A sizeable increase has been observed in the number of manuscripts from outside Spain that appear in the Spanish Journal of Prison Health in the last five years (2016-2020). Only 14 articles of those published in this period were written by Spanish prison healthcare teams and eight (more than half) came from prison teams in Catalonia. There has also been a marked drop in non-Catalan Spanish original manuscripts, to the point where no article of this type was sent to the journal in 2020. Obviously there are prison healthcare professionals who send their work to other biomedical journals, but 14 original manuscripts is a very low number for what should be a basic activity of medical¹ and nursing², professionals, especially in a country like Spain, regarded as the tenth ranking country in terms of medical research³.

The causes of the low level of research activity in the Spanish prison sector are most likely several. These include the lack of training in this field, which limits potential initiatives, and the absence of research habits in primary care in general and in prison primary healthcare in particular. Another possible cause may be the lack of time, especially in prisons under the ambit of the Ministry of Home Affairs, where staff numbers have been drastically reduced, to the extent that all the staff's time and effort is now spent on work, and so other highly recommendable activities such as research are now feeling the pinch.

We believe that another highly important factor is that prison research usually takes place in the prison itself, which is managed by a “non-medical” administration that is traditionally reluctant to show what goes on inside a prison and which also gives higher priority to problems that have nothing to do with health. This mentality neither stimulates nor creates an environment conducive to research activity.

Finally, we believe that the organisation of healthcare also plays a role: little in the way of collaboration between teams, and the chronic isolation from conventional health networks, which makes it difficult to share work with healthcare services outside prison or even coordinate and prepare common projects with other health services within the prison healthcare setting.

Despite all this, research is an activity that should be demanded both inside and outside prison. The objective of research is to create knowledge, solve practical problems and act as a professional stimulus. The only limits on research should be the technical conditions of what is to be researched (quality, feasibility and, above all, relevance), the privacy/confidentiality of the material used, the informed consent of the population being researched and the ethical conditions of the project.

Although at first sight this seems complex, there is information and standards on how to do research in prisons. Legal requirements are found in Spanish legislation (including the current Prison Regulations and the Regulations on the Organisation and Functioning of Prison Services in Catalonia) and in international regulations (standards drawn up by the Council for International Organisations of Medical Sciences [CIOMS]⁴, supported by the World Health Organisation [WHO]); there are also many certified and independent clinical research ethical committees with recognised prestige and experience on the oversight of moral issues. Any intervention that focuses on research should be based on such regulations and be carried out not in a restrictive spirit, but rather with the aim of encouraging and improving the activity within the limits we mention above. However, health research in Spanish prisons is scarce, which implies that there is a problem that needs to be addressed. What is going wrong?

In Spanish prisons managed by the Spanish national government, prison research is regulated by Instruction 12/2019 on “Research in the prison setting” of the Secretary General of Prisons (SGIP in Spanish). In the other prison administration, there are no specific instructions or circulars, but research is much more common and appears to take place with far fewer obstacles. However it is difficult to obtain data about medical research in Spanish prisons.

The 2018 General Report of the SGIP⁵ states that the General Sub-directorate of Institutional Relations and Territorial Coordination authorised 116 research projects or studies in said year. The vast majority (81.9%) were approved for external demands, in other words, for studies not requested by professionals working in prisons. What is not shown is how many applications there really were, how many projects were about issues of prison health, how many were rejected or what the main reasons for the rejection were. One can deduce from all this that the General Sub-directorate of Institutional Relations and Territorial Coordination is the body responsible for evaluating the projects, but the names and qualifications of the members of the evaluation committee (if there is one) are not mentioned.

The final decision is left to the discretion of the Administration, when the recommendable thing would be, as is the case outside prisons, for the evaluation committee to be publicly known, recognised for its experience in the field of research, and include experts from outside the institution.

Another recommendable feature would be that the evaluation process be described and its contents made public beforehand, while any final decisions should be contained in the final report, with sections describing the reasons for approving or rejecting projects that are presented, and the research groups that are affected.

Finally, the SGIP demands a favourable opinion from a clinical research ethics committee, which it then does not consider to be binding. This creates a situation where a research project that has successfully passed evaluation by an ethics committee is then rejected, which is surprising to say the least.

One of the arguments used to justify the lack of prison healthcare research is that it is restricted because prisoners are a vulnerable population group. This Editorial Committee supports the belief that research on incarcerated populations must provide absolute guarantees with regard to ethical issues.

Research on incarcerated persons must be done with extreme care, because of the limitations on their capacities and autonomy to make decisions, imposed by their imprisonment and by the hierarchical and dependent relationships that they are subject to. However, it should be remembered that prisons hold persons deprived of their liberty, but these persons have not been deprived of many of the other rights that belong to any citizen.

The Administration should ensure that this population is not inappropriately used, but it also has the duty to ensure that imprisonment is not a punishment that stops prisoners from benefiting from research. An adequate balance between the risks that research subjects might run and the potential benefits of same, and free will and the right to privacy/confidentiality, are basic features of any research project.

As far as free will and consent are concerned, a Spanish study showed that inmates who had already participated in a research project had done so of their own free will and without pressure. What is more, this participation, when it took place, was motivated more by altruism than by the supposed rewards that were promised or received⁶. International documents on research^4,7-9, operate along these lines (balance of benefit/risk, confidentiality, free will and ethics), and not on the prohibition of research with vulnerable groups such as prison inmates. If these rules are followed, there is no reason to believe that an inmate cannot give valid consent to participating in a research project¹⁰.

The reaction to past abuse and criminal practices and the obligation of the Administration to guarantee the life and health of inmates should not lead to them being converted into an overprotected population that, paradoxically, is harmed by the very same process¹¹.

What is clear from a reading of the regulations of the CIOMS/WHO⁴ is that the concept of “vulnerability” should be revised to ensure that it is not understood as a simple label for complete groups of people, but rather that it should facilitate analysis of the specific characteristics that may make people or populations more likely to suffer harm through research. This approach more effectively protects vulnerable persons and does not categorically exclude them from investigation, as has traditionally been the case with the wish to protect groups regarded as vulnerable. It is exactly because of such categorical exclusions that there is little evidence for diagnosis, prevention and treatment of the diseases that afflict such groups¹². This is a kind of inequality that the system needs to resolve.

The fact of the matter is that Spanish prison health research is very scarce. High quality research is a right for any population, including prison inmates. The absence of such studies can only be damaging for the prison population and discredits the prison administration, which has the obligation to encourage this activity and not to restrict it, and to guarantee that it is carried out in accordance with current international regulations on the issue.

Therefore, not researching, not researching enough or not doing it adequately, is a failure of the prison system. Success lies in doing it and doing it well. This is the challenge; we need to unite and work together to make it a reality.