Poor Medical Care for Prisoners Explains Why Number of Custodial Deaths Is Only Rising

In 2018, 1,845 people died while incarcerated. That's the highest number India has seen so far.

Mumbai: “I would see this one prison inmate being brought to the hospital every day for an entire week, and each time turned away. The escort police would invariably walk in around 2:30-3 pm, over an hour after the OPD (out-patient department) hours, and no doctor would be available to treat patients then. The inmate went untreated for over a week,” recalls a young doctor at Maharashtra’s state-run JJ hospital.

A week later, when the patient was finally brought during OPD hours, it was too late. “The patient had developed complications. He soon died of septicaemia and multiple organ failure.”

This patient, an undertrial prisoner lodged at Taloja prison in Thane district, was one of the 1,845 incarcerated persons who died in judicial custody in 2018, the worst-ever year for inmate deaths in Indian jails. The mortality rate in Indian prisons has shown a steady rise in the past two decades. In 2018, the figure crossed the 1,800 mark for the first time.

The National Crime Records Bureau (NCRB), last week, released prisons statistics for 2018. Of the total deaths, the data says as many as 1,639 persons died of “natural causes”, while 149 were categorised as “unnatural deaths”. Another 57 deaths were for “unknown reasons”, as some states have not furnished the required information.

Since 2000, when the NCRB first published prison deaths data, a shocking 26,426 incarcerated persons lost their lives in judicial custody. Since over 70% of the total prison population are usually undertrials, most of these deaths could be of those awaiting justice.

The report neatly lays down the categories of deaths under two columns – natural and unnatural. But a close look at the causes of death under the “natural death” category and the illnesses listed indicates that there is nothing natural about these deaths. The unnatural deaths category, too, evades judicial and state responsibility of providing proper mental health care and security to those dead due to suicide, attacks and other accidents while in judicial custody.

Among the natural deaths, data shows that a majority of the deaths were reported under heart-related ailments (411), lung-related ailments (231), tuberculosis (103), cancer (80), liver-related ailments (72), brain haemorrhage (59), kidney-related ailments (58) and HIV (46), among others. Prisoners’ rights activists, scholars and government hospital doctors say most of these deaths could have been avoided if proper medical care was made available on time.

custodial deaths

Source: NCRB

Source: NCRB

While in custody, the incarcerated person, along with her freedom of movement, also loses her freedom to choose her own medical care. This means she is entirely dependent on prison authorities, the judiciary and the state government to ensure she is provided proper care.

According to the recent prison statistics for 2018, 4,66,084 prisoners were confined in as many as 1,339 jails in the country by the end of 2018. The total prison capacity is 3,96,223. Among the states, Uttar Pradesh has reported the highest overcrowding, at 176.5%, followed by Sikkim (157.3%), Chhattisgarh (153.3%), Uttarakhand (150%), Maharashtra (148.9%), Madhya Pradesh (147%) and Meghalaya (143.5%). Among the union territories, Delhi has reported the highest overcrowding at 154.3%. The largest Indian state, Uttar Pradesh, has 71 prisons with a total capacity of 58,914 prisoners. But at the end of 2018, as many as 1,04,011 persons were incarcerated.

Overcrowding, along with shrinking available space for those jailed, also causes an unjustified strain on the already inadequate resources like food and medical facilities. The immediate impact of overcrowding is seen in the living and health conditions of those incarcerated.

For instance, in Maharashtra, there are 64 central and district prisons, which house 35,884 (as of December 31, 2018) prisoners. While the prisons here are grappling with 148.9% overcrowding, the state government has done very little to ease the situation for jailed inmates. Maharashtra has been one of the top four states in terms of custodial deaths. While in 90% of the cases, the state classifies these deaths as natural, the remaining have occurred due to suicide or atrocities at the hands of other prison mates or the jail authorities.

Also read: We Must Recognise That Discrimination Plays a Large Role in Custodial Torture

In almost every prison here, a medical facility is attached. But the functionality of these facilities is dependent upon the availability of staff, their motivation to work for ailing prisoners and the external supervision mechanisms in place.

Prisons, as per the 2018 data, are working at close to half of the sanctioned medical staff capacity. A total of 1,914 medical staff were actually posted in Indian jails against sanctioned strength of 3,220 at the end of the year 2018. Uttar Pradesh has reported the highest number of vacant medical staff posts at 240, followed by Bihar with 217 vacant posts and Jharkhand at 153.

And these are just the sanctioned posts. Most prisons in India are overcrowded, and so automatically the need for medical staff is higher. For the year 2017-18, Rs 6,068.7 crore was sanctioned for the prisons department across India. Of that, only 4.3% was spent on the medical needs of those incarcerated.

Source: NCRB report

Source: NCRB report

Dr Vijay Raghavan, who works at the Centre for Criminology and Justice at TISS and is the Project Director of PRAYAS, a field action project of TISS working in prisons, points to the shortage of medical care facilities for the prisoners, both inside prisons and in the government’s facilities outside.

In Metropolitan Mumbai Region (MMR) alone there are five prisons. Here, in most prisons, Raghavan says the medical officers deputed by the Directorate of Health Services are less in number. Also when a prisoner gets referred to a nearby civil hospital, the prisoners are brought to the hospital after the OPD timings are over, therefore the person has to be brought back again to the hospital, Raghavan points out. “Prisoners’ movement is highly dependent on the availability of police escorts which are also short. Most times the prisoners cannot be moved to a civil hospital because of lack of escort facilities,” Raghavan says.

