Member Spotlight- Dr. Ruth Elwood Martin

Q. What inspired you to start working at a prison medical clinic?

After working as a family physician in Vancouver for many years, I was overwhelmed by work, raising a family, etc. At the time, I had just turned 40 and a friend suggested shift or session work. I heard about a job vacancy for a physician at a women’s prison. Even though initially I was hesitant, I decided to give it a shot. During the first clinic that I attended, I saw more women with ill health than I had ever seen in my community practice, and I thought to myself ‘This is what I should be doing!’. Eventually, for sixteen years, I worked as a family physician in a Canadian correctional facility, one or two days a week - sometimes in a male facility, but mostly in the women’s correctional facility. 


Q. A cervical screening pilot for women in prison was initiated by you in 1998. Why cervical screening, and what were the results of this screening?

During my family practice, I had a great interest in primary care research - basically using your observations in primary care to foster research questions with the intention of improving things. Getting involved in the prison clinic made me realize that there were so many unanswered questions. For example, there was a very high prevalence of sexually transmitted infections that was obviously reflecting the socioeconomic condition and all the factors that contributed to bringing women to prison. Since I wanted to be involved in research in an area that would allow me to see improvement, I started to focus on offering Pap smears for cervical cancer screening for women in prison, but it wasn’t so simple. The ethos in the prison healthcare was to keep people alive rather than preventative care. 

Once we got started, we compiled all the Pap smear results and compared them with those of age-matched controls in the population with the help of colleagues at the cancer agency. We were horrified with the results! Women in prison between 25 and 29 years of age were eleven times more likely to have high-grade abnormalities on Pap smear than their age-matched controls in the general population with a p-value of 10^-10 (indicating that it was definitely not a chance finding). In addition, only 47% of women in prison between the ages of 20 and 34 years had received at least one Pap smear in the past three years as compared to 87% of their age-matched controls. So clearly, prevalence was high in this population, and screening rates were terrible. Once we had published the data, I was very hopeful that things would change; but I was naive at the time.

Following that, my mentor at the cancer agency (Greg Hislop) suggested that we apply for funding through the Vancouver Foundation. The plan was to appoint a nurse who would perform Pap smears on consenting women in prison, followed by educating them about its role in preventative care (the intervention). The goal of the intervention was to motivate women to continue to have Pap smears once they left prison. Unfortunately, when we compared the follow up of those who received the intervention at the prison with age- and education-matched controls, the results were disappointing. Once women were out of prison, the rest of life took over and Pap smear wasn’t a priority anymore. 

Q. One of the aspects unique to your research is community-based participatory health research. Could you tell us more about the concept of participatory health research (PHR), and the challenges faced to initiate it in the prison?

While working in the Department of Family Practice at UBC, I started doing an online Masters's program with the University of Manchester in 2005. My first course was on Participatory Health Research (PHR) and I was keen on applying my knowledge toward the improvement of the health of women in prison. I thought that if we invite women to tell us what we should be researching and get them involved in helping design the methods, gather observations, and interpret and disseminate the results, we may see some improvement. By then, I had started working at the Alouette Correctional Centre for Women (ACCW). Constellations of events coincided to develop this research notion further; a chance bathroom conversation with Vivian Ramsden, a family medicine researcher experienced in PHR, who agreed to mentor me; an enthusiastic conversation with the prison recreation therapist - Alison Granger-Brown; and the support of Brenda Tole, the prison warden, who viewed the PHR as a part of her goal of providing a therapeutic environment at the prison. 

With the warden’s support, we signed a Research Agreement with BC Corrections Branch and acquired UBC Research Ethics Certificate. We employed a summer student to conduct in-depth interviews with individual women in prison along with focus groups for guards and health care workers. The goal was to determine mainly two things - firstly, if we were to do PHR in prison, what would it look like; and secondly, what were the health issues that they perceived as important.

Once we had gathered all that information by fall, we were keen on applying for funding from the Canadian Institutes of Health Research (CIHR) due by November - so we didn’t have much time. Vivian suggested that the only way to move forward with a participatory funding application was to organize a forum to gather all the women to brainstorm through the issues at hand. So, after obtaining the warden’s permission, we organized a day-long event, in the prison gym, for all incarcerated women and prison staff, management, and contractors. It was also attended by the Aboriginal Elder Holy Cow, four academic colleagues from UBC, and Vivian Ramsden.

I still get goosebumps when I remember that day. The Indigenous Elder Holy Cow was invited to open for the day. She had us stand in a circle and hold hands while she and the prison Chaplain stood in the center. She opened the meeting with a prayer in Cree, that was translated into English, followed by a prayer by the Chaplain. This played an important role in incorporating spirituality into the health research agenda for the future. In fact, we included a drawing of the “medicine wheel” by one of the indigenous women in our CIHR application which included the four quadrants of health - physical, mental, spiritual, and emotional. 

