a lot of issues that are not necessarily depending on something they have done but of who they are now as very sick individuals is actually playing against them in having access to being released through the general system. So there is so much more that I could be saying about that and my work does have a component that looks at, you know, legal ways of challenging the status quo and problems related to release. But I'm going to stop here for the purpose of this talk and I just want to leave you with a couple of questions before we go into the Q&A. I want you to think of in these terms of what essential healthcare is and I want you to consider whether pain management or disability access to appropriate accommodation or, I don't know, access to psychiatric specialists. Is that essential healthcare? And how does the need of a 20-year-old in terms of essential healthcare defer from the health needs of a 70-year-old? Also, at one point, does having putting people in line for an hour to pick up their antibiotics in rain become cruel and unusual treatment? And who are these individuals in dangering? How is the ethical and moral explanation of incarceration play with this individual and is it still there? And ultimately, what are we going to do with them? And ultimately, at one point, are we complicit in this kind of situation, now that we know that it exists, are we becoming complicit in it and letting it go? And what is the solution to that? Thank you. Is there still for questions? Please just raise your hand. Thank you for your talk. I was wondering if, of course, did research you ever in across or looked into at how this issue was handled in the United States? How this issue of access to central services and what research is possible to do, how that kind of handled in the interagency of the U.S. and the United States? Yeah, so I don't even know if it's good or bad. For sure, there is a lot, a ton of work and a ton of improvement in terms of services, especially in the U.S. but also in Australia and England. They are probably leading in this field. And what I'm saying that it might not be good is because the explanation as to why they are so advanced is because they are also, U.S. at least, leaders in incarceration. And it is because they have life without possibility of parole. So when you know that there is absolutely no possibility of ever releasing people, you have to come up with solutions, right? So, but that being said, there have been significant issues in place. So one, there are some states in the U.S. that do utilize medical parole and compassionate release in significant higher amounts that we do. So that's one thing. But the other thing is also that they have hospices. They have, many of the jurisdictions do have palliative hospices, generally is one per jurisdiction. And that's where they are going to take them. They also have significantly increased their training, their staff training. So they have mandatory geriatric training. There is an amazing program in the U.S. in one of the jurisdictions, it's called, I think in Chicago, it's called Try Another Way. And it's basically you are teaching them how to respond and how to differentiate between say alcohol withdrawal and Alzheimer's or stuff like that because there are a lot of issues that manifest themselves differently in order of people. So they are actually actively training people.  Don't send them to higher forms. You have to, basically it's a mixture of better medical trainer for their first line responders. And they also have a lot of nursing homes type units. TrueGrid, for instance, is one of them that it's really, really working really well. They have a lot of programs. And I think that the great thing of that is not necessarily that, and UK also have some of them. And what is nice about them is that they are living units so they go back at night in their cells. And they are together during daytime. They have specialized programs that are actually relevant for all their age. They have also medical staff that is looking after them. But the nice thing is they also have a lot of specialized release programs, which I think is super important. And they are actually helping them make a release plan, looking for a nursing home for them to be released, especially in the UK. That's the target. The target is not to create a program to keep these people in prison, but the target is to create this program to target their release needs so to make sure that they're being released to the community and they are getting the help they need there. So that is the kind of program that we are like significantly behind. So I'm not saying that it's really great in the US. I'm saying that there are some models that are definitely seem to be working. And as we notice that our population is also increasing, we might want to look at that. Now, of course, there is a need for reform in healthcare and significantly better services. But I wouldn't want them to deter from the ultimate issue, which is these people need to find a way for them to receive the help they need outside prison. Yes. I just, hypothetically, even if someone's granted parole by exception, would they be eligible for medical assistance in dying? Yes. So that is actually a very, yes. So the Correctional and Conditional Release Act has been amended in accordance to the new legislation. So actually the big problem right now is that the Correctional Service Canada has implemented assisted dying in its prisons, but you can, and the way they envisioning it is that you are going to get compassionate release.  So that's their plan. The big concern with that is that we know that compassionate release doesn't really work very well. So if you're only going to have it once you have a decision that you are going to receive assisted dying, the biggest concern that I have is the fact that this individual should be released to the community and make the decision regarding what end of life care they receive, whether it's palliative or assisted dying, once they are in the community, but that's not how the current system works. So in terms of assisted dying, they have to make the decision why are they in prison and then they get released and receive it in the community, which I think there are a lot of issues regarding the coarsiveness of the situation that they are being placed in and there are a lot of issues regarding consent. Yes, Jenna. Thanks so much for your time. So as I was listening to you talk in the structure of it, I was thinking of the methodology we use in human rights monitoring and accountability, which is to look at standards, look at practice