Towards a health-informed approach to penal reform? Evidence from ten countries 3.2 Overcrowding Prison overcrowding is a significant contributor to the damage that imprisonment can cause to the health of both prisoners and prison staff. It is a cause of severe psychological stress, which exacerbates mental health conditions. It is a major factor in the spread of infectious disease and the worsening of chronic conditions. Overcrowding also makes rehabilitation all but impossible, presenting a heightened risk of re-offending after release. The overcrowding was very bad, there were 60 men in a 20 person cell. There were a lot of addicts… that made it more stressful. The worst thing was the hunger. If family members brought in food for us, we had to share it round. Male ex-prisoner, Brazil Overcrowded prisons mean cramped and unhygienic accommodation; a constant lack of privacy (even when using the toilet); reduced out-of-cell activities (due to pressure on staff and less access to facilities); limited access to treatment and medicine due to overburdened healthcare services; poor conditions for sleeping; unsafe conditions due to weakened prison management; and increased tension and despair among prisoners, which can result in violence, substance misuse, self-harm and, in extreme cases, suicide. The worst part in prison was the night time, when night comes there is no sleep, really there is no night time, just a different life that starts, a lot of fighting and noise, crying. It’s hell. The lights stay on and the guards are all over the prisoners. You go to bed in fear as you never know what will happen, who will beat you up. I still can’t sleep at night. Female ex-prisoner 1, Kenya The Care Quality Commission in England has recently confirmed that: ‘Overcrowding and lack of personal space are acknowledged stress factors for both prisoners and staff that impact on the delivery of an effective health service. The significant impact on prisoners’ general health and wellbeing includes increased risks associated with privacy/confidentiality, communicable diseases, sleep hygiene and anxiety/depression.’16 3.2.1 What is ‘overcrowding’? The starting point for determining whether a country’s prison system suffers from overcrowding is to look at the official capacity of the country’s prison estate – as stated by its relevant prisons authority – and the actual occupancy level shown by that country’s total prison population.17 If the official capacity for country X is stated to be 50,000 but the occupancy level is 60,000, this indicates that country X is operating at 120 per cent of its official capacity – or, it is overcrowded by 20 per cent. The occupancy rate alone cannot be taken as a definitive indicator of the extent of overcrowding or the impact it may have on health, for several reasons. First, there are no fixed rules on how much physical space should be allowed per prisoner. In Europe, the Committee for the Prevention of Torture has issued standards on living space per prisoner.18 These specify a basic minimum space of 6m² for a single-occupancy cell, excluding the sanitary facility; and 4m² per prisoner sharing a multiple-occupancy cell, excluding a fully-partitioned sanitary facility, at least 2m between the walls of the cell and at least 2.5m between the floor and the ceiling of the cell. For multiple-occupancy cells for up to four inmates, the standards recommend that 4m², per additional inmate, should be added to the minimum living space of 6m². 16 Written evidence to House of Commons Health and Social Care Select Committee (2018): Prison Healthcare inquiry. Available at https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/inquiries/ parliament-2017/prison-healthcare-inquiry-17-19/publications/ 17 ICPR’s World Prison Brief website provides information on the occupancy rates of most countries in the world. The information is based on the most recent official capacity figure published by a country, and the national prison population total as at that date. 18 CPT Standards on living space per prisoner in prison establishments, December 2015 14