After we shared the themes that had emerged from the summer at the forum, a microphone was passed around and women shared their thoughts and ideas about how to improve health, expressing mainly five values: respect, breaking the silence, listening and be heard, building on strengths rather than deficits, and all who wish to be involved in the research process may be involved.

Later that day, we gathered into five smaller discussion groups to be able to have more in-depth exchanges on each topic and to record the discussions. Contrary to my expectations, more women chose to attend the groups on “life skills and re-entry into society” and “children, family, and relationships” as compared to those on “mental health and addiction” or “HIV, hepatitis, and infections”. It was clear that they felt these areas needed were the most important ones to research for improving women’s health.

The next morning, twenty-seven incarcerated women from the forum showed up to assist Vivian and me with writing the CIHR application. They worked in threes to transcribe the audio: one would read aloud, another would write and the third would type. Some offered to gather letters of support, while others offered to scribe them to those who did not know how to write. 

Following the submission of the CIHR application, a group of women at the prison were very enthusiastic about continuing with research while waiting to hear back from the CIHR. So, they requested the warden for permission, following which “Research teamwork” was made an option for prison work placement. 

What were the kinds of activities involved in the PHR at ACCW and what was its impact in your opinion?

The PHR team developed a daily routine for themselves which involved the Indigenous way of engaging - in a circle. They commenced the meetings with ‘angel words’, where every person, in turn, would select a card and share what the word on that card meant to them. For example, peace, blessed, etc. This was usually followed by a reading from a spiritual book. ‘Angel words’ was my favorite part of the routine, and I would hate to miss it if I were late. I would volunteer once a week for the clinic and once for research. So, I had two hats “Dr Ruth the researcher” and “Dr. Martin the doctor”. On research days we would have various discussions about their passions, sleep problems housing, etc. I would bring books on how to conduct surveys and connect them to the Internet so that women could access information on various topics; and when I wasn’t around to access the internet, women would request the guards or nurses to look up the internet for them. Provincial prisons have short sentences and so women are going in and out. In order to maintain continuity, the women who had attended the original forum created an orientation package for the new women who joined in. They even taught themselves how to make PowerPoint presentations and public speaking.

The initial forum was pivotal for all the PHR events that followed in the prison, which were in turn instrumental for the development of the Transformative Health and Justice Research Cluster (THJRC) and other ongoing projects. For example, through the discussion groups at the forum and data emerging from several years of PHR, we identified nine health goals, such as improved housing, education, meaningful work, etc.; but we realized that most of the health goals were contingent on the conditions outside of the correctional facility. So, we surveyed women as they were leaving prison to examine the barriers and facilitators that they experienced for these nine health goals and we observed that the first few days after their release were critical, and that women needed support for their transition into the community. This was the seed for the peer health mentoring and unlocking the gates program (UTG) aimed toward the successful reintegration of women released from prison.

I still remember when the PHR was discontinued, while I was working part-time at UBC, I received a phone call from a woman who had been released. During my work at the prison, I had always said to the women that they should get in touch with me at UBC once they were released. So, Kelly showed up, and was enthusiastic about continuing research outside the prison. Along with some of the women who were released thereafter, they formed the “ACCW alumni” on Facebook which then morphed into “Women into Healing”. They wanted to persist with PHR in the community, to be able to continue with the things that they couldn't do while they were inside. A bunch of people got involved to take this forward including Mo Korchinski, Pam Young, Chas Coutlee, and Marnie Scow. Initially, it was hard trying to organize meetings because of transportation issues, unemployment, child care, etc. So, we applied for funding that could be used toward employing women as research assistants for which previous incarceration experience was a requisite.

It was important to make people aware of what was going on in prison and one of the things that Mo would often say when we did conference presentations is that ‘this audience gets it, but we need to convert the people out in the general population who don't understand it. We need to convince politicians to make things better’. So, a few of the women took media training to be able to speak to newspapers and television, and make documentary films. We then published a book, Arresting Hope, which is basically women's stories from the PHR and includes all the documentation that didn't go into academic journals; and used this book to educate people about what PHR in prison looks like. We later published Releasing Hope, in which women share their experiences about their transition from prison to the outside community.

Q. You helped initiate the Mother-child unit or ‘Bonding Through Bars’ program in 2005 at the Alouette Correctional Center for Women (ACCW). Could you tell us more about the program?