on the ground, then the big component is to try to understand why. Why are you seeing that gap between the standard to which you are entitled and that which you actually receive? And so my question was first, what are the kinds of policy forces that are leading to this big and beautiful language in the law and policy? Is it these charter cases that are requiring them to at least formally acknowledge the standards or entitlements? Because there's something unusual in the standards being set so high. And then second are what are the implementation factors that are leading to such small and disparaging implementation on the ground? You named it in passing like security, but I think in terms of human rights accountability, we need to turn all of these thousands of decisions, thousands of individual cases into something that's more systemic. Yeah, absolutely. And we're gonna make an argument. So I'm looking for those kinds of systemic factors to explain frankly the grotesque treatment in the prisons. So there is a lot and a lot of my work actually does look at that outside of this. And I think there is a combination of factors. So I think that what led to such a, you know, salutary piece of legislation and progressive way of looking at it, there have been a number of things. And we have quite a significant body of early prison law lawyers and activists that have really went in. Michael Jackson at UBC is one of the first ones. And they've been done so much work in prison and on the ground. And they always negotiated that relationship with the prison administrators and with the legislator in terms of what can be done and how it can be done and how we can work from the inside to improve things. And then it was of course the charter that came in and it was very clear from the beginning that we have that kind of obligation. So that a number of people championing human rights in prison in the late 80s and early 90s together with the charter have worked together and have come up with this really amazing piece of legislation. So there were a lot of, it was more of a liberal government at the point in time. So it was a lot of solitary work that has been done. And I'm sure that there were a lot of really good intentions that poured into all of that. And I don't think that anybody said, oh, we're just gonna create this legislation in order to do our best to circumvent it. I'm sure that it was actually a real genuine attempt to improve the situation in prisons because it was quite frankly really bad in the 70s and 80s similar to what was going on in the US. But what happened afterwards, it was the reality is that the prison culture is very intransigent and the reality is that there is a lot of a blue wall situations where people are going to cover for each other. And there is a lot of situations where the big problem in terms of legal issues is the fact that the courts have systematically for the last 20 years been extremely differential to the prison administrators. So on one hand you have the prison administrators who are doing their best to preserve the status quo on the ground and who genuinely are seeing human rights. And I've heard that numerous times they are feeling that the human rights and the charter rights are being there just to obstruct their work. So on the ground a lot of times that is the mentality. And even some of the more senior officials are having that mentality. So they are doing, we know how to do things. This is security, this is not you. You are academics and politicians, you don't know any of that thing. So we are going to, you're making our job really hard right now. And then when problems happen, they are covering for each other. And we saw that in Ashley Smith, we saw that in many cases throughout the last decade. But on the other hand, when they do make it to court there is this absolutely horrific, chilling effect that is happening because the judges say, well we are deferring to the expert even the administration. And there has been this historic refusal to intervene in any court's issues. And quite frankly, I think that there isn't another area of law or environment where the fact that the charter is used with a double standard is as obvious as in prisons. They're clearly, in all the cases there is a double standard that's applied when the people are in the community and when the people are in prison. They clearly on paper have the same rights in practice realities that they don't. And then this is something that is being continually perpetuated by the courts, including by the human rights tribunals, including by the Supreme Court. Time and again we're seeing that. So I think things are slightly changing. There have been some cases going on. Regarding segregation and solitary confinement that people have put a lot of hope in how they are gonna reform. But I think the case in Ontario that came out just like two weeks ago is the best example of how horribly misunderstood this area of law is. And again, the judge just came out and perpetuated the same issue. They said, you know, you need to, sure segregation can continue to go on is not a problem as long as somebody from the institution supervises it or somebody internal to the CSE. How does that even work when we've just established that part of the problem is the internal attitude of that. So we'll get the same differential attitude from the judges that were supposed to come with a solution. So it's massive amount of work. Yes. So you were talking about the attitudes of the administrators. Did you in your research come across any kind of like what I'm asking is like, what's the severity of the crime of the prisoner impacting their rule of fairly asleep? Is that, could that be a factor? Technically they shouldn't, on paper it shouldn't. I think that that was more, and in terms of access, I don't think it was something that it was impacting it. But obviously the type of crime or the, not even the type of crime by the level of likeability of the individual was something that was playing on how well they were treating in prison. A lot of these people were grumpy old individuals who were not very well liked. In Milhaven, which is the maximum security for instance, there was, I interviewed this guy who was 59. He looked like 75. And the second he came in, the people, when I asked for him to be interviewed, they thought it was the most hilarious thing ever. There were eight officers there. And he came and the slide, there is a metallic sliding door that's going to let the guy come out of his cell and then that one closes and the other one opens and they go really slow. But you have an emergency