3.  Damage to health caused by imprisonment above official capacity since at least 1980. The resulting prison overcrowding has created ‘hothouse’ conditions for the spread of tuberculosis and other infections. Inhumane, degrading and unsafe living conditions have also served to increase the incidence of violence, sexual assault and other behaviours known to heighten the risk of infection. In 2015, the severe health risks presented by overcrowding in one South African prison, Pollsmoor Male Remand Detention Facility, were the subject of a successful constitutional challenge by the NGO Sonke Gender Justice (discussed in Nevin & Keehn, 2018).12 Brazil, too, has experienced rapid rises in cases of tuberculosis among its prison population: recent research has concluded that controlling the disease in prisons is critical for reducing its prevalence in the community (Sacchi et al, 2015). Another recent study compared the incidence of tuberculosis among prisoners and in the wider community over several years (Mabud et al, 2019). It found that the prison environment drives the incidence of TB to a greater extent than do characteristics of the prison population itself, despite that population generally having higher risks of infection. Our health was bad. People died when I was there. I got fevers, I had TB. I thought I would die. Male ex-prisoner, Brazil 3.1.3 Non-communicable diseases In most jails, prisoners alleged that the same medicines were given for viral fevers, body aches and, at times, even for skin allergies. … Prisoners suffering from chronic illnesses are the worst hit … due to the unavailability of specialised medicines in prisons. Jail doctors also cited procurement of medicines as an issue… the state warehouses either had insufficient or incomplete supply of medicines. Commonwealth Human Rights Initiative, India (idem) Worldwide, numbers of people suffering from heart disease, diabetes, cancer and respiratory illness are on the rise, particularly in lower income countries and in more marginalised communities. Studies have shown that prisons carry a heavier burden of these diseases than wider communities (for example, Herbert et al, 2012) and that their prevalence in prisons is growing. This is, in part, a reflection of their greater preponderance among socially and economically disadvantaged groups in all societies. A further factor is the rapidly rising number of older people in prison in many countries (in particular in the United States, Australia and England and Wales). This, too, has resulted in more prisoners having one or more of these illnesses. The prison environment is often characterised by some of the main causes of non-communicable diseases: high levels of smoking; inadequate physical activity; and unhealthy diets. Across both higher and lower income countries, diets in prison are generally too high in carbohydrate and fat content (Herbert et al, 2012). In higher income countries, prison meals are often too high in calorific content or sodium levels, while in lower income countries they sometimes fall short of the recommended daily energy intake. They never explained why they did not let us out for exercise. This would make the inmates very frustrated and they would take out their frustration on other inmates by shouting at them or beating them up. Male remand prisoner 3, South Africa 3.1.4 Substance misuse in prison Drug use is endemic among incarcerated populations across much of the world, reflecting the high levels of drug dependence seen in people who are sent to prison. There is also evidence that considerable numbers of people who use drugs in prison acquired the habit in custody (Stöver & Michels, 2010). 12 Sonke Gender Justice v. the Government of South Africa, Western Cape High Court, no. 24087/15 (unreported). Sonke Gender Justice is an NGO working across South Africa to strengthen government, civil society and citizen capacity to promote gender equality, prevent domestic and sexual violence, and reduce the spread and impact of HIV and AIDS. 9