One of the hardest things for me to do was to care for pregnant women in prison, watch them go to hospital to deliver, only to return to prison without their babies. Women would say that it made their substance use worse, and left them with a feeling of hopelessness and being a ‘bad mother’. We were already aware, through the PHR forum, that the women wanted to improve relationships with their families. So, when Brenda Tole asked my opinion on the idea of women returning to the prison with their babies after delivery, I was very excited about working toward it. So, in 2005, Brenda created the Infant and Mother Health Initiative at the Alouette Correctional Centre for Women (ACCW) as a partnership between BC Corrections and the Ministry for Children and Family Development (MCFD), with the collaboration of BC Women’s Hospital and Health Centre. 

Worldwide, an estimated six percent of incarcerated women are pregnant while serving prison time. Between 100 to 150 women were housed at ACCW at any one point and a total of thirteen babies that were born between 2005 and 2007. Nine of these babies returned with their mothers after being vetted by the MCFD and stayed until the mothers were released.

Successful breast feeding was one of the positive health outcomes of the ACCW Infant and Mother Health Initiative.  Once a baby is taken away at birth, there is no going back to breastfeeding how much ever an incarcerated mother may express and send packaged milk to the baby. Of the nine babies that returned to prison with their mothers, eight were breastfed for the duration of their stay. Fifteen months was the longest stay of any infant in prison. Along with the appropriate authorities, Brenda brought together a plan for the release of these mothers so that a supportive residential system was in place to help them transition to the community. The new mothers expressed joy about being able to nurture their babies while being able to benefit from the support of the other women in prison and staff - after all, it takes a village to raise a baby! Besides, it completely changed the ethos of the prison in a very positive way.

Q. What was the journey like for the mother-child unit at the ACCW after 2008? Is it still functional at the ACCW? 

Unfortunately, the mother-child unit was shut down by the Ministry of Public Safety in 2008. We now had to tell pregnant women that their babies would be separated from them after birth and they could not bring their babies back to prison.  I wrote a long letter to the then Minister of Public Safety outlining the health benefits of what we had observed and how damaging the impact of discontinuing the mother-child unit was with all the evidence. In addition, BC Women’s Hospital wrote a brief supporting the benefits of the mother-child unit; but we heard nothing from them. Women were obviously upset and finally two mothers with incarceration experience at ACCW challenged the decision and took their case to the BC Supreme Court. Disappointingly, it took five years until the court ordered the reopening of the mother-child unit at ACCW in 2013 at which time the court acknowledged that the closure of the program violated the rights of children and mothers provided in the Canadian Charter of Rights and Freedom.

I had stopped working at the prison in 2011, but as director of the Canadian Collaboration for Prison Health and Education (CCPHE) at UBC I saw an opportunity in 2013 for us to influence policy for incarcerated mothers and their infants across Canada. So, we invited over 50 delegates - including wardens from New Zealand - from more than 40 organizations to help develop the guidelines. We finally launched the Guidelines For The Implementation Of Mother-Child Units In Canadian Correctional Facilities in 2015 and received endorsements from many of the participating organizations. When BC Corrections reopened the mother-child unit in prison, the then-warden gave me a tour of it and mentioned how the CCPHE guidelines helped to influence their policy. She conducted training of correctional officers once she recognized that the officers were afraid of the liability of something happening to the babies on their watch. More recently I have heard that there have been some mothers and infants living in the ACCW unit, and the Elizabeth Fry Society of the Lower Mainland provides support for women with their infants in ACCW, and parenting programs for all women in ACCW. 

Dr. Ruth Elwood Martin in a snapshot: An excerpt from ‘Arresting Hope: Women taking action in prison health inside out’:

‘I have observed, over my years inside a women’s prison, that hope tips the balance of a woman’s life. Imagine life as a teeter-totter with belief in change at the pivot. As hope grows and swells, the teeter-totter balance of life shifts - emotionally, spiritually, mentally and physically - and inner-self emerges with “I think I can do it!”

This prison gave incarcerated women the opportunity to be passionate; to feel joy, laughter, fear, anger and grief; to be curious and to try; to succeed and to fail; to believe and to have faith. In addition, this prison gave incarcerated women the opportunity to develop relationships with people who believed in them and who affirmed them with, “I know that you can do it.”

Some women tell us that the presence of babies in prison turned their lives around. Other women tell us that their emerging faith or spirituality inside prompted them to change. For others, the passion of doing meaningful work in prison opened their eyes. Other women tell us that having fun, for the first time in their lives, made them realize that they could live without drugs. Most women will say the fact that someone in prison believed in them for the first time, belief that they could do it, had a profound impact. This gave hope that change was possible.’

First Nations land acknowledegement

We acknowledge that the UBC Point Grey campus is situated on the traditional, ancestral, and unceded territory of the xʷməθkʷəy̓əm.

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