Towards a health-informed approach to penal reform? Evidence from ten countries disabilities requires substantial adjustments to the physical environment. For example, narrow cell doorways make it impossible to enter in a wheelchair; and bunk beds or very low fixed beds will be impossible for disabled or frail prisoners to use. Prisoners with chronic diseases are entitled to the same standard of care and treatment in prison as they would receive in the community. This will usually mean provision of primary care within the prison to the extent possible, together with outpatient appointments in the community where necessary. For those prisoners who have serious physical disabilities, or who require end-of-life care, a humane approach will require consideration of alternative, non-custodial provision. Non-communicable diseases place significant additional burdens on prison healthcare systems, but they are preventable, chiefly by interventions to control their principal causes. Preventive work is a key part of limiting the risks of non-communicable disease in prisoners and the associated healthcare costs. Research has shown the capacity of prison regimes to reduce risk factors for noncommunicable diseases by carrying out regular, detailed health checks and by introducing measures to promote healthier living. (See, for example, Butler & Milner, 2003.) Prisoners should receive advice and education materials on healthier living and regular health screening. Prisons may consider banning smoking in shared areas. A nutritionally adequate and balanced diet should be provided (catering for the distinct dietary needs of women and of people who wish to observe religious dietary rules). If prisoners are allowed to buy food and snacks, these should be healthy and not highly processed. Providing appropriate opportunities for prisoners to exercise is also a key preventive measure. Healthy diets, together with exercise and the social interaction it brings, have been shown to have physical and mental health benefits, with improved conduct and inter-personal relationships in custody reported (World Health Organization, 2014). The food was never enough, it was never warm, and was not cooked properly. Even pigs would reject it . Female ex-prisoner 1, Kenya The implementation of healthy regimes is greatly hindered by prison overcrowding, as it generally leads to reduced space for exercise and limited staff supervision time. Reducing overcrowding is therefore an essential precondition to ensuring that prisons can control risks for non-communicable diseases. If you tell them you have TB they isolate you and take you to TB ward, but the medication is only available sometimes, not all the time, so often its days before you get what you need. 4.3.3  Continuity of care Continuity of care for prisoners is important across the whole custody process. This means assessing on reception into custody whether the prisoner was receiving treatment in the community and ensuring any necessary medication is continued in prison. Effective continuity also requires individualised preparation for release, including proper handover of the prisoner’s care to community-based services. This is particularly important in the context of prisoners with a Female ex-prisoner 2, history of mental health problems or substance issues. The heightened Kenya risks of overdose or relapse should be managed. Compared to the general population, people released from custody face a very high risk of premature mortality from opioid-related overdose. This risk can be reduced by making naloxone, a medication that reverses opioid overdose, available upon release (Stone & Shirley-Beavan, 2018). It is also important to ensure prisoners with a history of drug use are directed to support services in the community in advance of release, given the high risk of suicide associated with this group.36 36 (See section 3.1.6 above.) 28