Should prisons have government-sanctioned tattoo shops?

Health and medicine explained.
Sept. 16 2010 10:02 AM

Ink Well

Should prisons have government-sanctioned tattoo shops?

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A tattooed Filipino inmate 

Nothing says "I've been in prison" like an armful of tattoos. Worldwide, studies report that up to half of prisoners get tattoos while doing time. Because prison tattooing is illegal, inmates create their inking equipment with whatever they can scrounge: ink made from burned Styrofoam cups, shampoo, or anything else that can be turned into a dark liquid is injected through makeshift tattoo guns using parts from radios, PlayStations, or anything else with a rudimentary motor. And a needle can be crafted from just about anything sharp—even a staple.

Now, a newly published review of more than 100 studies has confirmed the connection between tattoos and hepatitis C virus. Nowhere is that relationship more apparent than within prison walls. Rates of HCV are 10 to 20 times higher in prisons, compared with the population at large; as many as one-third of the more than 2 million inmates in the United States are infected. As a blood-borne disease, HCV is easily transmitted through dirty tattoo needles and can survive for some time in ink. Considering the high prevalence of HCV, the popularity of illegal tattooing, and the commonness of sharing used ink needles, the disease is probably being spread through this route. Studies have found higher HCV rates among tatted-up prisoners than in their ink-free inmates.

So it makes sense that many prison and human rights advocates are looking at safer tattooing programs as a way to lower HCV transmission rates. Correction Services Canada ran a pilot program from 2005 to 2006 offering sanitary tattooing by inmates and education about blood-borne diseases. It was shut down prematurely by the incumbent government, but even the short run demonstrated its clear benefits.

Though it's impossible to know for sure whether any cases of HCV were avoided, a look at the expenses of the program vs. the expenses of an inmate with HCV show the potential benefits of such an investment. Start-up and implementation cost about $913,000.   Considering the high costs of treating HCV and HIV (mildly transmissible through tattooing), the program could be considered cost-effective if one out of every 38 tattoo sessions avoided an HCV infection, if one out of every 50 sessions avoided a case of HIV, or if one out of every 248 sessions avoided a liver transplant (a late-stage option for many HCV sufferers). Given the frequency of tattooing and the high HCV rates among people entering prison, these figures are realistic.

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The shop art cost about $5 for a two-hour session—cheaper than so-called range tattoos, which typically cost $10 to $15 on the prison black market—creating an incentive to take the sterile route. The potential savings could improve even more since a long-term program would enable purchases of bulk ink and nondisposable nozzles. As a side perk, the shops provide useful employment for inmates, giving them not only an activity while behind bars but also a skill that's marketable on the outside.

Prisoners weren't the only ones to benefit from the program. While the official tattoo shop was in operation, guards seized less ink-slinging contraband, and they reported feeling less concerned about needle-stick injuries. Such injuries aren't routine, but they do happen during cell searches, both on purpose and by accident, and are a common fear among prison staff members.

Saving money and protecting guards aren't the only reasons to embrace government-sanctioned prison tattoo shops. We should also keep in mind how much suffering is in store for inmates who contract HCV. These are persuasive arguments for government-sanctioned prison tattoo shops. Because the disease is silent, up to 75 percent of those with HCV don't even know they're infected until it's too late for treatment. Many people do not respond to the currently available medications, and liver transplants are costly and not always available. Although some patients do spontaneously recover, most don't, and there is no way to predict who will develop end-stage complications, which include cirrhosis and cancer.

Why not just test inmates and treat those who are positive for HCV? By law, HCV testing cannot be compulsory. Many prisons don't even offer it. And although some states have solid health care for prisoners, many do not, so those in need of HCV treatment don't necessarily receive standard care: a 48-week treatment with two drugs, pegylated interferon plus ribavirin. Many states refuse to medicate prisoners who might leave prison before completing the course; because an incomplete treatment is unlikely to help patients, it's a waste of money to start what can't be finished. (New York City is an exception here, allowing abridged treatment for prisoners who will follow up with a regional doctor upon release.) Even more problematic, one of the major side effects of interferon is depression, so anyone seeking treatment must be in good mental health before the drugs are given—and prisoners are disproportionately affected by mental illness.

Still, as a strategy to reduce HCV transmission, safer-tattooing initiatives are not without problems: For instance, a lot of prison-borne tattoos signify gang associations; and during the Canadian pilot program, other inmates reportedly preferred the work of prisoners not employed at the shop. A safe-tattoo program would have to forbid such body art, so some market for DIY tattooing would remain.