button you can press. So in case there is a riot or something it just slams. So when this guy, this guy was moving so slow, he had, he was diagnosed with cancer and a lot of other problems. And he came like really slowly and the guys like just smashed the button and it hit him right over the face. They thought it was the most hilarious thing that ever happened. They laughed their butts out. And I was appalled and I was telling, he was like red and I was like, well, we need to make a complaint. And he said, well, miss, you're going to leave and I'm going to stay. So no, thanks, but no thanks. So a lot of that attitude, and he was not nice to them. He was like flipping them off and all of that. So it was part of how he was treated for sure. Yes. I'm kind of interested in the circle of time. It was on the systemic biases in the medicine agenda from aspects of the system. Like the analgesia example for analgesia, for example. We know there's issues with racial and socioeconomic biases in the effect of administration analgesia in medicine and community life. So do you know how that frames a number of compares to similar demographic self-reporting in community settings for effective pain management? So how it's affecting them based on their... People have similar demographic makeup as the prisoners. What's their self-reported rates of effective analgesia? Oh, I do see what you mean. I didn't do a systemic comparison between the community and the prison. So it's very hard to tell you exactly what is their make or what is their racial profile, what is their report in those kind of terms. So I don't have data on that. Could you speak? I know you were able to access them. Could you speak to your knowledge of how these circumstances differently affect women and why they're discriminated against? Right, so also the women population is... The women population is also increasing in age and what is specific to the fact, to women, aside from having certain very specific healthcare needs that are probably not being addressed. But the other very specific thing is a lot of the women, men too, but way more women, come from their aboriginal or other visible minorities. That themselves come with a background of disadvantage in receiving healthcare in their own communities, right? So I would imagine, even though I cannot test that, I would imagine that that would play a significant role in how the profile of the old woman is actually in prison as they are growing old in addition to their particular gender-based susceptibilities. But it was interesting because I tried a lot four years in a row actually to get access to see women and the response was, because they are a smaller group of people, the response was, well, you've interviewed so many men, why don't you apply your results extrapolate to women? So that is part of the CSE culture. They have been told time and again why that doesn't work. They have been told that for the last 20 years. They have been told that by course. They have been told that by everyone and yet here we are in 2015 was, 2016 was the last time I attempted to get access to women and I'm told again that I have so much data, why don't extrapolate it to women? I mean, was the problem still prisoner? Same thing, right? Yes, Sheila. Okay. This is all about the role, yeah. Yeah, so I'm not familiar with each other. One of the things that the care of the individual is separated, so we have health care who we don't know any of this in order to find the person in jail and that's found by long-source and then the Corrections Center is funded in another. And then how most people access care outside of medical care is funded by community services, which they lose when they find the drug in the Corrections Center, so things like that are interesting. So I'm wondering if you've seen any models that work together, it's a double-edged sword, we don't wanna know why people are in jail because of that potential closeness, but on the other hand we can't address certain issues in the psychological form of food without that information. So I'm wondering if you've seen any situations where community services, Corrections Centers, and provisioning under the federal and funded health care are able to work together? So that's actually really good and it's really one of the problems that we see in the federal system as well and we might even see it at an enhanced level because in federal system all healthcare is federal, right? It comes through the Correctional Service Canada. So basically there is this absolutely abrupt discontinuation of their healthcare, so what we do see, not only that we don't see a better work between the community and prison, but what we do see there is the fact that people are coming in with medication and whatnot, diabetes and mental health problems. The second they enter prison, their healthcare is completely discontinued because you cannot get medication from other sources than the Correctional Service Canada and that takes a long time to update because they don't communicate properly and you'd have to have it prescribed by the doctor in the prison. So sometimes people with essential medication are gonna lack a month or two of medication completely and it's the same thing when they are being transferred and the same thing when they are being released because once they are being released they go from the care of the federal system into provincial and again, their healthcare, nobody's giving them their file and say here you go, go see a doctor, rather it just stops following them around. Now the only system that I've seen that's, I'm sure there are others, but the one that's actually particularly strong is in Norway because they have the healthcare that is in prisons under the exact same umbrella as it is in the community. So the individual, there is a complete communication between them, there is no discontinuation in the healthcare model. Again, smaller country, a lot of other things are very, it's easy to say we should do that, it's probably very hard to do that because of a lot of geographical factors that are not in system, but it's working quite well in that their healthcare and files are not at any point discontinuing. Basically, going from community to prison is only like changing your GP or something, right? So it is the same kind of level for those people, but it's the only model that I've seen where there is an absolute continuation and then the prison also takes it very seriously and when the individual is released they are making sure that they are transitioning them back to a GP like you, they don't just release them, they release them