4. Developing a health-informed approach to penal reform Chapters 2 and 3 have demonstrated that prison populations bear a far greater burden of mental and physical health problems than general populations. This is partly due to pre-existing health problems among people who enter custody and partly also to factors in the prison environment. We have noted that existing health problems can be exacerbated by imprisonment; and that new health problems can come about as a result of poor conditions and lack of treatment, especially in countries where prisons are overcrowded. In this final chapter, we first address some of the implications of these unequal burdens and elevated risks of poor health in prison populations. We then set out the case for a health-informed approach to penal reform. In doing so, we highlight a selection of advances in research and practice that could contribute significantly to higher standards of prisoner health and healthcare. We present interventions capable of addressing mental or physical health risks and needs at different points along the custody process, from first contact with the police, through sentencing, to preparation for release from custody. The advances we discuss have been drawn from among the countries featured in the ten country project, but could be adapted for use in other systems. 4.1 Imprisonment and the associated health risks: the implications A sentence of imprisonment is a sentence of deprivation of liberty, not of damage to health. There is a wealth of evidence to suggest that governments in many countries are failing in their duty to protect prisoners’ physical and mental health and provide adequate health treatment. Throughout this report, we have presented accounts from people who have first-hand experience of the damage custody can do to prisoners’ health. These accounts describe overcrowded and under-resourced prisons struggling to provide basic sanitation, drinking water, food, medication, exercise, or sufficient living and sleeping space. They reveal how prisoners are often unable to access the care and treatment they need, even for life-threatening conditions like diabetes, tuberculosis and HIV. Being imprisoned in such conditions would take a heavy toll on the health of anyone; but when a person’s health is already poor on entry into custody, as is so frequently the case in both developed and less developed countries, the toll is even heavier. The implications are serious, from several distinct perspectives. From an ethical and human rights perspective, it is scandalous that people in poor physical or mental health are being detained in It was very dirty, our children inhumane, degrading and unsafe conditions without adequate medical regularly got sick, with diarrhoea, treatment. The consequences are disease, violence, intimidation, skin diseases, cholera, they had self-harm and suicide, representing gross infringements of the human colds all the time. rights of prisoners and prison staff. If the state cannot offer decent Female ex-prisoner 1, Kenya and humane living conditions in its prisons, or provide healthcare equivalent to that provided in the community, incarceration is open to challenge on human rights grounds. It was a ruling to this effect by the United States Supreme Court that ultimately forced California to enact reforms to bring an end to decades of mass incarceration (as explained in Simon, 2014).22 The Court held that California was infringing prisoners’ Eighth Amendment right not to suffer cruel and unusual punishment, because the state’s criminal justice and health policies were effectively causing thousands of prisoners to be exposed to extreme medical and mental health suffering. The ruling made history in its declaration of dignity as a constitutional value as it relates to prisoners and My body feels so stiff. On average we probably may well stand as the high-water mark of American get out of the cell about an hour a week….I jurisprudential protection for prisoners’ rights. From a public health perspective, there are serious risks in holding people in insanitary and overcrowded prisons without access to screening, treatment or basic harm reduction measures. The risks of communicable diseases spreading quickly do not get given my [TB] medication daily as it was prescribed. This makes recovery difficult, particularly since there is little air in the cells and lots of second hand smoke… There are lots of sick people inside the cell. We all have bites from lice. Male remand prisoner 4, South Africa 22 Brown v Plata 563 US 493 (2011) 19