4.  Developing a health-informed approach to penal reform The heightened risk of suicide for released prisoners has been linked to several factors that could be managed at and immediately after release from custody, with a view to facilitating transition to life after prison (Haglund et al, 2014). Interventions include increased clinical monitoring and early involvement with community mental health services. In addition, the mental and physical health consequences of potential homelessness and unemployment should be managed and mitigated through community-based services. I came out with lack of self-esteem, I fear other people, can’t talk to people, was stigmatised, just learning to cope now, don’t know if I’ll be able to cope. When I got back, my partner said it was over. Former remand prisoner, female: detained for one week. Kenya Peer mentors in the form of ex-prisoners can provide valuable support for people leaving custody who need to access community health, rehabilitation and social care services. This assumes mentoring schemes are properly designed and run. (For examples of potential pitfalls and good practice in peer mentoring schemes in this context, see Fletcher & Batty, 2012.) 4.4 Conclusion Although imprisonment can sometimes provide an opportunity to stabilise or improve the health of people with high levels of unmet health needs, the prison setting is more frequently detrimental to health. This is all the more so for the considerable numbers of prisoners whose health-related or other vulnerabilities place them at greater risk of harm in custody. Therefore, the primary focus of reform should be on providing more effectively for health needs – particularly those linked to mental health and drug or alcohol problems – without resort to imprisonment wherever possible. When community health responses or treatment options are overstretched or do not exist, people who need treatment or support for mental health problems often find themselves in and out of police stations, courts and prisons instead, with all the distress and upheaval this brings. Over-reliance on criminal justice interventions when a health-led approach would be more effective leads to poor re-offending outcomes and heavier workloads for police, prosecution, court and probation services and puts added pressure on prison places. More fundamentally, it raises serious ethical questions, as discussed at the beginning of this chapter. Prisons in developed and less developed countries alike contain large numbers of people whose health, already poor, will only worsen during their time in custody. In countries where community health standards are poor, prisons – especially overcrowded ones – will inevitably struggle to make even basic provision for disease prevention, screening and healthcare, presenting major risks for public health. The important goals of rehabilitation and preparation for release are defeated when there are no resources to achieve them, or when conditions and healthcare provision are so poor as to threaten prisoners’ health. When a state’s justice and health policies lead to the systemic incarceration of people whose healthcare needs cannot be met in the prevailing prison conditions, those policies will infringe constitutional and international human rights protections. This has been established in proceedings against some of the ten countries discussed in this report. Jurisdictions have been ordered to reduce their prison populations in order to be capable of safeguarding prisoners’ basic rights to healthcare. The urgent questions that are thus raised for every government include: • Whether all available routes are being pursued to prevent overcrowding in prisons and thereby minimise the associated risks to public health; and • How the work of criminal justice and community health agencies can be reconfigured to prevent the imprisonment of people whose health needs could be better met in the community. 29