in the care of certain services. Last question. Yeah, yes, Shiloh. I want to go back to the last question. I just, let's do a little more for a response on how, on law's role or law's potential role in responding to these systemic problems. And certainly the systemic sort of levers of forces creating this kind of impact, I'm reminded of, I think it was Michael Jackson who was talking about some of the forces leading to the changes to the CCRA and 92 and one of them was prison riots. We had the Kingston Pen Rite, we had some really serious sort of explosions within prisons and the public was alerted to these conditions and part through those floors. And so in a way you can see it as a kind of, an attempt to quell prison or dissatisfaction in order to stop that kind of rioting in a very just utilitarian way. Or you can also see it as an attempt to respond to the public which was now alerted to these conditions in new ways. And it seems to me like we've come around historically to another moment, much like that, because when you think back to Ashley Smith the fact there was video footage and so the public has had a window in to in that case. We kind of missed the opportunity to do that, right, by 10 years. Case, and there's so much more, I mean that's one of the cases. Anyhow, and so your work I see as in part contributing to that. So you're bringing it to life, things that many of us, we didn't know all this in the kudos, right? So part of that contributes to a policy conversation. We try and help change through that. But that's one way of laws and your disciplinary work can change. But then there's a couple of other ways, and I'll just put them to you and see all the time you spent on this. We now have a sense of which is the softest and the most potentially yield some change. And one is to go on a case-by-case basis on compassionate release. Because it seems to me that is so easy and a lot makes so much sense. You're gonna go, you're gonna say, exercise your discretion here, because you gotta do it in light of charter values. You try to get charter stuff and like, if you don't win, you take that to court, and if the judge differs, you're gonna find another judge who's not gonna differ. Like, well, you gotta do that one. But that's case-by-case and maybe I'm just wrong. And then the second one, you're trying to attack the policies. Policies are practices on a systemic basis. That's harder in light of the charter. And then the third one, and I ask you because you've done an article years ago on using tort, is you're trying to do a class action tort claim. And so in part, you gotta think of, okay, what's this gonna yield? The tort claim is gonna maybe give money for folks. But you ultimately want, yeah, it would be great to get some money. If you can, but without what you want to release, right, in the community. So, and that's something that I've been advocating in my work for ever. I would do a combination of them all. And I think that in the moment when the responses, institutional responses are being intransigent, the only other way to counteract that is by a group of really dedicated people who are equally intransigent about it, right? So it's kind of like fighting fire with fire at that point. Which is easier said than done. I wouldn't go through the tort section as much. I know I've talked about it. I would like to see it more. I wouldn't go about it because the only cases that we have are civil and money is a very strong incentive. So what the correctional service does is the second that they are seeing that there is even the potential that they are gonna win. They are settling it out of court. They are giving money. These are poor people. They are gonna take the money. They are not there to change the world. They are trying to survive. So of course they are taking the money and the settlements are secret. Nobody knows. It nothing changes. We never hear about it. There are tons, hundreds of cases that have been actually settled through tort. But we don't know about them because they have been settled out of court. So a civil action, that's not, it might be good for bringing people some money and I'm not saying that they don't need it but it's definitely not something that's gonna help us progress. Now I would be very aggressive in pursuing charter avenues and they have been done but we've seen how horribly it blew in the face in Ontario. So I would think that that's something that we should keep on trying and also the case by case. But I think that brings to a bigger issue. And the bigger issue that leads into is the one thing that needs to be systemic in order to get all of these is the access to justice for prisoners. So I think if we are to start somewhere is not by thinking should we do it case by case, should we doing charter because I think that all are viable options and I do think that if we are dedicated to that they are gonna bring the change that we need but how do we get around to even bringing a case forward? And that's by creating prison expertise, by having more and more prison law courses in our schools by creating expertise within the students by bringing them and making sure that they are not gonna die of hunger if they do prison law and if they do represent clients from Bono because that's a very significant issue and then ensuring that people have access to lawyers and to legal information while they are in prison. These people have never heard of compassion at release. They have never, they tell me please do not put a complaint for me because I'm gonna be in this prison and you're gonna go. They are terrified and it's just simply because there are no minimal, the only when you have access to be represented is at a disciplinary hearing is the only time when you have access to have a lawyer with you. In no other cases you have actual like right like you might find pro bono lawyers of course but like you don't have a legal right to them and it's very, very, very difficult to access a lawyer to access legal education, to access legal information anywhere and that's where Sheila's work and people from Elizabeth Fry has contributed because it does do a bit of legal education even if it's just in one institution it still helps with that but those are, it's not systemic, it's in one where we happen to have somebody who's dedicated and wants to do that and there might be one in BC and there might be one in Ontario and that's that but the bigger problem is that they do not have a real adequate access to claim their rights and to find out about their rights. I think let's conclude the seminar and thank you again. Thank you. Thank you.