Towards a health-informed approach to penal reform? Evidence from ten countries Most of the jails do not have specialised doctors such as dentists, gynaecologists, dermatologists, psychiatrists and psychologists to deal with predominant health problems like dental issues, gynaecological issues faced by women inmates, skin allergies or scabies, depression, anxiety or even drug addiction and drug withdrawal. [Medical Officers] deal with almost 80100 outpatient cases each day, which is a very high number and might mean that proper attention is not given to each patient. From Inside Haryana Prisons, December 2018, Commonwealth Human Rights Initiative, India Full inspection report available at: http://hslsa.gov.in/sites/default/files/ December2018/HaryanaPrisonReport.pdf of physical and mental health’, without discrimination as to status.8 Specific international instruments set out what this means in terms of the healthcare provision to be made by prison administrations.9 Those charged with the medical care of prisoners have a duty to protect their physical and mental health and to afford treatment ‘of the same quality and standards as is afforded to those who are not imprisoned or detained’.10 These rights apply from the point of first admission to prison, throughout the entire course of the prison term and at the point of preparation for release. Even in times of grave economic difficulty, nothing can relieve the state of its responsibility to provide for the health and healthcare of those whom it has deprived of liberty. There is a long way to go before these principles become reality. Even when prisons are properly resourced, there will be challenges in ensuring that they are healthy environments. In countries where resources for prisons and wider justice systems have not kept pace with the increasing demands placed on them, or where health services in the community are lacking, these challenges become all the greater. 3.1.2 Communicable diseases It has long been recognised that prisons can be fertile breeding grounds for infectious diseases, particularly tuberculosis, hepatitis B and hepatitis C. There tends to be greater prevalence of infections among people entering custody; and infections are more likely to occur in prison due to the characteristics of the environment (World Health Organization, 2014). Intravenous drug use, unprotected sex, raised levels of violence and lack of sanitation and healthcare are all factors increasing the risk of disease transmission. Many of the world’s prisons have a rapid turnover of people entering custody, particularly remand prisons and low- to medium-security establishments. This presents challenges for limiting infection through screening and treatment. The risks of infection are further compounded when prisons are overcrowded or have limited access to clean water, sanitation, healthcare, vaccination programmes and basic harm prevention tools, as is the case in many of the ten countries under study. I feel really claustrophobic all the time… One toilet is not enough for all of us so we are forced to use a bucket. The smell is disgusting. There is not enough toilet paper, cleaning materials or soap. So the place is disgusting and people get sick all the time. Male remand prisoner 1, South Africa South Africa currently carries the world’s highest HIV burden11 and one of the highest burdens for tuberculosis (World Health Organization, 2016). The country’s prison population has more than doubled since 1965 and has been operating well 8 Articles 2 and 12, International Covenant on Economic, Social and Cultural Rights. 169 countries have ratified this treaty and are therefore bound by its terms as a matter of international law; 71 signatory countries have yet to ratify (including the USA). In addition, the UN Basic Principles for the Treatment of Prisoners (Resolution 45/111) state: ‘Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.’ 9 The Appendix sets out the main regional and international rules and standards. 10 The United Nations Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. 11 UNAIDS website, South Africa country listing, as at March 2019: http://www.unaids.org/en/regionscountries/countries/southafrica 8