Towards a health-informed approach to penal reform? Evidence from ten countries 2. Health problems with which people enter custody This chapter gives an overview of some of the main health problems of people entering custody in the ten countries and more generally. 2.1 Health problems in populations most affected by imprisonment Although it is sometimes said that prisons are a microcosm of society at large, in reality the social and economic groupings in society are not represented evenly in prison populations. In fact, it is usually possible to identify the marginalised groups in any society by analysing its prison population (Coyle et al, 2016). Health problems seen in marginalised groups in the community will frequently be mirrored in the health of those in prison. Prisons are too frequently used as a place to hold people with problematic drug or alcohol use disorders or mental health conditions who (perhaps as a result) cannot find secure work or accommodation and who live in poverty. Prisons often hold disproportionate numbers of people from racial and other minority backgrounds. In some countries, non-nationals and minority ethnic groups may even be the largest grouping in the prison system (as is the case in the Netherlands (Jacobson et al, 2017)). Physical health problems are also more prevalent among those entering custody, some of whom may have untreated (even undiagnosed) conditions. Infectious disease prevalence is higher among people coming into prison than in general populations. Prisoners show higher prevalence for tuberculosis, hepatitis B, hepatitis C and HIV/AIDS and other infections. They may be more susceptible to infection because their general immunity is lower, due to pre-existing health conditions, poverty, substance use, homelessness and previous incarceration. They may have had little or no access to information and treatment. This greater prevalence of infectious disease among people entering custody has been noted in higher income countries as well as low- and middle-income ones. For example, it has been highlighted as a particular concern in England and Wales (House of Commons Health and Social Care Select Committee, 2018) and in New South Wales, Australia (Butler & Milner, 2003). People entering custody in Brazil (which now has the world’s third largest prisoner population) have recently been found to have unexpectedly high levels of active syphilis (Correa et al, 2017). This study of over 3,000 prisoners in the state of Mato Grosso do Sul also showed that almost 90 per cent of prisoners who tested positive for lifetime or currently active syphilis infection had been unaware of their status. People entering custody are also at higher risk for some of the main non-communicable diseases including diabetes, cancer, heart disease and respiratory illness. This may be due to prior histories of smoking, alcohol use, poor diet and other factors connected with socio-economic deprivation. Numbers of older people in prison, many with chronic physical health problems or mental health impairments, are rising exponentially in many parts of the world. 2.2 Mental health conditions and their criminalisation A wide range of mental health conditions are associated with criminal conduct or with behaviour that might be perceived as disruptive or threatening. Many people who enter custody (whether on remand or under sentence) do so on account of behaviours that, to some extent, reflect an existing mental health condition. In a recent report on Kenya’s criminal justice system, a review of police-recorded reasons for arrest showed almost a quarter of all arrests were for offences relating to: ‘disturbance or nuisance’, ‘being drunk and disorderly’, ‘loitering’ and ‘using offensive language or conduct’. The apparent condition of individuals taken into police custody included 16 per cent of cases that police recorded as either ‘drunk or appearing to be drunk’, ‘sick’, ‘mentally disturbed’ or ‘abnormal’ (National Council on the Administration of Justice, 2016). In much of the world, there is a higher prevalence in prison populations than in general populations of mental health conditions such as depression, personality and anxiety disorders, schizophrenia, bipolar disorder and psychosis (World Health Organization, 2014; Fazel et al, 2016). Major depression and psychotic illnesses are estimated to affect one in seven prisoners (Fazel et al, 2016; Fazel & Seewald, 2012). Women and young people 4