CAT/OP/MKD/1 (e) The conclusion of the health professional as to whether all recorded elements are consistent. 27. The Subcommittee is concerned that owing to under-resourcing, medical staff can only provide “primary health care”. That consists mainly of providing painkillers, sedatives or antidepressants, often inappropriately prescribed. The delegation seldom observed other types of medication and only elementary equipment was available, often consisting only of a blood-pressure manometer, a stethoscope and bandages. In one facility, medical examinations took place on a desk in the basement with limited access to running water and heating. The Subcommittee noted that specialist health care was very difficult to access for most detainees and was usually subject to the availability of the facility vehicle and the capability of the detainee to personally pay for such services. 28. The Subcommittee is also concerned at the widespread use of methadone treatment and psychoactive medication with limited or no psychiatric supervision available in most places, and no psychosocial intervention provided in conjunction with such treatments, sometimes resulting in death through methadone overdose. While “educators” are employed, their role and competence is unclear and detainees interviewed denied receiving any form of counselling, much less a formal drug rehabilitation programme. 29. While appreciating the good medical facilities in Kumanovo prison, the Subcommittee is concerned about inadequate and unhygienic clinical premises in other institutions visited. As an example, the infirmary at Idrizovo was referred to as “the prison within the prison”; was overcrowded, with 70 beds for 120 individuals, leading to many sleeping on the dirty floor; the toilets reeked of urine; there was no regular water supply; no regime of activities; included medically ill and regular detainees; and included detainees suffering from diseases such as tuberculosis and HIV, who could not be isolated, if necessary. 30. The Subcommittee is concerned that in general the number and quality of medical staff is inadequate and that while medical personnel claimed to attend various training courses, such as on the management of contagious diseases and drug addiction, they were generally unfamiliar with the Istanbul Protocol. The Subcommittee notes that medical professionals in criminal justice institutions are under the authority of the Ministry of Justice rather than the Ministry of Health and believes that this may impair their medical autonomy, causing conflicts of interest and deterring them from reporting injuries evidencing torture or ill-treatment. In one prison, a doctor admitted having been ordered to “drop” a case of a detainee who had been heavily beaten. 31. The Subcommittee recommends that in all places of deprivation of liberty, the State party: (a) Ensure that medical care, including specialist care, is guaranteed and accessible to all detained persons upon their request; (b) Facilitate the provision of sufficient medical staff and medical supplies (pharmaceuticals and equipment) to all places of deprivation of liberty, and improve the material conditions of prison medical units, particularly in Idrizovo prison; (c) Ensure that, when necessary, detainees suffering from transferable diseases can be isolated from others; (d) Establish clear protocols for the prescription of medication, referring to international pharmacological standards; (e) Place medical personnel under the authority of the Ministry of Health, which should be involved in monitoring health in prisons and in the recruitment process of health professionals; (f) Improve its training of medical personnel working in places of detention, particularly on the Istanbul Protocol and other international standards, as well as on the duty to detect and report torture and ill-treatment; 7