Correspondence 2002 www.thelancet.com Vol 377 June 11, 2011 The Review on the health of prisoners by Seena Fazel and Jacques Baillargeon 1 draws attention to an important subject. We would like to show that some real achievements have been made during the period covered by their Review. Substantial work has been done in the past decade or so in terms of reducing the spread of HIV and tuberculosis in prisons. 2,3 Additionally, data produced regularly by the European Monitoring Centre for Drugs and Drug Addiction are of central importance to the issue of drugs in prisons in Europe, and huge efforts have been made in reducing the harm from illicit drugs. The work of several organisations, such as WHO, the UN Office on Drugs and Crime, the International Harm Reduction Association, and AIDS Foundation East-West should be mentioned in this regard. Fazel and Baillargeon rightly draw attention to the 1998 Council of Europe recommendation on integra- tion of prison health services into public health, but they do not mention the more recent and probably more influential Moscow Declaration of WHO in 2003. 4 This declaration was one of the outcomes of the WHO Health in Prisons Project, which has produced authoritative and evidence-based publications on drugs, mental health, and communicable diseases in prisons. Up until as recently as the early 1990s, prison health was of little interest to prison authorities because such bodies were judged on security, and was of no interest to public health services because prison health was usually the responsibility of ministries of justice. This situation is now changing, and by 2009 three countries in Europe (Norway, France, and England and Wales) had passed the responsibility over to ministries of health. Many countries in Europe want to know more about this transfer and how best to achieve it. They have asked WHO to establish an expert group to give advice and support. 5 We declare that we have no conflicts of interest. Andrew Fraser, *Lars Møller, Brenda van den Bergh lmo@euro.who.int WHO Collaborating Centre for Alcohol, Illicit Drugs and Prison Health, Department of Health, London, UK (AF); and WHO Regional Office for Europe, 2100 Copenhagen Ø, Denmark (LM, BvdB) 1 Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. 2 United Nations Office on Drugs and Crime, UNAIDS, World Health Organization. HIV testing and counselling in prisons and other closed settings. http://www.who.int/hiv/pub/idu/tc_ prison_tech_paper.pdf (accessed Dec 14, 2010). 3 Tuberculosis Coalition for Technical Assistance and International Committee of the red Cross. Guidelines for control of tuberculosis in prisons. http://www.scribd.com/doc/28734882/ Guidelines-for-Control-of-TB-in-Prisons (accessed May 25, 2011). 4 World Health Organization Regional Office for Europe. Moscow Declaration: prison health as part of public health. Copenhagen: WHO Regional Office for Europe, 2003. http://www. euro.who.int/__data/assets/pdf_file/0007/ 98971/E94242.pdf (accessed Dec 14, 2010). 5 World Health Organization Regional Office for Europe. Final report of the WHO national counterpart meeting on prison health. http:// www.euro.who.int/__data/assets/pdf_file/0004/ 127759/e94508.pdf (accessed Dec 14, 2010). Mediator: who’s to blame? Asher Mullard’s World Report sum- marising the story of Mediator (benfluorex; March 12, p 890) 1 shows that there are important lessons to be learned about dealing with old drugs. We do not wish to defend the drug, the manufacturer, or the French regulatory system, but to focus on the scapegoating to which Mullard alludes. The regulatory body AFSSAPS has removed Anne Castot and Carmen Kreft-Jais, its most senior pharmaco- vigilance personnel. It is clearly wrong to blame them personally for wider system failings: such people have to work within legal and bureaucratic frameworks and resource limits set by others—ie, politicians and senior executives. It is very easy with hind- sight to say that the drug should have been withdrawn in 1999 on the basis of just two cases, but the major problem then was a lack of capacity to undertake rapid pharmacoepidemio- logical research in France to confirm and measure the risk. Also, desire to protect data privacy worked against the availability of suitable data resources. Pharmacovigilance personnel, who have to monitor the safety of thousands of substances, should not be expected to remove ineffective drugs—the regulator should put in place a separate unit for that purpose. Castot and Kreft-Jais are respected worldwide as competent profes- sionals, with an exemplary commit- ment to public health. Removing them is pure political expediency. The loss of their experience will not only reduce the likelihood of improvements being made to the French system, but also serve to discourage able people from entering the field. Americans and whites in the USA have exacerbated racial health disparities. 3,4 With growing correctional popu- lations worldwide, the long-term health consequences of incarceration are taking an increasing toll not just on prisoners, but also on the communities to which they return. Mitigation of the collateral conse- quences of incarceration will require not only improvements in prison health-care services, but also attention to the social and political circumstances that have led to such unacceptable disparities. We declare that we have no conflicts of interest. *Samuel L Dickman, Josiah D Rich samdickman@gmail.com *Department of Medicine, Division of Infectious Diseases, Miriam Hospital and Brown Medical School, Providence, RI 02906, USA (SLD, JDR); and Center for Prisoner Health and Human Rights, Providence, RI, USA (SLD, JDR) 1 Fazel S, Baillargeon J. The health of prisoners. Lancet 2011; 377: 956–65. 2 Massoglia M. Incarceration as exposure: the prison, infectious disease, and other stress-related illnesses. J Health Soc Behav 2008; 49: 56–71. 3 Massoglia M. Incarceration, health, and racial disparities in health. Law Society Rev 2008; 42: 275–306. 4 Johnson R, Raphael S. The effects of male incarceration dynamics on acquired immune deficiency syndrome infection rates among African American women and men. J Law Econ 2009; 52: 251–93. For publications from the WHO Health in Prisons Project see http://www.euro.who.int/en/ what-we-do/health-topics/ health-determinants/prisons- and-health