Women’s barracks in Mandya prison. Photo: Sukanya Shantha/The Wire

The Directorate of Health Services has stipulated a prison ward in every civil hospital. But very few of them are functional. Like in the MMR, only JJ hospital has its jail-ward working. “The Thane civil hospital, after it ran in some controversy and one of its medical staff was suspended for dereliction of duty, stopped hospitalising prisoners,” Raghavan recalls. Ever since, all patients get referred to JJ hospital which has a 30-bed facility separately earmarked for the prisoners, he adds.

But how feasible is this arrangement? “Imagine a prisoner from Kalyan district prison being taken to JJ hospital, over 50 km away. This prisoner will only be ferried to the hospital if an escort team is available on that particular day. And on a lucky day, even if the team is made available, the team has to reach the OPD before 1:30 pm. These specifications just make it impossible for a prisoner to avail immediate medical care,” a senior doctor at the JJ hospital told The Wire.

The prison department, the police escorts team and the medical department have not been able to work out a coherent arrangement even after repeated deaths. For example, JJ hospital in Mumbai has a dedicated prisons ward but there isn’t any provision made for the police escort team that accompanies the prisoners. “So, the police escort is reluctant to have the patient hospitalised and tries every trick in the book to return to the jail, irrespective of the medical requirements of the patient,” a social worker at one of the Mumbai prisons said.

Explaining the reasons behind the difficulty in providing police escorts, a retired prisons superintendent in Karnataka said that the police department is forever facing an acute manpower shortage. “Any policeman cannot be a police escort; only armed reserve police can be escorts. These men are first needed to ensure undertrials are taken to the court regularly. Medical emergencies are never looked at as the priority,” he added.

To avoid such situations, Raghavan says, the Maharashtra government appointed Justice (retired) Dr S. Radhakrishnan committee has recommended that a team of five medical experts – one gynaecologist, one general physician, one skin specialist, on psychiatrist or a social worker with psychological training and one paediatrician visit jails once for two hours, every week. “When prisoners can’t be taken to the hospital, the hospital was to be made available for them at their door step.

The recommendation was made in 2017 and they are yet to be implemented. The Director of Health Services has issued a circular instructing all discuss civil surgeons to arrange this facility every week but this is hardly implemented”, Raghavan, who was also a member of the committee, points out.

Interestingly, when there is judicial intervention, the prison authorities and the state government have acted more responsibly. Raghavan says soon after the Bombay High court issued guidelines in one PUCL versus State of Maharashtra case in 2006, a team of doctors (with similar composition as recommended by the Radhakrishnan committee) have been visiting the Byculla women’s prison. “The system has been effective,” Raghavan says.

In December 2016, The Wire had published an exhaustive report on the recorded reasons for custodial deaths in Maharashtra. In most cases, according to the record maintained with the state prison department, the deaths were reported because of “headache” or “weakness”. These symptoms went undiagnosed and the prisoner had died before receiving proper treatment.

Mandya prison’s kitchen. Photo: Sukanya Shantha/The Wire

Why a judicial inquiry

The Bombay high court that year had rapped the Maharashtra state for not doing enough to ensure that the due process of law was followed in handling cases of cases of custodial death. While hearing one such matter, the high court had directed the state to ensure a judicial magistrate’s inquiry as stipulated under Section 176 (1A) of the Code of Criminal Procedure. This inquiry, prison department sources say, has still not been conducted. “The department still follows the executive magistrate’s inquiry process and sends out the report to the national and state human rights commission,” an officer confirmed.

Just a handful of states, like Tamil Nadu and some districts of Karnataka, follow the procedure of judicial magistrate’s inquiry. The courts have time and again pulled states up for flouting the process, but the system hasn’t changed.

The only publicly available data on deaths in prisons is published by the National Crime Records Bureau every year. This data categorises deaths as “natural” and “unnatural”. Unnatural deaths comprise cases of suicides and murders committed by prison officials, inmates or deaths due to other external factors. Although the category itself is inadequate, it is still subjected to a certain standard of scrutiny – both by the state and the judiciary. But it is the natural deaths which really go unexamined. No questions are raised about the ‘naturalness’ of these deaths, purportedly caused by ‘headache’ and ‘weakness’. The reason, however frivolous, is the only thing taken into consideration by the prisons department in order to classify a person’s death as natural.

Also read: Emulating Rajasthan’s Open Jails Model Could Ease Overcrowding in Indian Prisons

The NHRC in 1993 had issued a general instruction to all states that “within 24 hours of occurrence of any custodial death, the Commission must be given intimation about it. These intimations were to be followed with Post-mortem Reports, Magisterial Inquest Reports/Videography Reports of the post-mortem etc.” The NHRC, however, has not gone beyond collecting these reports and accepting them at the face value. Only in a few cases, where the deceased person’s relatives have moved the commission, some intervention has been made, mostly in the form of compensation.

In 2010, the commission issued a ‘guideline’ negatively impacting the statute’s effectiveness. In what appears to be a narrow reading of the section, the NHRC’s guideline stated, “When there is no suspicion or foul play or where there is no evidence or allegation of an offence, an inquiry by a Judicial Magistrate is not mandatory.”

The NHRC’s guidelines explained the “practical difficulties” in conducting such inquires. The commission seemed more concerned about the difficulties states face that the rights of those behind bars. Stressing on the word “offence” as defined under Section 176 (5) of the CrPC, the commission obfuscated the entire procedure and said a judicial inquiry was mandatory only when an offence was committed.